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HomeMy WebLinkAbout271 ROBIN HOOD LN - Building Permits • CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER rficia PERMIT B02-01546 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 271 ROBIN HOOD LN Status: ISSUED Suite: Applied: 09/24/2002 Vicinity: Issued: 09/24/2002 Parcel Number: 42621305 Zoning: Applicant: VIGIL, DON ISSUED BY: / _ Address: 4762 WEST 137TH ST7.7 UNIT B Phone: 310-679-7726 HAWTHORNE,CA Zip: 90250 Owner: WOLFE, JULIAN R Address 271 ROBIN HOOD LN Phone: COSTA MESA,CA Zip: 92627 Contractor: D L V CONSTRUCTION Address: 4762 WEST 137TH ST UNIT B Phone: 310-679-7726 HAWTHORNE,CA Zip: 90250 License: 213199 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT REPLACEMENT OF 10 WINDOWS(SAME SIZE; NO CHANGE IN FRAMING)IN A ONE-STORY SFD. NO OTHER WORK AUTHORIZED WITH THIS PERMIT. • FEE SUMMARY Plan Check: $0.00 Calc Valuation: 55,000.00 Permit: $111.25 Claim Valuation: $5,000.00 SMIP Res: $0.50 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $111.75 PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days,or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(WOO) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: O I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the ork for which this permit is issued. I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: .< ) Carrier: n T,-r" I//✓D PolicyNumber: i -' J �fi �p (This section notbe temple ed if the permit is valued at one hundred dollars($100)or less.) i ❑ 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 become subject to the workers' compensation laws of California and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. --- A Applicant Signature: YO L.4.-...._..... L_ Date: “� O WARNING:FAILURE TO SECURE WORKERS'COMPENSATI COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIM PENALTI AND CNIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000),IN ADDmON TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Profess ns Code,and my license is In full force and effect.Lk.II .• Class N 13— Contractor's Signature: de _ _ - L. • Deter 2G,r. -._- ‘.2_,,7 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). O I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Wit the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Flre Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.__ r..f _...__ ..—._ ..._ .__._ _ 3 Does or will the applicant or preseentt oor future b building occupant nee_d to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous-materials)? ❑Yes ❑No (Section 25534 of the Calif omia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aggermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes J No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If'yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No ` _ ____ 8 (If'yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) Date l.7 - And/Or Authorize Applicant L ( Date ...__._ CODAL INSPECTION TYPE PATE MAC CODE! Itl$PECTIONTYPE PAIL ItCMALe 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site , 204 Final Demolition 250 Final Building/Occupancy ©i art? er, ;;- u • CITY OF COSTA MESA BUILDING DIVISION ,.,,, I DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER mntmr, PERMIT IPA 1602.01545 (714)754-5273 • Fax(714)754-4856 • www.d.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 271 ROBIN HOOD LN Status: ISSUED Suite: Applied: 09/24/2002 Vicinity: RESIDENCE AND ATTACHED GARAGE Issued: 09/24/2002 Parcel Number: 42621305 Zoning: Applicant: VIGIL, DON ISSUED BY: Address: 4762 WEST 137TH ST UNIT B Phone: 310-679-7726 HAWTHORNE,CA Zip: 90250 Owner: WOLFE, JULIAN R Address 271 ROBIN HOOD LN Phone: COSTA MESA,CA Zip: 92627 Contractor: D L V CONSTRUCTION Address: 4762 WEST 137TH ST UNIT B Phone: 310-679-7726 HAWTHORNE,CA Zip: 90250 License: 213199 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT REROOF:T/0 EXISTING ROCK ROOF,REPAIR SHTG AS NEEDED,2 LAYERS 15#FELT,APPLY"20=YEAR COMP SHINGLES."PITCH APPROX 3:12 28 SQUARES • FEE SUMMARY Plan Check: $0.00 Calc Valuation: $5,000.00 Permit: $111.25 Claim Valuation: $5,000.00 SMIP Res: $0.50 SMIP Corn: $0.00 Other: $0.00 • Inspection: $0.00 Total: $111.75 PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days,or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 . 244646(&00) DECLARATIONS 1' WORKERS'COMPENSATION DECLARATION: I hereby affirm under penally of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the ork for which this permit is Issued. I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: pp Carrier: 477C roi0 Policy Number: / Io`I� Qrci—a.