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Home My WebLink About1719 SAMAR DR - Building Permits CITY OF COSTA MESA S e'er 9 • BUILDING DIVISION FA �IpP$ 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us ‘i. Ira ? FOR INSPECTIONS CALL: (714)754-5626 PERMIT NUMBER. BC07-00163 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: RES ALT DATE ISSUED: 08/08/2007 ISSUED BY: SOK JOB ADDRESS: 1719 SAMAR DR CM Suite/Unit: APN: 13927308 Zoning:R1, , Vicinity: REAR YARD Primary Occ: 7 Const Type: V-N SQ. FT: 300 Valuation: $37,720.00 SCOPE OF WORK: 300 SF ADDITON AND INTERIOR REMODEL OF SFD.WORK TO INCLUDE: EXTENSION OF (E) MASTER BEDROOM WNVALK-IN CLOSET AND INTERIOR REMODEL OF 3 (E) BATHROOMS-(EL, MECH AND PL WORK). EXISTING 3 BEDROOM, 3 BATHROOM SFD TO REMAIN. OWNER: JUGE, RICHARD W Ill Address: 1719 SAMAR DR Unit: Phone: 714-556-7494 City/State/Zip: COSTA MESA,CA APPLICANT: GRADY RABORN Address: Unit: Phone: 714-469-3032 City/State/zZip: _- - CONTRACTOR: GRADYS HOME IMPROVEMENT License No. 542146 Phone: 714-4693032 - Address: 19301 SALMON LNUnit: Cell: City/State: HUNTINGTON BEACH, CA ZipCode 92646 ARCHITECT: WARREN C PITT ARCHITECT License No.C13718 PHONE:714-963-9337 ENGINEER: License No. PHONE: COMBINTATION PERMIT FEE SUMMARY Building Plan Check: $339.98 Building Fees: $523.05 Electrical Fees: $165.00 - - Mechanical Fees: $51.70 Plumbing Fees: $136.35 SMIP Residential: ' $3.77 SMIP Commercial: $0.00 TOTAL FEES: $1,219.85 "Refer to lee receipts for all fees paid for project 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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. 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. CODE INSPECTION TYPq DATE IN1mALS CODES INSPECTION TYPECAE IN111IALS 1618 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final BIocldRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site f ''' ''---' ') 204 Final Demolition 250 Final Building/Occupancyrw ot(4 K ai/Olt E/�y�.34�r WORKERS'COMPENSATION DECLARATION: Owner ID verified by dri nse. ❑Yes D No I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires: • Q I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed): compensation, as provided for by section 3700 of the Labor Code, for the . performance of the work for which this permit is issued. • ❑ I have and will maintain workers'compensation insurance,as required by DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: 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 0 I hereby certify that no excavation five(5)or more feet in depth into which a number are: person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,ar demolition Carrier: or dismantling thereof,will be more than thirty-six(36)feet high. (Chap.3.2.Grp (This season need net be completed dthe pert is refired et one hundred doears(S100)or less) 2,Art 2,Sec. 341,Title 8,Califomia Administrative Code). Policy Number: ❑ As owner-builder, I will not employ anyone to do work which would CJL _L.certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division. to the workers' compensation laws of California. and agree that if I should become subject to the workers' compensation provisions of Section 3700 of Applicants Signature Date the Labors ,I s a rthwith comply with these provisions. C'P 'O 7 Division of Industrial Safety Permit Number: t Applicant's Signature . Date -- _ HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No ($100,000), IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEY'S FEES. 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 LICENSED CONTRACTORS DECLARATION: 500 pounds. or a volume of 55 gallons,or 200 cubic feet of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure). with Section 7000)of Division 3 of the Business and Professions Code,and 2. Does or will the applicant or present or future building occupant need to file my license is in full force and effect. O Sr 7 Q a registration form for acutely hazardous materials? 0 Yes 0 No Lic.# (Class-# i (Section 25533 of the California Health and Safety Code, with some _ _ / exceptions, requires registration with the Costa Mesa Fire Department by e�G�----� �'Y" 7 each business which at any one time has on hand a quantity of acutety els Signature . /__Date 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 CONSTRUCTION LENDING AGENCY: temperature and pressure). L] I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? 0 Yes CINo (Section 25534 of the California Health and Safety Code provides that the Lender's Address: 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. Signature Date 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes 0 No I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the Califomia Govemment Code requires that the requested that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits). 