HomeMy WebLinkAbout241 SHERWOOD PL - Building Permits Applicant to fill In all spaces except those within heavy border lines and sign all appropriate declarations.
f 'TY OF COSTA Ila C STRUCTIO RMIT P�OyIT_NO. /�� TRACT NO. LOT NO. UNIT NO. A P # Zona
ojticTl}4Ndressl-"•c _,�,. o . ar(�ia `7//3 t/O_ r1 - S Main Building: Accessory Building:
Applicant's Mailing Address C1 I I TYPE OF CONSTRUCTION U NEW Li ADD H ALTERATION H REPAIR E Z
1 !CQ„2�2/ CI CONVERSION CI DEMOLISH ❑ OTHER T Front O
Owner's Name •YVl • .K✓- ' Phone1l1n� ✓ r/ DESCF�IIT • OF WOR SE OF BLDG. ' B Rear N
Address �L A • . an 05 0 it _, ry �; _ . A I
Arch/Eng. ' License No. TYPE OF PERMIT ❑ GRADING ill OUNDATION ❑ STRUCTURAL I C Right N
Address • • -CI TENANT ❑ ELECTRICAL Li PLUMBING ❑ MECHANICAL S• Left R
/''/�) Q/� ❑ BOTHER -� .Ping. Ref.# Parking Req./Provided
Contractor's Name lPhone
PROJECT DESCRIPTION SD. FT. OCCUPANCY Plannin Notes:
Address(mailing) CONSTRUCTION TYPE VALUATION$ g M
City License No. — ZONE LRADING CU.YDS. ACRES
LICENSED CONTRACTOR DECLARATION S.
I :+ •• .at am licensed under provisions of Charter 9 c• men nRemarks: /�tI/' �I�. a4 X• • s
with sectionis 7000) o • of r - - •n Code,and ^ 'a .J�1^�+•�� M- _ ELECTRICAL FEES
CC:
my license is in full torr e act. /(3-A /`fin J��_'__a II
Da License Class License •-. PLUMBING - L I FEES ■ Automatic Washer - Transformer 0 15-50 KW
Date Signature
WORKERS'COMPENSATION DECLARATION Construction Pole Sub. 0 50+KW
'•.ereby affirm that I have a certificate of consent to self-insure or a certificate Bar Sink ShowersI
iii
Workers' Compensation Insurance, or a certified copy thereof (Section Cooking Unit Meter ❑up to 100 amps
.600, Lab. C.) Backflow Preventer Service Sink
Policy No. Company Backflow Irrigation Sewer Cap Dishwasher Meter Dover 100 amps
8 Certified copy is hereby furnished. Dryers ❑Gas DElectric Sub Panel
Certified copy is filed with the city Building Division. Bathtubs Sewer Connection
Date Applicant FanEXEMPTION FROM WORKERS'COMPENSATION DECLARATION Clarifiers Solar Collectors Motors 00-1 HP ❑1'h-8
(This section need not be completed if the permit is for one hundred ($100) or F.A.U.'less). Dishwasher Solar Piping Inc.Solar 09-15 HP 016-15+
I certify that in the performance of the work for which this permit is issued, I Fi
shall not employ any person in any manner so as to become subject to the -Drinking Fountains ■ Solar Tank ! xtures Micro -
Workers' mp nsa pg Laws of Califo
Date 4t—IR p Signature Floor Drains Swimming Pool w/Spa Device Boxes 'ole Light
NOTICE:If,after making this declaration,you should become subject to the -
Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks Urinal Outlets Range
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY / Gas$efvipe 'DUtlet$ Switches Sign
I hereby affirm that there is a construction lending agency for the performance / Water Closet "7 d. g
of the work for which this permit is issued (Section 3097 Civ. C.) Interceptors Water Heater Disposal Standing Sections
Garbage .
Lender's Lender's Name
Lender's Address Kitchen Sink Water Service Generator ❑0-5 KW 05-15 KW Trash Compactor
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the ContraCtor's License Law for the Lavatories Auto-Wash
following reason (Section 7031.5 Business and Professional Code: Any city or
county which requires a permit to construct,alter,Improve,demolish or repair P-Trap Laundry Treys
any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he/she Is licensed pursuant to the provisions of Roof Drains
the Contractor's License Law(Chapter 9(commencing with Section 7000) of
vision 3 of the Business and Professions Code) or that he/she is exempt Reinspection Fee $15 Issue Fee $ 3
refrom and the basis for the alleged exemption. Any violation of Section
.31.5 by any applicant for a permit supjects the applicant to a civil
`penalty of not more than five hundred dollars($500). I DEVELOPMENT SERVICES REQUIREMENTS:
TY Las owner of the property or my employees with wages as their sole Reinspection Fee 6 $15 Issue Fee $ 3
c mpensation, will do the work, and the structure is not intended or-offered Zoning Approved By • Date
for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES Building Approved By s a /// Data
License Law does not apply to an owner of a Property who builds or improves1Sjp-�ii`
thereon, and who does such work himself/herself or through his or her own Boiler Hood or Type 0 Application Issued By _ _-- – _ gab �.
