HomeMy WebLinkAbout128 SANTA ISABEL AVE - Building Permits Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
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I-CITY'OF'COSTA MESA•'- ; -( : t PERMIT NO. ' •TRACT NO. LO NO. •BLDG.NO. 1 (-^ • _ . "- --.. ,
;i CONSTRUCTION PERMIT - e - ' •_ 1 I ..1 „ '• : ,", I . 1 ,. : y' • w 1 I x , , I,,.
BE/�-� ' ���.5 I ; I ; - -3[Jet7 13%0'111/831 ', 34'.00 It
Applicant's Mailing Address '-S ' - ' ' /i •TYPE OF CONSTRUCTION : ; U NEW U ADD' ALTERATION 'U(REPAIR r, - - I ' i cu 1 I .' ! C I
i Project Address- '- 1. r-/' - is ' Ce _ "¢ ❑ CONVERSION ❑ DEMO ISH‘ ❑.OTHER•" ' • • 1 -t ' •_ - . - ': r . ' _ . j .? ' 1.. - . 2 . '
DESCRIPTION OF WORK 'DQE G ' •�6�
tQwner's Name ' Ta4 en'oP ✓-- -Phone C'✓GSI p'1 �� " ' = , ^ r. ' _r sls `EGULATIa I
4 . 012 • L . '- O: '.oL_-�I�'" � ?
Address -.Z ISS�' r r S ?I7 u c' ,p • I 'i J d 7 • 7 • .o'
• s. Ir r . C ,- TYPE OF PERMIT/ ,GRADING '� FOUNDATIONr�y M,STRUCTURAL ' - -3.4.13...-.- W.— .ZONE
' Arch/Eng. i I I - License No, P ❑'TENANT Led ELECTRICAL ❑'PLUMBING Lvl MECHANICAL t C t rt PLNG. REF.*. , i '• r ;BUILDING' .I •• 1
! 1 • ,- 1 i - i. I _ , - 'crTnnrr rn--c1- '
I D I '- - r - ,- i ,t 4 I r'I . i i- _ •
Addr@ss, r I - 1 '` O,OTHER .. i - _ I 'TO BUILDING . { ' = I '.REAR VP.RD ISO P/U •999- i • ^ If ''
o ' TROPE RTY LINE • •
. Contractor's Nemn �) /I•¢ IA;a r I •Phone C�t!G t: <PRO.IECT DESCRIPTION SG.FT.' 'oCCuparvC7 ' -�
f - „ 1 i I - ' / i ,LEFT SIDE YARD RIGHT SIDE YARD F l - �,.
• CONSTRUCTION TVPF 1L- VALUATION$
Address(mailing) - - ' ) 1 • = , I
• ) , , ZON)= - GRADING CU.YDS.' - • ACRES PKG.SPACE'REQ. 1 PROVIDED $ I i I ,_
License No. - __ .-. . . - -
LICENSED'CONTRACTOR DECLARATION - - , " Remarks: // n� .STREET WIDTH ' 2- 'PARK FEES .- ' ' I ' Ig:
Thereby affirm that I am licensedZunder provisions of Charter 9 (commencing _ �� � J�,�U, M' � �� _ + / •- P
wit h"section 7000) 01.Division 3 01 the Business and Professions Cotle,and /' SPECIAL CONDITIONS: I I lis 4 L ' a)
my license:la In full force and effect, { _ 1 I I 1 l 1 �� - �� I ' n - 1 c 1
1 License Class - • - License No.' ' _ ! i i I ' i 1 PLUMBING - i i i I 1 ' I '. - - ;it !I.
Data ' Signature ' ' - j Bar Sink ' Sewer Cap. • I - ELECTRICAL ', .
WORKERS'COMPENSATION DECLARATION ' j
, - - - - -
; I hereby affirm that I have a certificate of consent to self-insure eor ra certificate - ` i ' i Automatic Washer •Meter Dover 100 amps-- -
of Workers' Compensation-Insurance,:or"a'certifietl copy thereot-(Section Backflow PrB've0ter-_ ),__.y, _ _$eNRr Connection ! { _. ,_
Construction Pole .Sub Panel ` , r:
3800, Lab, C:) I i S ' } 1 ' i I Baekfloev Irrigation 3 Solar Collectors { - • ' " •
Policy No, 1 • Company I • ' l Cookm9 Umt j Sub Pole . ` '
'r, 8I ', Bathtubs ' Solar PiPing `I I i i i •. j + 1 ! i I
Certified•copy is hereby furnished. P 9 '
Certified copy Is filed with the city:Building Division. , `• , , j • 1 • ! � I •'~ Dishwasher I ' Motors ❑0-1 HP 011/4-6 ' j
Date '' 1' Applicant ' I ' Clarifiers , Solar Tank , !'
