Loading...
HomeMy WebLinkAbout2806 SHANTAR DR - Building Permits i p a ► O�a M CITY OF COSTA MESA - ) BUILDING DIVISION F -411 DEVELOPMENT SERVICES DEPARTMENT PER IT NUMBER PERMIT a 00-01213 �garg�pru� (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.rslf�LDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 2806 SHANTAR DR 1 Status: ISSUED Suite: Applied: 08/10/2000 Vicinity: HOUSE&ATTACHED GARAGE Issued: 08/10/2000 Parcel Number: 13940308 Zoning: R1 R1 Applicant: GALLA RIM, MILES ISSUED BY: Address: 346 E MEADOWBROOK Phone: (714)974-6424 ORANGE,CA Zip: 92668 Owner: BOUK, GALE R TR Address 1185 GLENEAGLES TER Phone: COSTA MESA,CA Zip: 92627 Contractor: GALLA RINI, MILES Address: 346 E MEADOWBROOK Phone: (714)974-6424 ORANGE, CA Zip: 92668 License: 663983 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT REROOF EXISTING SINGLE FAMILY RESIDENCE 8 ATTACHED GARAGE(32 SQ).TEAR OFF EXISTING LAYERS OF ROOFING&INSTALL NEW 7/16"OSB PLYWOOD SHEATHING.APPLY 1 LAYER OF 30#FELT UNDERLAYMENT&REROOF WITH 25 YEAR GAF ASPHALT SHINGLES. , FEE SUMMARY Plan Check: $0.00 Calc Valuation: $7,175.00 Permit: $153.25 Claim Valuation: $7,175.00 SMIP Res: $0.72 SMIP Corn: $0.00 Other: $0.00 • Inspection: $0.00 • Total: $153.97 - 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: Theworkauthorized 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 fora 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(6/00) - 4. DEiLARATIONS O f WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: 0 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. "CI.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'��!-7 compensation Insurance tarn and policy number are: Carder: ,1-f.( AA Policy Number.-- Co COO l b St -(This section need not be comdlated if the permit Is valued at 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 Califomi ,and agree t t if I s Id b c e subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comptywith these ons 1{ / d pplicam-signature:- - c /L ( ICS /b ft 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 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 thattam.licensfid under provi ons of Chapter 9(commencing with Section 7000)of Division 3 of the Business anfff Pr��rff...e,,,ssions Code,and my license is in full force and rs-Signator -Date:N.f� CantractoYsSignature�— ff.�f {/Q(%y / ! Date:, g/J/7/O a 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). Lenders Name: Lenders 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 end 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.). ❑ 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 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 ❑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? 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 a plication apermit 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 LI 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 ❑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 Califomia 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. 44_,Afiroded02.,,vnerW) I Dat A •r A.honed 1 CODE t INSPECTION TYPE 2ATE INamRAL5 CODE. INSPECTION TYPE PATE IMIAL4 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final / �,,.I nj208 Final Plumbing 200 Final Re-Roof /' ” /"Y�110 Final Electrical 201 Final Block/Retaining Wall ,lJ/ 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 J Applicant to fill in all spaces except those within heavy border lines and sign all appropriate • 9120 2/ 10/66 a OG TL p p g declarations. o • - - - if PERMIT ' TRACT NO. , LOT,NO. "UNIT NO. - 1_._- _ _ - CITY OF, COSTA MESA- .�CO(Nj/SjT�R(�U(,/T�IhON PERMIT ' . , _ l. ,-�r] I • r - - r • , • _ ' • Project Address J/1A Of0 J U+�f ✓/O1,'(/ • ., 7 i _ - _ ! , • 1 , ,,. - 'ApplicanYs Mailing Addr¢54 .TYPE OF'CONSTRUCTION ❑ NEW ❑"ADO ❑ ALTERATION �R ERAI R - - 4 /,�, ^/p�,r /y�/ -7� ❑^CONVERSION ❑ DEMOLISH ❑ OTHER ' ' . A.P.# - - _ _ Zone Owner's Name • (.l(/ �(�!l /i Phone / / / DESCRIPTION OF WORK/USE OF BLDG..' Address SCt.�'�LP� - c III---III��� _ - S ' Main Building: ' - , Accessory Building: 1 1 . . Z Arch/Eng. License.No. _ TYPE OF PERMIT, ❑' GRADING FOUNDATION ❑ STRUCTURAL .T Front , ' • ❑.TENANT ❑ ELECTRICAL PLUMBING ❑ MECHANICAL B . N Address •Q/}/� / pS /��zsr ❑ BOTHER - I A Rear - - - - Contractor's Name p` /V e�/ .tttfr/' ' p//Phone Cf', 9'7f.7JJ • _ .