employees, provided that such improvements are not intended or offered for ' ����_
sale. If, however, the building or improvement is sold within one year of com- Canopy Type II ❑ SUMMARY OF FEES
pletion, the owner will have the burden of proving he/she did not build or im- Duct-Under Ground
prove for the purpose of sale). BUILDING PERMIT $ SMIP $
0 I, as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System
tractors to construct the project (Section 7043,Business and Professions Code: PLAN CHECK $ PERMIT
The Contractor's License Law does not apply to an owner of property who Duct-Ventilating 00-10r,s00 BTU 0100,000 BTU ISSUANCE $
builds or improves thereon. and who contracts for such oroiects with a con-
PLUMBING $ S•o-r
tractor(s) license pursuant to the Contractor's License Law). I am aware that Exhaust System 0 Multiple 0 ystem Repair/Alteration PLAN CHECK 25% $ ENERGY P.C. $ _proof of of their Worker's Compens�ona�ur nce should be provided to me. , ELECTRICAL $ GRADING $
am exempt under Section B.& P.C.for this reason Firepl/Fact.BIt. ICBG# Fire Dampers MICROFILM $
�/�p���/�y /d{ PLAN CHECK 50% $
Date �`7"I"r- Owner ^- 1-• a•-f-'de- Heating System& Ducting Registers .'
I hereby certify that I have read this application and state that the above '00-100,000 BTU 0100.000 BT MECHANICAL $ $ �, 00
TOTAL FEE
information is correct. I agree to comply with all city and county ordinances PLAN CHECK 25% $
and state laws relating to building construction,and hereby authorize repre-
sentatives of this city to enter u•on the above-mentioned property for
Inspection purpgns A / /; [�
Drivers' 1J SS 4• .M .5'K Date /I.-9+F Reinspection Fee $15 . Issue Fee $ 3 . 01 00019128-00019128 TOT 5.4J0
Drivers' License or SS# • - ��,
DATE: 11/091E$ 7I14E: 14:44
0865-46,rev. 5/88 White - Building; Canary -Applicant; Pink -Accounting; Goldenrod - Assessor
-ktONSTRIJCTION AND PLANNING POC SPA
Date Inspector • # Date - Inspector
APPROVALS Permit# i APPROVALS Permitt
1 LTernporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. , 53. Steel Reinforcement •• '
3.,Electrical Conduit Utility-Undrgrnd. : I 54. Forms
14:'Electrical Conduii(-Undrgrnd; 55. Electrical Bonding !
5. Steel .Reinforcement , 56. Rough Plumbing & Pressure Test
6.':Elect'rical UFER Grnd. I 57. APPROVAL TO COVER-GUNITE '
7..;Footi,ngs I CI 58. Electrical Conduit-Undrgrnd.
S.i Foundation 59. Gas Pipe, ❑ Undrgrnd.,Test ;fl .
9.IWater Pipe-Undrgrnd. , 60. Backwash Lines, P-Trap, 0 Undrgrnd.
10:;:Structural Floor System 61. APPROVAL TO DECK
11•..Property Sewer Line & House Connection 62. Backwash & Receptor-Final ' !
1
12.jSewet Cap ' 63. Heater & Vent-Final
13:1 RooflDrpins 64. Plumbing System - Final
• 14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
[1,6r-Rough Electric Wiring 67. Fencing & Access Approval
1171 Rough Wiring Sign 68. APPROVED FOR PLASTERING
.18) Rough-Electrical-T Bar Ceiling }} 69. POOL/SPA SYSTEMS FINAL
19' Rough-Heating 8i Air Conditioni ig FIRE DEPT. REQUIREMENT
20. Rough FN ctory Fireplace+ = .-'t APPROVALS Permit#
2r. Ducts, in Structure - 70. Underground Hydro
-� t
22. Ducts, Ventilating I 7 71. Product Piping 0 Gas 0 Oil
23. Gas Pipe-,Rough & Te'st r.� 72. Underground Flush
24. Roof Framing .. ', 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing 7 - 74. Overhead Hydro
26. T-Bar Coiling (Structural) &;Monocoat 75. Dry Chemical
27. Frame and Flashing ' 1
11 76. Dry Standpipe
28: Lathing'& Siding I ! 77. FIXED SYSTEM FINAL
et
29. Inwlatron .- 78. FIRE PREV. FINAL
30. Drywall.Nailing ; 1, HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat .1-. 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
I .