EXEMPTION:FROM WORKERS'COMPENSATION'DECLARATION '- Dish Washer 1 Swimmin POO(W/Sp2° ''-' Dryers ❑Gas, ❑Electric..«_ Inc Solara❑9-15 HP ❑1515+, 4.,---.L '
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(This section need not be completed if the permit is for,one hundred ($100)or ' ) 1 - g j ; I Fan j .Microwave ( ' I
' Ilecertify.that in the performance of the work for which this permit is.issued I i Drinking Fountains Urinal- ' , + - ' ,�
shall°not employ any person in any man�f/so'as t become subject.to file , j• F.A.U. I j 1 Pole''Light j ( •fit ! {
WorkeR�,Co pe Ion:Laws of CaliforNa , , - , . Floor Drains 1 Water Closet} ( I '
Date; {/a �f ! Signature td ,.e4c1' Lfr-ti�14 • •1 Fixtures • r } y i ,
NOTIC€:.If,;after,making this declaration,you should becomes ect to the ti - Floor Sinks 1 i W Water Heater, I - 'Range V ,
r"Workers^ Compensationprovisions of the Labor Code, you•m st forthwith • " , -"-' -"I y "; - `" - •
comply with such tprovisions.or .this permit r shall1 be;deemed, evoked:. I - / Gas Service[ ; :Outlets Water Service •' ' •} Oevice Boxes , { • Sign,gnding Sections ! 1 •
P
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' CONSTRUCTION(LENDING 'AGENCY-. ` ' •
I hereby affirm that'there is a-construction lending agency for the performance I I Interceptors - y' ' i • ' ' I
of the 'work 'for,.which this permit cls ,Issued' (Section 3087. Civ. 0.)' - , - , - - Switches .
1 c ' + - I - > t I 'Trash Compactor ' I { I.
Lender's, Name' - I - Kltthen-Sink; _ x t I I , j { / '7� +
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Lenders UILDE f '/4 N� ` t " i ' - • r ! i Garbage Disposal i ; 1 i I I
OWNERSBUILDER DECLARATION a 1 I e , I - ' , I i 12vatorjes i 'y , r- • C" + -4. , l-: i +: •
I hereby affirm Shat I amt exempttfrom the,Contractor's''License Law for the' - i a -- , , • , _ 1 , Generator ❑0-5 KW ❑5-15 KW ' I I I I • 1
following reason;(Section-7031.5',Business and-Professional{Cotle: Any city or. P ,Trap, jr I c l cr s, I f' ' '
',county which requires a permit:o construct,alter,improve;demolishlor,repair ) ,. . . ) • Transformer 015-$0 KW 70; I 1 '
,any structure; prior to its issuance,also requires the.applicant for such permit , Roof,Drains i ' , • ,y 4 I , , 1 `�O� j
to file a signed statement,that he/she is licensed pursuant to the provisions of • - - - _ ❑50+ KW/ ' 'Reinspection•Fee I j
' the Contractors'License Law,(Chapter 9(commencing;withiSection'7000)of • ; t' 1 1. I '' I - .i i " ' •Reinspection;- IF. ' 1
'Division:3:of the/Business and Professions Code):or,that he/she, is,ekempt Showers „ C _ spa _ I $15 ,
• therefrom.and the:basis for the alleged exemption:Any violation.of,Section - . _- s - - ' - - / Meter Dula to 100 amps . !Issue Feel . i : '$ 3. I
,70nalty of not mo applicant
five hundred dollars mom.,ects 'i
;applicant "to a.civil I• Service Sink - 1 Issue Fes,' I $ 3 I.