- V Address(mailing). A7 Cf yf� •i/ fr • _ PROJECT DESCRIPTION SQ. FT.- TICUPANCV -K Right G 7 f CONSTRUCTION TYPE VALUATION $ s Left R a_ City License No: l ZONE' - GRADING CU.YDS.I ACRES = 'E `�•lyt_\J ,LICENSED CONTRACTOR DECLARATION Ping. Ref.#' Parking Req./Provided I hereby affirm that am licensed under provisions of Charter 9 (commencing Remarks: Planning Notes: 1}t�LQ M _^ with section 7000)•of Division 3 of the Business and Professions Code,'and • I LI VLU FEB : I sT 1 1 -my license is' I .rte and effect. % , Rt i 3 ' License Clas / / e•s+y _ • �` 'Date' ��O�� 'gnature �I / � PLUMBING FEES ! , ' ' WORKER- COWL E4 ION DECLARATION Bar Sink • ' . Showers ELECTRICAL FEES ' hereby affirm that I have a certificate of consent to self-insure or a Certificate • . - M Workers'.Compensation Insurance,.or. a certified copy thereof (Section - Backflow Preventer Service Sink" 0 Lab. � �•��� /p„ ,,,��g///��/`, g Automatic"Washer Transformer 0-"15-50 KW-.- v, /\No. 1:C75 )laO Company R (.(/� Backflow Irrigation Sewer'Ca 050+KW P Construction Pole Sub., rtlfied copy is/- furnished. 1./ -Cert ifi-. c,. is1� with the uty `tll� ••'`'.oy .. Bathtubs Sewer Connection • Cookin Meter Dup to 100 amps Date - /a b Applicant EXEMPTIO FROM W•RKERS'COMPENSATION DECLARATION ' Clarifiers , _ Solar Collectors 'CD � wesher Meter Dover 100 amps (This section need not be completed if.the permit is for one hundred($100) or' �,1r - '--- • - ' less). Dishwasher I Solar Piping CA. _ Y r ryers ❑Gas ❑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 become subject to the Drinking Fountains Solar Tank D tE Fan Motors 00-1 HP 01%-8 Workers' Compensation Laws of California. /"� . _ Date - - Signature • Floor Drains • Swimming Pool w/Spa ' F.A.U. Inc.Solar ❑9-15 HP 016-15+ '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 - -� • Fixtures Microwave ' - ' comply with such provisions or this permit shall be deemed revoked •- CONSTRUCTION LENDING'AGENCY - ' Gas Service. , Outlets Water Closet 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. CJInterceptors - _- r Water Heater ��7/ � Range Outlets Re Lender's Name lThLQ� • Lender's Address - ' Kitchen Sink , Water,Service - , r - Switches Sign OWNER BUILDER DECLARATION ' I hereby affirm that I am exempt from the Contractdr's License Law for the Lavatories Auto-Wash - ' Garbage Disposal ' ;Standing Sections 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 LaundryTrays 'i. ' any structure, prior to its issuance, also'requires the applicant for such permit - y _ Generator ❑05 KW ❑5-15 KW Trash Compactor' 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 ' - - 1 ' Division 3 of the Business and Professions Code) or that he/she is exempt - - , • M1erefrom and':.the basis for.the alleged exemption. Any violation of Section ''031.5 by any applicant for a permit subjects the applicant to a' civil r enalty of not more than five hundred dollars($500). '. • I - 3 •`J �+ , `. I, as owner of the property or my employees with wages as their sole - Reinspection Fee V $15 Issue Fee _ . $ ..-' - . compensation, will do the work, and the structure is not intended'or offered - - • Reinspection'Fee I $15 Issue Fee $ 3 for sale (Section 7044, Business and Professional Code: The Contractor'sMECHANICAL ' ' ! FEES License Law does notapply to an owner of a'property who builds or improves - - DEVELOPMENT SERVICES REQUIREMENTS: thereon, and who does such work himself/herself or through his or her,own Boiler Hood or Type I ❑ • ' employees, provided that such improvements are not intended or offered for. yp - Zoning Approved By - • Date sale. If, however, the building or improvement is sold within one year of tom-, _ Canopy Type II ❑ - pletion,the,owner will have the burden of proving he/she did not build or im- Duct-Under Ground' - • - , 1Building Approved By / ” ' • Date , prove for the purpose of sale). ' y El l', as owner of the property, am excluively.contractirig with licensed con- Duct-Structural , r• Refrigeration System - Application Issued By V/ • Dar ' -114 • 1 tractors to construct the project (Section 7044,'Business and Professions Code: , The Contractor's License.Law does•not applylto an owner of property who Duct-Ventilating - ❑0-100,000 BTU 0100,000 BTU ' - ? ,- SUMMARY OF FEES : builds or improves thereon, and'who contracts for such projects with a con-1 - . - .. - tractor(si license.pursuant to the Contractor's License Law). I am aware that ❑ BUILDING PERMIT' $• SMIP $ ff Exhaust System ❑ Multiple SVstem;Repair/Alteration proof o their Worker's Compensation insurance should be provided to me. _ - PLAN CHECK $ �•1 PERMIT ❑ I am exempt under.Section B.