HomeMy WebLinkAbout787 SHALIMAR DR - Building Permits 11J CITY OF COSTA MESA
4
BUILDING DIVISION
. %� ,.,.,' : `r DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
1. 1 .1.."7.1 . PERMIT
J4.
„c 801-01333
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 787 SHALIMAR DR Status: ISSUED
Suite: Applied: 08/27/2001
Vicinity: APARTMENT BUILDING Issued: 08/27/2001
Parcel Number: 42405404 Zoning:
Applicant: KAISER, MIKE ISSUED BY:
Address: 928 CHEYENNE ST
Phone: (714)979-5314
COSTA MESA,CA Zip: 92626
Owner: WILLIAMS BRIAN K
Address P O BOX 15214
Phone:
NEWPORT BEACH,CA Zip: 92659-5214
Contractor: KAISER ROOFING
Address: 928 CHEYENNE ST
Phone: (714)979-5314
COSTA MESA, CA
Zip: 92626 License: 682897
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF EXISTING APARTMENT BUILDING(25 SO).TEAR OFF EXISTING ROOFING, INSTALL 30#FELT
UNDERLAYMENT,&REROOF WITH 25 YEAR GAF COMPOSITION SHINGLES.
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $3,100.00
Permit: $97.25 Claim Valuation: $3,100.00
SMIP Res: $0.50
SMIP Corn: $0.00
Other $0.00
Inspection: $0.00
Total: $97.75
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
246666(6NO)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty 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
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'fom4p,�enation I urance carrier and policy number are:
Carrier: ti Sta' \ rLk Vt c( (Policy Number: 2fl • 01 00 D /li Zr
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ll f
O 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 prov� 'isions. y a
Ant Signatures- /N 41,1 Date: O -27-0/
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLIARE($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 thet.l-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 andeffect!Lic.Mj 6 p q Class k. I C-3
Contractor's Signature: lQv Date: • F'.L7- Cy
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 fora perp*
subjects the applicant to a civil penalty of not more then five 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 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 drivers license. 0 Yes 0 No Drivers 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 live(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:
I 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 0 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 California 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? ❑Yes ❑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 ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ul Yes 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? ❑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 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.
z.� '/Signature Of Legal Owner(s) Date
/�l l 8":27-6_(_
And/Or Authorized Applicant _ / Date
CODE 6 INSPECTION TYPE lall INTIMLS CODE I INSPEC110N TYPE fAIE !MALI
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
p
200 Final Re-Roof �L -11'-0( 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
ADDRESS OF MOND 787 SHALIMAR DR WIT: CITY OF COSTA MESA — BUILDING PERMIT
OWNER'S NAME IPaam: WETTLER, KENNETH PERM NO: B 082609
ADDRESS 400 COUNTRYWIDE WY SV-35
SIMI VALLEY, CA 93065 PERMIT NO: B 082609 PLAN CHECK NO: N GOVT: Y SUPP: N
AWL.KCMG ADORES& CONSTRUCTION TYPE : V—N PERMIT TYPE: STR PURPOSE: OTH
ARCRRECT OR ENCdIEER: Ue140- JOB DESCRIPTION : ALLEY CONSTR/799-787 SHALIMAR SQ FT: 10, 000
ARMOR END'S ADDRESS: WIT:
CLAIM VALUE: 10, 000 . 00 CALC—VALUE: 10, 000 . 00 GROUP OCC : R-1 /U-1
CON1BACTWES WE: BETA CONSTRUCTION ( 714 ) 828-5300
COMRACTORSMMDID 1651 PLACENTIA AV COMMENTS: MONOLYTHIC POUR PCC—C-3250/ 8" OVER 2"SAND PER SPECS
ADDRESS COSTA MESA CA uex0: 482901 ***********rt+Eie****N•***********St#**fESEir*iEiESt**ir+t****At*St+r***rcfE** *Stit****ir****)E***Stii-
92627 WIT: M Z ON ING R EQU IR EMENTS
UCENSED CONTRACTORS DECLARATION:I hereby Nim under penalty of perjury that I am licensed under prov®ms of Chapter 9 S E TB ACK S
(commencing with Section 7000)of Division 3 d the Business end Probations Code.and my Danes' in hall force and effect.