Li • • ' I .. 'Zoning Approved By G ' 'Date __.•. L/1
pe sown, ll; the work, or: structures with intenf sole I i ,
: compensation, wilb tlo the work,and the structure is not intended or offered ! ' e ` ' MECHANICAL t ; ' - ,
- z I 1 _ _ Application Approved By Date -
for sale:(Section 7044', Business arid;Professional Cotler:The:Contractor's - - " -- - - - -- - -
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" License Law does;who'does/apply to.an owner of a grope or o his or improves I , •Boder, ; `; I '` I i i : Refrigeration System j - 1 Appjication Issued By I - ! ' 'Date
thereoyeeand;who'doesl such work-himself/herself or through his or her own i - i -
e it, es, ever,provided that such Improvements issolt intended or offered for { 000.100,000 BTU 0100,000 BTU'. , , ) ,
sale. If, however,the building or improvement sold within one yeanof com- j { Ductc,under,Ground 1 i _ i , . r 1 I , ' SUMMARY OF FEES ! ,
rect�plat n, the ownerowlll have the burden of proving he/she did not build or in•- i ' , ,S-0
r e purpose of sale). : r I I- ,..s / 1 1 . Duct-Structural i i 1 i System Repair/Alteration _ IBUILDI NSG PERMIT $ �i!•S� SMIP I $
a wner of the property,am exclusively contractinglwithi licensed con •-
onstruct the project (Section 7044,Business and Professions Code: 1 , Duct-Ventilating t I ; 1 ' i I I I • i PLAN CHECK. $ - , PERMIT 1 i i I i
-The Contractor's License Law-does-not-apply-to an•owner-of-property who-- 1 1 _ _ _ , ' I ISSUANCE $ 1 '
builds or'improves thereon,and'Who contracts for such projects with a con- I. Exhaust System 0 Multiple 0i - ' I 1 'PLUMBING $ ' 1 l I f
tractor(s)license pursuant to the Contractor's License Law) I , i 1 GRADING I 1 $ i'
i ' 'PLAN CHECK' $ i
❑'.lam exempt under Section • B,& P.C.for this reason Firepl/Fact.Bit. (CBO# 1 i j I 1 f f $ 1 1
15f,{ yA_i' i • 9 Y g i i I i I !ELECTRICAL } $ .� 1 '
Data Owners z"=�( ay-s- �!i� ' / Heating System&Ducting + ( ; O C j MICROFILM + $ ( I i
T• - ,e' - PLAN CHECK 1 $ I 1 i
(_hereby certify. th I,have"read.this application an state that the above ❑6100,000 BTU 0100,000 BTI. ! 1 i t
information is<or�a Lagree n • ply with all city-and y authorize
. ' " ' -'.f—_i.� -I ' Q� ( TOTAL FEE , $ ; -
'MECHANICAL $ , . I i j
and".state laws r-•IT'ng•t• •• •'ng construct)above- hereby authorize repro- ` H'ood Or T e I ❑ i , ' ( 1 , I ,
inspection
of! city} • e err upon the above-mentioned :property for { 1 yP 1 ' Reim eetion Fee g{r/ I LESS t.
Inspection Dur:• e 4 - ' j Canopy .Type II a I r ' p, f i :'"- 'PLAN CHECK'. $ I
Signature 1 ' f . • sate _ • I 1 i t ADVANCED PC = $ L, •
r I � I , ' •• Registers ' I I i i Issue Fee $ 3 I t s 1 •i I i •FINAL'FEE i $ ! 3T.•� . •
o Drivers'License or 55 . ' I i if : I
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CMF 0865-46'rev,12/82 -White reuliding;Canary=-Applicant;pink=3Accountln9;GOlden'otlf-'Assessor ' -''' --: `- -' " •1 ---- . -. ,- • - - •---, - - -• --•-t-- - -- "- . "-
2 ryCONSTRUCTIONANDPLA ING �r 't��=o -' ' :C^ `.r -:gin y'r- POOL :7&a4 _ t y-.., a rl H ,- I :
- c -' :bE4'�1 /5:Dater ' •Inspecton • ° -.•...• -! =' 'Date• ! 'Inspector's
APPROVALS Permit# - , _ ; APPROVALS. '-Perm t,# t _
Ei Temporary Electrical Service oc Pole ; N` � •6'2 ' '52' Pool'&REquipment L`owtion}• - , F ` • ••
.•IZ t2 +So11•Pipe-Undrgrnd: - ' I. r I i �? , c , M1 . z53. SteehRernforcement -.,, , , , ,
31 , - - 1 _ ,_ I •.J i _ _r=,. - „?: '
{Electrical Conduit Utility�Undrgrnd r "g �54.'Forms,., a „- t ,
'•4.1Electrical Cond _
uit-Undrgrnd.- � ; Ti = t: =;zr _55.'Electi al Bondingc - `c ,1- .- 1 .