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 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes 0 No applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes', the facility must meet the requirement of Sections 25534 and 42303 five hundred dollars(5500).): of the California Hearth and Safety Code). ❑ I, as owner of the property,or my employees with wages as their sole 7. If a permit from the South Coast Air(Duality Management District or other compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the offered for sale(Sec.7044, Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by California License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No thereon,and'who does such work himself or herself or through his or her own 8. (If es", attach certificate of compliance from theappropriate air employees, provided that such improvements are not intended or offered for . Ppollution Sate. If, however, the building or improvement is sold within one year of control officer). completion, the owner-builder will have the buiden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the did not build or improve for purpose of sale.). . information given above is correct. I agree to comply with all state laws and ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding,Hazardous Materials and Emissions. LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of Signature Date property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that 0 I am exempt under sec. the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of Business and Professions Code for this reason: 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. u of er(s) Date Signature Date //ry JR-S---07 3057-46(3/07) �/� -• el r Autnonzet Applicant (Date OA A ' M CITY OF COSTA MESA . I III BUILDING DIVISION F1 ,1 DEVELOPMENT SERVICES DEPARTMENT PER NUMBER i PERMIT • ti, 03-01621 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.�UILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 1719 SAMAR DR Status: ISSUED Suite: Applied: 09/24/2003 Vicinity: ROOF • Issued: 09/24/2003 Parcel Number 13927308 Zoning: R1 R1 Applicant: JEFFREY PELLICIO ISSUED BY: _ Address: 1653 SUPERIOR AVE 1, Phone: (949)642-7222 COSTA MESA,CA Zip: 92627 Owner JUGE, RICHARD W III Address . 1719 SAMAR DR Phone: COSTA MESA,CA Zip: 92626-3629 Contractor: LEE ROOFING OF COSTA MESA Address: 1653 SUPERIOR AVE Phone: (949)642-7222 COSTA MESA,CA Zip: 92627 License: 349686 Arch : Eng: Address: • Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT TEAR OFF EXISTING ROOF.INSTALL 7/16.OSB,301$FELT UNDERLAYMENT,30 YEAR CLASS A,COMPOSITION SHINGLES.35 SQUARES FOR RESIDENCE ONLY. FEE SUMMARY Plan Check: $0.00 Calc Valuation: $7,500.00 Permit: $153.25 Claim Valuation: $7,500.00 SMIP Res: $0.75 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 • Total: $154.00 r / 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 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 2448-48 WOO) f 1 / WORKERS'COMPENSA ION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: S 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 work 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'compensate n�su�ra/nce carder and policy number are: �j D Cartier. �& ku Policy Number: 7(J ifTh ; (This section need not be completed U the permit is valued at one hundred dollars($100)or less.) 0 I Certify that in the performance of the ork 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 Calif. ia,an gr that it I should become subject to the workers'compensation provisions of Section 700xof t e Labor Code.I shall forthwith comply with Nese provi4i•.( — / - � Applicant Signature: t Date: /�/ ,,I WARNING:FAILURE TO SEC N- •- ERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMIN PENALTI S AND OVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,•... IN ADDMON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: thereby affirm that I am Iicerd914n le•'revisions of Chapter 9(commencing with Section 7000)of DMsion 3 of the Busingss a 1 rof 'Code,and my license is in full force and effect.Lie.ft ' l Q r I/ Class a (7 s 7 Contractors Signature: / Q/M/0/01" Date: //(,/ CONSTRUCTION LENDING AGENCY: O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Soc.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 live hundred dollars($500).): O 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 Ucense 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.). - O I,as owner of the properly,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors Ucense 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 drivers license. 0 Yes 0 No Drivers Ucense No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: O 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). O 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 preseQnt 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 U 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 lime during a reported year a quantity of hazardous materials equal to or greater then 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 Io file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health end 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 sr will thet needo p applicant or present or future building occupantrepare an RMPP(Risk Management and Prevention Program for acutely hazardous materiels)? 