Cm UC.NO.: 040576 UC.CLASS: H u482901 EXP: 00/00 MAIN BUILDING ACCESSORY BUILDING
Dere: 312 1 7- FRNT: FT IN REAR: FT . IN FRNT: FT IN REAR: FT IN
Contractor: LEFT: FT IN RGHT: F"I IN LEFT: FT IN RGHT: FT IN
OWNER BUILDER DECLARATION:I hereby affirm under penally of perjury that I am exempt from the Contractors License law for the
'Slowly reason(Section 7O31.5B&nirasand Professions Cede:Any city or county whim requires tomnstrw,alter,improve. PARKING REQ: PROV: PARCEL: 42405404 ZNE: REF NO:
'woolen or repel any structure,prior b b issuance,elm requires the applicant or such permit to filo a signed statement that he or she
a licensed pursuant to the provisions of the Contractors License Law[Chapter 9(commencing with Section 7000)01 Dbeen 3 or the PLANNING NOTES>
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.My violation of Section >
7031.5 by and applicant for a permit subjects the applicant to a civil penalty of not more than fere hundred dollen l55001). *************************************************************i******if**********
O I.as owner ol the property or my emMoyees with wages as their sole competes:6m,will do the work,and the structure is nol intended DEVELOPMENT S ERV ICES REQUIREMEN T S
or offered for sale(Section 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of properly
who bulb or improves thereon.end who does such work himself or herself or through his or her own employees,provided that such
improvements not intended a offered for sale.II,however,the building or improvement is sold within one year of completion, ZONING APPROVED BY �� . DATE: .:,-
b..,
'
ownerbuider will have the burden of proving he or she did not build or improve for the purpose of sale). n��
❑ I.as owner of the properly.am exclusively contracting with licensed contractors to construes the propel(Section 7044,Business and S DATE: l�
Professions Code:The Contractors License law does not apply to en owner of property who builds or improves thereon and whoH U I LD I N G APPROVED B Y g 7 7
contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law). 'L 77 n
Q Iamexempt under Section: B.SP.C..famereeson: APPLICATION ISSUED BY: ` DATE: 7-JQ 77
*********************************************** , ***********at**********
Date: oro»: LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:Y
I do hereby candy that I am aware of and understand the requirernente of California is Health end Safety Code Sections 25505.25533.and
25534.and that I ce any future building occupant will/wR not(circle one)need to comply wilt said slats codes and IM requitement,for
a permit for construction or modificalbnha"IMAM Quality Management(holder.Residential construction applcatinsareexempt from these BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
prions. PERMIT 162 . 25 1 . 00
Date: Applicant: SMIP/NON—RES
WORKER'S COMPENSATION DECLARATION:I hereby affirm under penally of perjury one of the following declarations: IS
SU
SSUE FEE
O Ihave and will maintain acertificate or consent to°eD.inuure for waken?compensaton.asprovided fabySection 3703of the Labor BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK _ TOTAL PAID DUE
cnde,f«1M pedcew
mr .Nwork hnapemdissued.
TOTALS----> 0 . 00 0 .000 . 00 • - 0 . 00 . 00 . 00
rip I have and coil maintain las'compensation it:Nuance.as requiredd .forperformanced by Section 3700 the labor Codethe performance the r .
work for which this permit is issued.My workers'compensation insurance canter and poky number are:
Canter: ARMSTRONG—ROBIT EXPIRES REVENUE DIVISION TOTALS--> COLLECTED: . 00 OVER/SHORT: . 00
Poky Number. 141? IVVol 174-1 07/01 /97 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
(This section need nal be completed I the Forma is for one hundred dollars(3100)or less.)
❑ I may that in the performance of the work for whim this penis is issued I shall not employ in any manner so as to
become to the workers'compensation laws of California.and mat dl sidled to the workers' *************************'*********'K'*'!C******'lE'*********************jE*****-)f#******
prom ion provisions d SSwam3700 of the Labor Code,I stall I with those IND IV IDUAL FEE BREAKDOWN
\ Date: '� _pr/V- 9 Apq'rad:
Wining:Fallen m secure warri compruauon coverage Is unlawful,and shall subJaer an employer to criminal penalties and TYPE QTY DESCRIPTION . ( UNIT COST TOTAL COST
NO Groes W to one Modred thousand dollars($1]0,000A m addition to the coat of compensation,damages es podded for In
Seduonn06elthe Labor Cody,Intent,and°lmm .
ayiaes SFR 10000 ALTER BY VALUE RESIDENTIAL NOZONE 1 . 00 10, 000 . 00
CONSTRUCTION LENDING AGENCY:I hereby affirm under penally of perjury that there is a construction lending agency for the END) OF FEES'
performance of the work for with the permit is issued(Section 3097.Civ.C).