G.iStee( Reinforcement 1 n 4:4_ , ,.; - =56.tRogh:Plumbin &`
g Pressure Test_, _ ,
' � I I ' :-- ' I n'a 1,, ;57' APPROVAL TO;COVER=GUNITE, ' �r t':, I=i I '
6.1 Electrical'UFER Grndt 1 : - I ; i1 I
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7.1 Footings. I I I i - I l 7 'z r I •• w �° j 58.`Electrical Condmt.Undrari4:.;t• 9 I : '
8-IFoundation _ I 1 I 1 c _ ; t , 'I ' 1 `_ ,f i= '.59.:Gas Pipe, O,„Undrgind:,.Test-` - '•
9.f Water Pipe-Undrgrnd- 1 j ?it - I ' I , _ ;_'60•`Backwash,Lines P-Trap; O Undrgrnd:'
1 I `= 0 i , I ' I' 61.'APPROVAL TC+DECK = z ' ''
10.{Structural jFl`oor System , _ o ;
11.IPioperty Sewer Line & House Connection ; 1 '62.-62. Receptor Final' _ _-
• 12.ISewer"Cap1 o
I ;j 1 ! ^ I `_ 63.'.Heater & VenYFinal - •
- - _
13,I Roof Drains j , '1 , I 1 i p ;, u'm
64.tPI6ing System'•Final _ 7 -�,_ - • '
i. 14,• Rough'Plumbing' : !• . `.� ' ° --; :1:d65.AElectrical-Final' i •-- .- • =` • 7.- . I ' . • :
' `'15'.�iRoughElectrical=Conr--
duit "- I'�"{--I- f-' -'i--1 --1-1�r66.-Solai-SYsten=Finalr"--,-- -i-; - - ---.."-r, -i- - ; '
n r , t- t- c R . , I - 1"" . I
�_16:i Rough Electric Wiling ., 1 = I II a� . 'I�'' :i - :r:I r-67}-Fencing&A-L-- Approval r - " -'-,,`-- -_- _H
1N °^L m•- 1 ',__.J d r 1 5 . r 1 t s i : 1 i '< 7 ,
:-'17.',1 Rough Wiring,Sign'_ �; r t ' '•t I!" = 1'-' I ' ` ; ' T I ' ° 68 APPROVEDFOR PLASTERING ; " _ • -
.. _ •- - f. 1 1. I C , ,. ,l 1 - .1 r j ._ i,,,19..
I .. - 't .... ..-
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18.:j Rough Elecitrlical-T,,iBar Ceiling •11 ;, I' - 1 1 + ' I I 11 {69; ,POOL%SPA SYSTEMS FINAL( ` ' ' -- ! ; _
4i 19- RbougHeating&Aii,Condltloning , i ; I 13 I 11 1 FIRE DEPT: REQUIREMENT r ' IL. '
,; 201, Rough'Factoyy Fireplace! ' _ I I! I 1 I I I ( APPROVALS I Permit# ` ""'•. i {
n ., c. a " ) ,i 1 , I I I r 1 I
• 1 '21)1 Ducts;Sn:Structure n ! ! " ,i I1 j I ' I 70. Underground Hydro I I I - . r•C t 1
'','r22v`Ducts Vntilting.., 1 o i ;,-1 q II I I I I I 11 1711- Product;Piping0Gas 'DOH : , , I
1 'e
Via,. ,� a , - ac• 11 f _
(2 2a;GaslPipe_Rough&Tests 14 ` i I 1 ( j I 1 .72. Underground Flush '..11. ? I {
-24(1••Roof'Framing i I 1 c 1 e it `!i- il`v j•` I x I v I r I ,2 I z I c i- j.73. Undergrnd}Storage Tank•O Gast boo , I I f
y' it n:• - t. , , _ _ , ;