33. Final Electric ;•.' - Notes:
34. Final Heating & Air Conditioning / J
35. Final Gas Pipe-Test i/�,y S
36. Hood or Canopy ,(
37. Final Factory Fireplace •
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final 1 ''`
V
41. Solar Domestic-Final 1
42. Backflow Preventer �, )
r
43. Backflow Irrigation ._ .) i
• 44. Landscape Irrigation System it ,
45. Sound Attenuation /
I
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING
48. Special Requirements Completed
49. Electric Release to Edison
50. as Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY '
No. Date I-)
•-AWPlicant-10 fill in all spaces except those within heavy border lines and sign all appropriate declarations. -
CI,T! �F COSTA MESA ONSTRUCTION PERMIT PER T TRACT NO. LOT NO. UNIT NO. 8672 4� /%/I� •
5r0iti 1 'I1
I F 241 S e'yw». Pict ce_ 3 Z) !o/
F Address
A,pplicant's Mailin Address `- 4 J •.4.• J --: • TYPE OF CONSTRUCTION Li NEW ❑ ADD U ALTERATION ❑ REPAIR •
a 4Yt ❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P.# Zone
Owner's Nang 1i1�5� � Ct+'.. Phone DESCRIPTION OF WORK/USE OF BLDG.
Address 1l eYl J 9CI P1 4-1« S Main Building: Accessory Building:
Z
Arch/Eng. _ License No. - •~ TYPE OF PERMIT• ❑ GRADING FOUNDATION ❑ STRUCTURAL T Front G
j',• ❑ TENANT ❑ ELECTRICAL PLUMBING ❑ MECHANICAL B Rear N
Address - - A I
OTHER
Contractor's Name Phone C Right N
Address(mailing) PROJECT DESCRIPTION SQ. FT. OCCUPANCY K G
g - - _ - CONSTRUCTION TYPE VALUATION $ $ Left
City License No. ZONE GRADING CU.YDS. ACRES R
LICENSED CONTRACTOR DECLARATION - - -- PIOg. R¢f. # Parking Req./Provided E
I hereby affirm that I am licenied under provisions of Charter 9 (commencing Remarksi Planning Notes: QM
with section 7000) of Division 3 of the Business and Professions Code,and, _ T
my license is in full force and effect. -
License Class - ' License'No. •- $
Date Signature '• - - .. PLUMBING FEES •
WORKERS'COMPENSATION,DECLARATION Bar Sink I Showers
I hereby affirm that I have a certificate of consent to self-insure or a'certificate ELECTRICAL FEES
of Workers' Compensation_ Insurance, or--a certified copy thereof (Section,' Backflow Preventer Service Sink
3800, Lab. C.)` • - Automatic Washer - Transformer ❑ 15-50 KW
Policy No. • Company _ ' Backflow Irrigation Sewer Cap Construction Pole Sub. D 50+KW
8 Certified copy is hereby furnished. , _ '
Certified copy is filed with the city Building Division.. V Bathtubs Sewer Connection Cooking Unit Meter Opp to 100 amps
Date Applicant - --
EXEMPTION FROM:WORKERS'COMPENSATION DECLARATION ' - • Clarifiers Solar Collectors Dishwasher Meter Dover 100 amps
(This section need not-be completed•if the permit Is for one hundred ($100;or * '
less). Dishwasher Solar Piping Dryers DGas ❑Electric Sub Panel
I certify that in the performance of the work for which this permit is issued,•I'..+ .,
shall not employ any person in any manner so as'to beco a subject to the-, ' / Drinking Fountains Solar Tank FanMotors DO-1 HP Dl'A-6
Workers',C,g9mpe sa on Laws of,Califorryryy��a -
•
Date �f t4rtSignature tJ 4n�rea,r-e1r�- Floor Drains Swimming Pool w/Spa F.A.U. Inc.Solar ❑9-15 HP 016-15+
NOTICE: I after making this declaration,you should become subject to the —
Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks UrinalFixtures
comply with such provisions or this permit shall be deemed revoked. itl_'A\ Microwave
-
CONSTRUCTION LENDING AGENCY Gas Service ' Outlets Water ClosetW Device Boxes
I hereby affirm that there is a construction lending agency for the performance Pole Light
of the work for which this permit is issued (Section 3097 Civ. C.) Interceptors Water Heater Outlets Range