LENDER'S NAME:
LENDER'S ADDRESS: - /'
I certify that I have read this epplication and Mate that the above information is coned.I agree to comply with all city and county ordinances
and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property
for inspection purposes. • ,
STEVE MAR SD EN
Print Nema�, /t j 04-30-199RCPTh lli@05566
""y'9 //I i" Data: PERMIT:082609
Signature of Omer/Agee .. . WContrador
(5151-45 W P) White-Building A Safety:Green-Fla:Crory-Appimnt:Pink-Revenue:Goldenrod-Assessor
CONSTRUCTION AND PLANNING PO( SPA
APPROVALS Permit# Date Inspector APPROVALS Permit # Date Inspector
• 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location •
2. Soil Pipe-Undrgrnd. 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 UF ER Grnd. 57. APPROVAL TO COVER-GUNITE
•
7. Footings 58. Electrical Conduit-Undrgrnd. •
8. Foundation .59. Gas Pipe, 0 Undrgrnd.,Test
9. Water 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
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 -I
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign •
- 68. APPROVED FOR PLASTERING
18. Rough Electrical-7 Bar Ceiling 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 0 Gas 0 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) & Monocoat 75. Dry Chemical
27. Frame and Flashing 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
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes:
34. Final Heating& Air Conditioning CLC-.77- O�C 110 , e ctv
35. Final Gas Pipe-Test t--'CwL( 64.at
36. Hood or Canopy
37. Final Factory Fireplace C
38. Final Plumbing
39. Water Service•Final
40. Gas Service-Final
41. Solar Domestic-Final
42. Backflow Preventer
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING --((.q7 �t4
48. FINAL PLANNING �� ll
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No Date
-
BUILDING SAFE' DEPARTMENT v 1486
P. O.. Box No. 317 -- -
Costa Mesa, California
Date J " e - A
CITY OF COSTA MESA
CERTIFICATE OF OCCUPANCY to?
Building
Building Permit Not'33 2 Electrical Permit M(4147 VSPlumbing PermitNooJ Pa 44,
r
Use of Building /��•�✓�-�` -� 't A - V
Y ye4 1
The building located at 7J 7 - ..c_-Y '-�z_- 64 '"'_r.%f ? CSV 4-)
Legal Description ' 'Z • '5";-•7 ` R
(See reverse side for Metes and Bounds)
has been inspected and found to comply with the provisions of all City of Costa Mesa Ordin-
ances applicable thereto for a Group A/ �!� Occupancy.
ISSUED TO:
my- City Building Official
/'(Owner of Building) j/ By `-�
CC: 0 Original—Owner 0 1st copy—Gas Co. 0 2nd copy—Edison Co. 0 3rd/copy—File
Form 208 S-B P 1M 1-60
Ilk .: i 26 E: . RECEIVED
COSTA MESA BUILDING-SAFETY DEPARTMENT NOV 23 1960
P. O. BOX 317 COSTA MESA. CALIFORNIA FINANCE DEPT.
For Applicant to Fill In Completely APPLICATION AOR PERafSiA MESA
TYPE OR PRINT
BUILDING • BUILDING
ADDRESS 787 Shalimar Drive
COSTA MESA. CALIFORNIA For Office Use Only
OWNER Larry Sade & L. Sugar I RECEIPT ND. I ,gEEly`y�o,�
MAIL RECEIVE Y DATE RECEIVED p1ITTE�IS338 WD .
ADDRESS 125 N. La Brea I was- 6 p f/-�S'-6 c
WE
Los An eles TEL 92167 BUILDIN A s'g -Gat--
CITYg NO. WA ADDRESS /
ORCENGINEER Cliff Olsten TEL. 31221 COSTA MESA. CALIFORNIA •
ADDRESS 9025 E. Florence Avenue FIRE
ZONE TYPE GROUP
CONTRACTOR L. Sade APPROVED �£� ,biATE it.- O
ADDRESS 1135 N. La Brea ZvI INC a.-�
ZONE HOOF USE OanNEW `�-
CITY Los Angeles fl �..FLA NB YBUILD%NG�.e� A el/
uc.TNo. 117457 MEL. HO 9-1158 LEGAL %' / f l/ _ 'j- //✓��}YYYY�.�/ Y
DESCRIPTION 1���" ( / / JS.
SIZE I NO. OP BLOCS, III///
OF LOT 54 x 135 now ON LOT A.P.NO. / \
USE OF YARDS EVES
EXISTING BLDG -- _ _ _ APPROVED ALLOWED
SETBACK LING FROMlO (CENTER LINE ET.)
CENTER DP STREET 5D REAR YARD S4 FRONT 5-D
FT. s- - IN.
SIDE YARD I LEFT 116 I RIGHT 86 R.SIDE // FT. L7 /W IN.
DESCRIPTION OF WORK c. /
III� II L.SIDE 7 FT. ul (/i IN.
NEW I XIIII ALTERATION I N ADDITION I REAR V FT. O t_ IN
REPAIR I A MOVING I II DEMOLISH I BPP W E5/ 0 ( IbATE //-;-:)-.V-6()
BUILDING 2 NO OF .-I
SIZE 64 x 34 ROOMS 18 STORIES 2
EXTERIOR WALL ROOF 1 �/ � �
COVERING Plaster!COVERING BT/Rock 74 1 2 4 / ( a
USE OF BUILDING AND WORK TO BE PERFORMED
4 unit a.artment buildin: �q/�
I HEREBY ACKNOWLEDGE TN I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM• PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING
BUILDING CONSTRU-•O VALUATION /� 1."'tSIGNATURE OF Jr
f o PERMIT FEE $ SD2.
PERMITTE �A F o
$, a0 PLAN CHECK $
AUTHORIZED AGENT !^/ E
E
•� �� TOTAL FEE $421:1;7r-H;5::;0 /amu