i I _ 25 Roof;Sheathin I I ia' K �'P 1 I ' 1 74. Overhead H dro = ' : i I I
--il n .g I 1 I ,.) • 711' !,. I ICi FI = I i.,, f y 1." `� I. I : I ,
t 17 26!I T Bar Celling'IStructuragl& Moriocoat ' _ I •'I - I 1 ; 1 I s 1 75. Dry 1Chemical 1 - „ A 1- . j g ' -r ! _
K. 1 e i , a r- _ ,
• - 27.ricrameand°.Flashing . ({ lS1 1 `•-P3 j 76. Dry Standpipe .. ! 7 _ I • ' ' I `• 1
1 , I c I� . �"S
:I : 28d`Lathingl&�Sldmg . _ I., I ,II I: I 1 I 1 ' ; 1 177. FIXED SYSTEM FINAL" - ,:s2• ' I ,
I 29 !.Insulation; I ..I c 1 ',dil(l' i; I I ! I', I ' !' I 178. FIREPREY. Flis-JAL r 4 " I 1 I 11 - ' 1
-i 301 Drywall:Nailing I ?- "I I VI; 1 i I I i I I I I, ' Notes: 1 I !' . ' ' i ' ' , '
i,s q
zp - , - ' - -1- - - I- j ' - - -- '--- -- '---r- - - ---r- -I
31 i`Plaster Brown Coat" ! i I j{ jy I I ! , : I 1 t i I I I I , , I ' 'i
5 ', I 1 1 •
" ' 32P.ElectricalPoweNMeter-Final( Il r _I:- I 1 1 I ; ' I ( + ' •-1
• ' 33.x-Finaal-Electric I i ; i I 1 , L I 1 I i I 1 1 I I 1 1 " I ; I
" nom__--x -- -.S._�I� � t_.. _ ._I,_ x...,. ... -6. _ -- ___I. - '- - -.. _ ! _
34, Final'Heati tocrr2
35. Final�Gas Pipe Test I " Iri �I In 0 : I- 't .r �1< , 2 �t. , _ . 1 , -
36. Hood or Ca'noPV'q ?I I r: 1 I a1 1 1 ! I - ° '
n I ' t . ,.- I I of ,. 1.. ; 1- It I- 1 I - I � � 1 � -.1 ' i .. II „, - -. ,
I! • , ..'-I ,2 , +- ; - a , c 1 C i , 1' I : ,. ,,, , -.
37. Final•:Factory Fireplace I -.1 91 R 1 a - 1" I I , , 1 1 ' , 1 , 1,,; ;-. , -=t, 7 • ,- : •
_ I :� _ - ,
38. FinalTPlumbing I I 1 I o1, f I I I j1- I I I 1 ; ' _
c - i' ,- 1 1 - 1 : , i ._ •t'. e
39. Wate� Service-Final I 1 t 1 . I1. I I ! 1 ; , , 1 1 1 _ _ ..
, , '
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40. Gas Service Final I 1 ; I ' ' , 1 i
11 i al iI 1 �, 1 , •
41. Solar dome 'I '_ 4_,L
,r . 'stic-Final! 1. ; II L_ r r. i 1-�--- 1 1 - 'd'.
42. Backflow.Preventer. I -.4. r {% '' ' i I _ I -
43. Backflowliri ati'on'--'t I ;11 • , •
44. Landscapellrrigatiion:'SYstem 'I ' I_' : i '.1.1:' l - I •`-'.I : ; ',s'}I ^' • ' I ri : . It
r r ,_•
45, Sound,Attenuation l t ' s t . I t= 1 1'- I r 1 1 I . 1 I I I 1 ., -'; ' !;
.. - " t' '!
46. Handicap Rlation
egu4 I m 1".1 �' 1*? I• I, , 1 , I 1 1 .1 I 1 i 1 . , :, r' •i "
47. FINALISTRUCTURE &(BUILDING 'S grf6I I ' ' I IF . a '
s I, t i I i i , ., . . - . 1 , ! 1 t t i,!