Lender's Name
'Lender's Address Kitchen Sink Water ServiceSwitches Sign -
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash Garbage Disposal Standing Sections
following reason (Section 7031.5 Business and Professional Code: Any city or P
county which requires a permit to construct,alter,improve,demolish or repair P-Trap Laundry Trays Generator 00-5 KW 05-15 KW Trash Compactor
any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he/she is licensed pursuant to the provisions of Roof Drains
the Contractor's License Law(Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code) or that he/she is exempt
erefrom and the basis for the alleged exemption. Any violation of Section
31.5 by any applicant for a permit subjects the applicant to a civil
.•-Ity of not more than five hundred dollars($500). $ 3
1 '`�� I, as owner of the property •^ ^^^• '^^•=^'� Reinspection Fee $15 , Issue Fee
v - will do the work, and the structure is not intended or offered •
for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES Reinspection Fee $15 Issue Fee $ 3
License Law does not apply to an owner of a property who builds or improves
thereon, and who does such work himself/herself or through his or her own Hood or Type ❑ DEVELOPMENT SERVICES REQUIREMENTS:
employees, provided that such improvements are not intended or offered for Boiler Zoning Approved By Date
sale. If, however, the building or improvement is sold within one year of com- Canopy Type II ❑ �{
plebe n, the owner will have the burden of proving he/she did not build or im- Duct-Under Ground
prove for the purpose of sale). Building Approved By Date ///Yl-
❑ I,as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System Application Issued By Date L7/ S( OQ
tractors to construct the project (Section 7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who Duct-Ventilating 00-100,000 BTU 0100,000 BTU 'SUMMARY OF FEES
builds or improves thereon,and who contracts for such projects with a con- _
tractor(s) license pursuant to the Contractor's License Law). I am aware that Exhaust System 0 Multiple El System Repair/Alteration BUILDING PERMIT $ SMIP $
proof of their Worker's Compensation insurance should be provided to me. _ - PLAN CHECK $ PERMIT
❑ I am exempt under section e. & P.C.for this reason Firepl/Fact.BIt. ICBG# Fire Dampers PLUMBING $ Je•Q0 ISSUANCE $
Date `_____ _aa_ Owner : - f-.• .__A„a Ay-a. .�— Heating System&Ducting Registers PLAN CHECK 25% $ ENERGY P.C. $
I hereby certify that I have read this application and state that the above 00100,000 BTU 0100,000 BTL ELECTRICAL $ GRADING $
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction,and hereby authorize repre- PLAN CHECK 50% $ MICROFILM $
sentatives of this city to enter upon the above-mentioned prop rty for /
inspection ourgges. a0f/ MECHANICAL $ ,TOTAL FEE $ • D`."
Signature lJ ' -
CMF 0865-46,rev.10/84 White - Building; Canary - Applicant; Pink -Accounting; Goldenrod - Assessor
CONSTRUCTION AND RLANNING POOL & SPA
Date Inspector Date Inspector
APPROVALS Permiti# APPROVALS Permit#
1.,+Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. •y - 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings (7 58. Electrical Conduit-Undrgrnd.
•
8. Foundation 59. Gas Pipe, D Undrgrnd., Test
9. Water PiperUndrgrn - 60. Backwash Lines,P-Trap, 0 Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final
\ 13. Roof Drains 64. Plumbing System - Final
'14. Rough Plumbing 65. Electrical-Final
•
15. Rough Electrical-Conduit 66. Solar System-Final
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign68. APPROVED FOR PLASTERING
..