0 ❑Yes No (Section 25534 of the California Health and Safely 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 SafetyCode been fully complied with? 0 Yes—in No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a emit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 0 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? 0 Yes 0 No 8 (If yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penally 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 propertyGfor �inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Jit •n•rOr Authorized Applicant Date CODE. INSPECTION TYPE 2611 BMW CODE! INSPECTIONTYPE 261E =al 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final /I •d--- 208 Final Plumbing 200 Final Re-Roof Z- 7-nG 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/Occupanc-y 4.0!-- "'Fsy CITY OF COSTA MESA }j7 • - , ,\1�a P.O. BOX 1200 • 77 FAIR DRIVE • CALIFORNIA 92628-1200 ii)tu l L JDEVELOPMENT SERVICES DEPARTMENT. BUILDING DIVISION COURTESY NOTICE OF PERMIT EXPIRATION January 27, 2006 Richard W Juge 1719 Samar Dr Costa Mesa CA 92626-3629 PERMIT NUMBERS: B03-01621 FOR: Re-roof PROJECT ADDRESS: 1719 Samar Dr., Costa Mesa Our records indicate the above listed permits were obtained for property improvements or alterations at the above address. Per the 1997 Uniform Building Code, Section 106.4.4 Expiration, permits are valid for 180 days from the date of such permit, or the date of your last inspection for the project and additional fees will be required to finalize expired permits. According to our records, the permits listed above have not had an inspection for a period ` exceeding 180 days. If you have a signed inspection card indicating an inspection was conducted within 180 days from the date of this letter, please contact this office so we may correct our records. If you need to request an inspection please call our Inspection Request Line at 714-754-5626. If you wish to request an extension, requests must be made in writing addressed to Ed Petros, Chief of Inspection, at the above address, detailing circumstances and listing an estimated date of completion. If you do not have an approved final inspection, your permits will expire on February 10, 2005. If you have any questions, please contact the Building Division at 714-754-5273, between 8:00 a.m. and 4:30 p.m., and a staff member will be happy to assist you. The accuracy of records affecting your property is our goal and we appreciate your working with us to resolve this matter. Sincerely, Mary Jane Weidenkeller Office Specialist II cc: Lee Roofing of Costa Mesa 1653 Superior Av Costa Mesa CA 92627 Building Division(714)754-5273 • Code Enforcement(714)754-5623 • Planning Division(714)754-5245 FAX(714)754-4856 • TDD(714)754-5244 • www.ci.costa-mesa.ca.us 11289 FEE RECEIVED COSTA MESA BUILDING-SAFETY DEPARTMENT JAN 211960 P.O.BOX 317 COSTA MESA. CALIFORNIA FINANCE DEPT, d U FOR APPLICANT TO f/LL IN COMPLETELY APPCJIcP m qnsfACTUAERINIT TYPE OR PRINT BUILDING BUILDING ADDRESS 1719 Samar Drive COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY OWNER Kenkol Development Co. , Inc RECEIPT NO. �a ( �I G. MAIL 1555 Placentia RECEIVED BY DATE RECEIVED 1DATE ISSUED ADDRESS 1 L.-,` I /-O2/(.,OI dHN $ 1 WW.) CITY Newpor6 Beach Ta.. LL227 BUILDING SS ARCHITECT LIC. OR ENGINEER NO. COSTA MESA. CALIFORNIA FIRE / q' ' ADDRESS ZONE TYPE GROUP V CONTRACTOR K.W. Koll LISTATE 61195 APPROVED BY DATE Newport ADDRESS 1555 Placentia Beach ZONING ZONE NO.OF USE OF NEW LEGAL LOT(} 3 9I DESCRIPTION NO. BLOCK lHl ,,� / PLANS �/Y BUILDING NEN/Vie 1/. A.P.NO. APBYPROVED W t V' y �).�I ) DATE A, CJ�� OF LOT 71x100 irre I NO.OF BLOCS. 0 YARDS (j� //� EVES/ _ a��n 4 NOW ON LOT REQUIRED ALLOWED USE OFnone (CENTER LINE ST.) /� EXISTING BLDG. FRONT LOFT. IN. ' SETBACK LINE FROM C 0, REAR YARD 21 CENTER OF STREET J R.SIDE 7 FT. IN. LL, `'. SIDE YARD LEFT 5 1 I RIGHT 91 L.SIDE ✓ FT. IN. DESCRIPTION OF WORK -`/ IN. REAR ^ NEW I XII ALTERATION I II ADDITION I REPAIR I II MOVING I II DEMOLISH I B BUILDING 1840 sgf'�BpOOMS 7 WSTORIES 1 COVER NG WALL Stuc VOERING mingle USE OF BUILDING AND WORK TO BE PERFORMED Single-Family Residence and Attached Garage I HEREBY A 'OWLEDG THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE AND STAT HAT THE 'OVE IS CORRECT AND PEE TO COM. PLY ALL C Y O-•INANCES 8 ATE LA REGULATING PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. SO]LDIN mN. CONST C •N. L04_, VALUATION SIGNATU OF ^ ^- - PERMIT FEE $ 3 `, PERM W' cal . $' /� 9� /p r PLAN CHECK $ .[�/p . AUTHORIZED AGENT TOTAL FEE $ L 7 —