48. Special lRequirements Completed I 111 1 ', I I i ! I I ; I I7. y f;is , j ,
9. ElectriclReleaseto Edison ison I:. 1 1.;. -. ._ _-1--.t . __1__ _I I. _I I -I_ { _I__.r e •i. , I I : j 1
50. Gas Release tot SouthernlCalifomiaGasCo I 1. I I 1 ' I s-. -�• _ ,•< '*'
51. CERTIFICATE OF OCCUPANCY I{ L. L r._.1_._.i._j " I ' I_- " ._r '! 1
0 II j I. ! I I 1 I 1. I ` fir • I I I f I r '.i
NO + er.�a.?t_ d�n'tB r.1..:..: n'+d. z. ..,• .1-_.,,_ I.,._: __i-.:.- 1 �_.I-- _...L.,...? <. _. ---- - • . -----.._
APR 1 1 1962
OWNER ,TONES, DAVID DATE 11-1-61
JOB ADDRESS 12$__Santa Tsabel BUILDING PERMIT NO. 1763 -
GENERAL CONTRACTOR Kumar VALUE $ 300.00
AP No.119-022-02 LOT TRACT FIRE ZONE DESCRIPTION OF WORK Int.alt.to re s
INSPECTIONS Signature DATE GROUP I TYPE V ZONE R-tI
Soil SUBCONTRACTOR PE MITS ISSUED
Gas DATE NUMBER
Water
Rough Com. Refrig. 0 Air Cond. 0
Rough Heating
Rough Plumbing
o w a H-[ _L
Miscellaneous
Prop.Swr.Line 0 House Con. 0 St.Swr. [ _
Sprinkling System
Construction Pole
Underground ❑ Power 0
Rough Wiring
Trenches ❑ Forms 0 Steel Reinf. E
Floor System
Bond Beam 0 Steel Reinforce ❑
Sheathing
Frame and Flashing
Lathing — In 0 Out ❑
Plaster, brown coat
Ref rig. 0 Air Cond. ❑ Final
Heating, Final
Plumbing Fixtures, Final /14+5
Final Gas Test
Electric Fixtures, Final -
Building, Final /074C L/-/Sit)
OCCUPANCY •
FORM 6U4-5M - 7-61 i 25763
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57 FEE RENOV EI
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 317 COSTA MESA. CALIFORNIA .,.��FINANCE DEPT. (-'1 1961 UJ
For Applicant to Fill In Completely APPLIOCATCIOSNAFOR SPERMIT
TYPE OR PRINT BUILDING
BUILDING
ADDRESS 1'2.8 SA NIA ISARaI
COSTA MESA. CALIFORNIA For Office Use Only
\ RECEIPT NO. PERMIT.NO.
OWNER N l4 V 1� �1 d Irl 5S ad t").i
MAIL RECE ED BY I DATE RECEIV O DATE ISSUED
ADDRESS//6 4 U'-1 Q.flL -io 0 (����-/�///-�/ ITEL. BUILDING /E)
� f7�
CITY
l_OS`I-A aGG,A NO. ADDRESS
WJ `�d
ARCHITECT TEL.
OR ENGINEER NO. COSTA MESA. CALIFORNIA
/� .
FIRE - '-r
ADDRESS \/
ZONE TYPE syr GROUP �J`
CONTRACTOR Sg+.r' IU LVW o• APPROVES.
BY _/�.T DATE N._ / ..Li .
ADDRESS ZONING •
Z NE NO.OF USE OF NEW $hrl
CITY -' Y PLANS Z BUILDING A/7
STATE TEL. LEGAL
LIC.NO. NO. . DESCRIPTION�� �O 7-,:cUtl
SIZE I NO. OF SLOGS. (/ 9 - ° L L �- a
Z
OF LOT NOW oN LOT A.P.NO. I
USE OF ��[ 1 S+ I W G YARDS EVES
EXISTING BLDG. APPROVED ALLOWED
SETBACK LINE FROM (CENTER LINE STA
CENTER OF STREET REAR YARD • FRONT FT. 1/ IN.
SIDE YARD I LEFT I RIGHT R.SIDE / FT. `I '" IN.
DESCRIPTION OF WORK L.SIDE // 5 ' FT. N.
NEW I II ALTERATION I I ADDITION I REAR \/ FT. IN.
REPAIR II MOVING I D DEMOLISH I APPROVED ice_/ f0 DATE "#/t/c (
SBZELDING qdx (t. RNO. OF OOMS '4' STORIES I "✓LL /A� �r
EXTERIOR WALL ROOF �� 'TYPO:
Fv
COVERING Un ..Lab'c) COVERING f .
USE OF BUILDING AND WORK TO BE PERFORMEDJ
+h . Air . r
' 1 Lcc . (arr.
eo ( U Ne-- ''U&PesE
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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 Pow THE
PURPOSE OF, ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL CIORDINANCES AND ST TE LAWS REGULATING
BUILDING CONS TIf\Vj/MON. VALUATION �' GL-O
SIGNATURE OF S 1 c-f PERMIT FEE $
PERMITTEE V V"v'�� 5; /Q�/j n
$ `� `� i PLAN CHECK $ 4Y
S
AUTHORIZED AGENT q r`-'o E
1 TOTAL FEE 5 P. u