18. Rough Electrical-T Bar Ceiling ;r, 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit#
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping D Gas D Oil
23. Gas Pipe-Rough &Test 72. Underground Flush.
24. Roof Framing • 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Nlonocoat •
75. Dry Chemical
27. Frame and Flashing 1 • 76. Dry Standpipe ..
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing • HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat - 79. FINAL INSPECTION U
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED nn
33. Final Electric Notes:-lur''r MODE t- LE4 r
34. Final Heating & Air Conditioningr
7-5-Kar !"3m ,gcvla,
�e ,r � �o gs sic z43,-:
35. Final Gas Pipe-Test Vwc. 1.e.b
36. Hood or Canopy N
/
I b11gTam.; I N I
0.S >�O� 1-eA
37. Final factory Fireplace T�� Qacty
`I 11 L !q g-g -S -ff r}.L
38. Final Plumbing ! •-yl 1 - t- 'S'�'
S iIAC4a_ 1L.o atOult O LaSA-l0.w...e ••,. • r
39. Water Service-Final �
FTAAI •Ait 01"...4- Altht.-mri4 i✓,G�I . '6414 )j
40. Gas Service-Final I O .
r,n wd,e _B^ 'lir-TV -efrrr ,�-�
r , s
41. Solar Domestic-Final ,�
t Pte-C', �� _s cked Acle.) -Fov-
,
42. Backflow Preventer
i'e\5i . ov1 weA. (0112, tit f r4 t .(
•43. Backflow Irrigation I- t
44. Landsdape Irrigation System ,I
(2/30 $8 -vmecn` Pe0n _
'46fi
5. Sound Attenuation 'w
A a2 12-o Dt 5 4,6 PFi 'Q 8+EUrian
46. Handicap Regulations ,-t/
20,3 . ZNEettU"65K 04 t.iS wr1S Noe
47. FINAL STRUCTURE& BUILDING Pa REi4Jr ilir4 6bt5P&&noH., 7140 !lo.epac/Wit
48.,,Special,Requirements Completed
49. Electric Release to Edison
50. Gas Release to Southern Californ Gas Co :
51. CERTIFICATE OF OCCUPANCY _•
No. Date
31_ r'
- I
filEiCOSTA MESA BUILDING-SAFETY DEPARTMENT ' ' tlIVOElb
P.O.BOX 317 COSTA MESA. CALIFORNIA c/ 6/-(AO-[ 7i
i.
FOR APPLICANT TO FILL IN COMPLETELY APPLIC�j�10 �J; 8 R/MIT
TYPE OR PRINT SUI D'1N k MESA
BUILDING47“, 2141 Sherwood Street
ADDRESS. .b°
I.) COSTA-MESA, CALIFORNIA FOR OFF/CE USE ONLY
stn o evelot Corporation rp RECEIPT NO. I PERMIT r
OWNER /', • r7
ADDRESSMAIL n 419 E. 17thtreet �T - [ RECEIVED TY,�I DATE RECEIVED n1�ATEI Su D
CITY NCosta Mesas Calif.Cli TEOLLI 81159 BUILDINGU //"-1 L(/ !7 ,II uV 2 O �y54
Uarlson &
• ARCHITECTlr .t� LIC. COSTA MESA, CALIFORNIA
OR ENGINEER Middlebrook NO.
Jam/ A
ADDRESS Garden Grove, California FIRE l,,'
Dike & Colegrove, lnc. STATEZONE TYPE GROUP (A/Jy
CONTRACTOR ea.. LIC.NO. 1672931/ APPROVED DATE
ADDRESS 419 E. 17th Street, Costa Mesa ZONING
LEGALLOT 3378 LONE LI I NO.OF USE OF NEW
' DESCRIPTION I 10 I NO. I TRACT �`y J
BLOCK PLANS /^7j"SUILDINNG�wf Q�, 9_
BYPROV ED',/ L� 1 //0 DATE/1'5"--5-9
' SIZE 71'x 901 I NO.OF BLDGB.None YARDS �C/ O' �Oj/
OF LOT Now oN Loi REQUIRED '�ALLOWED
USE None OF (CENTER LINE ST.)
EXISTING BLDG. None
FRONT e//ST�
. FT. N.
SETBACK LINE FROM 45' 22'
CENTER OF STREET REAR YARD ` R.SIDE LS--;'FT. IN.
SIDE YARD LEFT 5' RIGHT 5' L.SIDE ..ST. IN.
DESCRIPTION OF WORK --�
X
, REAR ✓_FT. IN. y
NEW I XII ALTERATION I II ADDITION I
REPAIR I II MOVING I II DEMOLISH I
SIZE NO.OF (
BUILDING 1001 ROOMS STORIES 1 `
EXTERIOR WAL4uee0 ROOF
COVERING �I� COVERING shake
tiq
OF
], BUIL INND WORfC TO BE PERFORMED
Single fC=amilySresidence t
attached garage Plan Xy50Y
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
BUILDING CONSTRUCTTIIO�N. VALUATION L
'. SIGNATURE OF 2- PERMIT FEE $ 36.00
PERM ITTEE /-
$ 16� . PLAN CHECK $ 18.UU
AUTHORIZED AGENT Dike & olegrove, Inc. V 1.
TOTAL FEES 54•U0