$ P.C.for this reason' Firepi/Fact.Blt. ICBG# ' Fire Dampers PLUMBING $ 'O( ISSUANCE • $ ' Date ' owner • ' Heating System& Ducting Registers ' ENERGY P.C1 $. PLAN CHECK' 25% $' I hereby—certify that I have read this application and state that the above ❑0-100,000•BTU'❑100,000 BTL ' . - - - , ELECTRICAL • $I GRADING 1 $ ' ' 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 c't to;enter upon th- above-mentioned property fo . ' , inspection p ae / / aa/ / / /� `••? i� , MECHANICAL' $ TOTAL FEE $ _I TOO Signature ,.• _ . f'y a Date • ( �.J/O , - Drivers' License or SS%f ((( ,Reinspection Fee • $15 I Issue Fee $ 3 PLAN CHECK 25% $ , CMF 0865-46,rev. 10/84 White - Building; Canary -Applicant; Pink -Accounting; Goldenrod - Assessor - Y r + • CONSTRUCTION AND PLANNING POOLSPA - - ' - - - - 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, D'Undrgrnd.,Test ' .9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, DUndrgrnd. • 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 Sign 68. APPROVED FOR PLASTERING r . :18. Rough Electrical-T.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 PREY. FINAL 30. Drywall Nailing r,; (r HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION - - - 32. Electrical Power Meter-Final ,,,: 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: Sly-a6 Len-. c-40-c> . z:r2 Lai 34. Final Heating & Air,Conditioning J.: • { d'ef-eCo do ONE Uowttc, 35. Final Gas Pipe-Test - 36. Hood or Canopy iaS Peel 02,0,5 ,0 it. L.rEo 37. Final Factory Fireplace • 38. Final Plumbing - 39. Water Service-Final . 40. Gas Service-Final • - 41. Solar Domestic-Final -'-: ii, . 42. Backflow Preventer , • 43. Backflow Irrigation . 44. -Landscape Irrigation System •;`,' 45. Sound Attenuation ;-•• . . - 46. Handicap Regulations • . 47. FINAL STRUCTURE & BUILQINGe 48. Special Requirements Completed • - - co .. 49. Electric Release to Edison 't" - • • ' 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY • No. - Date , 9 16517 FIFE RECEIVED COSTA MESA BUILDING-SAFETY DEPARTMENT MAR 2 1862 P. O. BOX 3I7 COSTA MESA. CALIFORNIA FINANCE DEPT. • For Applicant to Fill In Completely APPLICATISN FOR PEREMA TYPE OR PRINT • BUILDING Lc#a' rfor 4319 BUILDING SHAW r,q ADDRESS 21306 SHA , pin✓S ti • COSTA MESA. CALIFORNIA - For Office Use Only RECEIPT NO. I PErB5 17 OWNER Pel4-3-Err le nWr✓sr UUJ ADDRESS /� -J J • //NG/�lLe ©�MAIL RECFJYED 9Y I D:2'RE�EIyF4.4._ o-,_{.TE {6SU'g62 CITY C05rn Mj SA, (agL/F Mx/96995 BUILDING rlY�- or(. ADDRESS ARCHITECT /� TEL. COSTA MESA. CALIFORNIA OR ENGINEER c6QL'/ALrEN/3Ann No.KE.S053:3 // y/Jy�/ ADDRESS n Ki rELti9 E. 11 E/M IRE ZONE • TYPE l� GROUP b. / CONTRACTOR AN0205 14N0 eo. APPROVED BY DATE ADDRESS iG sa M4'oen' be. ZONING �T C04i/ 4 ME5f1 /TL/r. a ZONE_ I NO.OF USE OF NEW /ryE . Td1 Ho CITY oy // t1J�� y� .t (� ��( Lot PLAN�SL SUILppINOti,RiR�]//tq 47 Y' LIC.NO. /(/ /I[O TEL. NO. /C/ 90 g/S DESCRIPTION `O E� 6, re 3 7 / SIZE 7/ 6LOOs OF LOT X �co I NOWNo. of ON LOT/i*WE A p NO USE OF YARDS EVES EXISTING BLDG. ,J Q �I�) APPROVED ALLOWED CENTERSETBACK (CENTER OF NE STR ETM YC/ REAR YARD G 7 FRONT LINE ST.)4f& FT. IN. l0 SIDE YARD I LEFT I RIGHT R.SIDE ! FT. IN. DESCRIPTION OF WORK L.SIDE 6 FT. IN. NEW I X II ALTERATION I ADDITION 1 REAR 2 •q. 6 7 FT. IN. REPAIR I V MOVING I SITE /D DEMOLISH I BYPROVEDtoto DATE a�/6 /6a DING !6 75, ROOMS / STORIES / 9 V EXTERIOR WALL /4/0001 ROOF M/004COVERING 0 G COVERING SN '. 9 • _ ' O USE OF BUILDING AND WORK TO BE PERFORMED )E - 6 iN6LE PAn/ Y Rs-slot-wet Q /)� ' NO ,QrrflLNED tMa46E I / PAllaiThei gI HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ; ` • THE AMOUNT SHOWN UNDER VALUATION IS FOR THE REGULATINGAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- 'PLY WITH ALL CITY ORDINANCES AND STATE LAWS PURPOSE OP, ESTABLISHING A PERMIT FEE ONLY. BUILDING coNSTRucTION. :. VALUATION �CJ SIGNATUREPERMIT FEE $ p(J ' N • / i $`(J /17 — PLAN CHECK $ /9 TOTAL FEE - — 0 IL I