� (This sect/on need t be leted if the permit Is valued of one hundred dollars($100)or less.) ❑ 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 become subject to the workers' compensation laws of Califomla,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these�provisions. ^ • Applicant Signature: N �/`- — Date: --- 1--h-j ,-- C.3 _ WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COV GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# 0- (9)1/4,17 2)1\q7 Class# /3—/ Contractor's Signature: CD. v` Cy:--40:--40q Date: t . .7`f 0 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Cade). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business end Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of properly who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-properly tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,Califomia Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes d No (Section 25533 of the Califomia Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the Califomia Health and Safety Code been fully complied with? 0 Yes 0 No ... _ ___ ructIo...o_.... 5 Does or;rill the applicantsAirou present or future buildingsoccupant at y other for the work which district the subject age c this application apermit for such oonstru<llon or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? �Yes LI No (Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? 0 Yes ❑No 8 (If'yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) Date CT - 9-7e And/Or Authorized A 'cant Dale CODE I, I)ISPECTIONTYPE DATE MEOW CODF( DISPECRON TYPE DATE EOM 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof /o -3O'd L 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy _ _ F r7- a'- s-el L COSTA MESA BUILDING DEPARTMENT FINANCE DEPT. P.O.BOX 317 COSTA MESA, CALIFORNIA ',M' - nr "ricin OirsA FOR APPLICANT TO FILL IN APPLICATION FOR PERMIT AADDESNS BUILDING 271 Robin Hood Lane COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY RECEIPT NO. p TTJ{([Vv�=O9 OWNER Sherwood Forest Deve)npnrs L'i rOJj MAIL RECEIVED BY DATE RECEIVED DATE ISSUED ADDRESS 3700 Newport Blvd. -Iyj 732 ]-a-/—S AUG 441155B CITY Newport Beach TNo. OF.3-1240 BG ADS OR ENGINEER Raymond Levannes NO. C-747 COSTA MESA, CALIFORNIA FIRE ADDRESS ZONE , ION[ NO.OF �y�, GROUP CITY LIC. lT�� PLANS /'T -7-4/1111 CONTRACTOR Lido Construction NO. 7520 U/fL' Y// TEL. ��n APPROVED ADDRESS 3700 Newnort Blvd. NO. OR's-12u0 BY DATE LEGAL LOT CORRECTIONS DESCRIPTION NO. 5 BLOCK TRACT R9 A.P.NO. JJ• SIZEo NO.OF BLOCS. OF LOT 79' X v0' NOW ON LOT none USE OF 11 EXISTING BLDG. SETBACK LINE FROM CENTER OF STREET 451 REAR YARD 311 • SIDE YARD RIGHT 51 LEFT 5' DESCRIPTION OF WORK i NEW ALTERATION ADDITION • REPAIR MOVING ' DEMOLISH BUILDINGNO.OF SIZE 1672' ROOMS STORIES 1 EXTERIOR WALL ROOF COVERING .StUCCO COVERING Rock USE OF BUILD NGEW Dwelling ciLL. t.ciia 4 OCi sq. 21. I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND •AGREE TO COMPLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING BUILDIN CONSTRUE. TION. I . I I VALUATION `6 1 PERMIT FEE ¢L./;,/ SIGNATURE OF / PERMITTEE _ . _ - I S//e 733. 3 ALAN CHECK S/2 AUTHORIZED AGENT 1G / TOTAL FEE Sic y Jim: COSTA MESA BUILDING-SAFETY DEPARTMENT G d 2.(c CC, CC, R 0.BOX 317 COSTA MESA. CALIFORNIA E INPINCE [SEPT. cSA FOR APPLICANT TO F/LL IN COMPLETELY APPLICA�TION�FOR PERMIT �/TYPEnO^Rn PRINT �, BUILDING ADDREISS 2 / , /I�SJI/�/7V0p ^^.•/ �r COSTA MESA, CALIFORNIA FOR OFFICE USE ONLY OWNER ,ru.UA-v WdGFc RECEIPT NO. 1b24--13 ^ _ 4.13TL�NO. MAIL /J�/ j7a /J .•`/ RECEIVED BY PATE RECEIVED 111Ve i`DJ'tAETE ISSUED ADDRESS �/ ,J RO.6''-r#Olp �-in-r' 1- 2-‘-'S i CITY G Ds/fJ , `V.^/ TEL. N O. BUILDING ADDRESS ARCHITECT LIC. COSTA MESA, CALIFORNIA OR ENGINEER _ NO. i- �j' QQQ - FIRE ADDRESS )� // ZONE TYPE /ZT GROUP CONTRACTORireA- CR/Cl�i(/41S LICTNO.Mao APPROVED DATE ADDRESS /02 72 ISfl2 � LW GAR. &4'4'6 ZONING �J • LEGAL 32F� ZONE I NO.OF I USE OF NEW ag �4/ DESCRIPTION NO. ...5- A.P. BLOCK TRACT /N/y/�E+/�(�II/ // . /- • PLANS BUILDING A.P.NO. f--O / S �� (j[ APPROVED �//// A /, !/ BY �/J DATE /C-G / SIZE NO.OF SLOGS. YARDS EVES OF LOT /� NOW ON LOT REQUIRED ALLOWED EUSE OF XISTING BLDG. Rf S (CENTER LINE ST.) +� FRONT S (/ FT. IN. SETBACK LINE FROM _ CENTER OF STREET • REAR YARD ` R.SIDE - / FT. IN. SIDE YARD I LEFT ' 0 I RIGHT L.SIDE .---'10-1. FT. IN. DESCRIPTION OF WORK . REAR )S FT. IN. NEW `,IryI II ALTERATION I II ADDITION REPAIR I II MOVING I II DEMOLISH I BUILDING NO.OF SIZE ROOMS STORIES EXTERIOR WALL I ROOF COVERING COVERING USE OF BUILDING AND WORK TO BE PERFORMED 4( a B- n ck 6.4.QbthN Iv/ltb./ 6 ' 11I6H. 6'27 i (041 . 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 CONSTRUCTION.JVALUATION SIGNATUREEOF/L...41 ^ PERMIT FEE $ a?. OAC PERMITTEE // ✓✓✓ $ /41/ p0 PLAN CHECK $ AUTHORIZED AGENT TOTAL FEE $ el—r"\ �•