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HomeMy Public PortalAbout5843 AGNES AVE_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS P,..[VGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT T� -IL,(_ 11106 *J!'LDIrrG ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING DDR SS or a certificate of Workers' Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) CITYC�I� ZIP ���O TTf�/ 9 LOCALITY Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified Copy is hereby furnished. 60 X a NEAREST CROSS ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. _ USE ZONE MAP NO, _ Date Applicant ASSESSOR MAP BOOK PAGE PARCEL ©�� , SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE /� WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADD ,/r�'• DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) <, ao CITY_ ZIP* I certify that in the performance of th k for which this permit tiYTjT�✓�to4F 04 is issued, I shall not employ any per on n any manner so as to i become b ct t0 the Workers' satin aws. ARCHITE OR ENGINEER TEL NO. v STATISTICAL CLASSIFICATION APT CONDO Date�� Applican ADDRESS CLASS NO, DWELL UNITS NOTICE O APPLICANT. If, ter making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONIF?PCTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith NeNplc FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATION SIDE CITY LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SJZE NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. a NEW BK PG , a ADD El C License Number Lic.Class DESCRIPTION OF WORK � , I Q Contractor Date ! ALTER [:] Wr U cc ❑ 1 am exempt under Sec. E 4&244 E7 REPAIR ❑ 0 BAP.C. for this reason DEMOL ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. URM ❑ attire APPLICANT(PRINT) TEL NO. LDMA Perm# i} Z I, as owner of the property, or my employees with wages as 9�r hlIe� » » ir their sole compensation, will do the work and the structure is ADDRESS . - not intended or offered for sale (Section 7044, Business and FINAL DATE, 0 "Cl.- `s =:�3 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Eli"T 1, as owner of the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY .. ..� ._ licensed contractors to construct the project (Section 7044, p{. YES 11 NO Business and Professions Code.) '3'y WILL THE INTENDED USE OF THE BUIBY THE APPLICANT OR FUTURE BUILDING - •ati OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ....--...-'.' iVtl"v V•: CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ NO7( �5 - 35-35 TOTAL n N the performance of the work for which this permit Is issued(Sec. HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING Y .2 3097, CIV.C.) CHECKLIST.I UNDERSTAND MV REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, - Si '1�C' TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS . t•• i.I.•..I v 5- TITLE Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. o Lender's Address CHANGE ``J1 O OWNER OR AGENT ., o I certify that have rea this application and state under penalty o P.C.FEE PERMIT FEE of perjury tha the ab e information is correct. I agree to comply with all count or ' ances and State laws relating to lding ♦� r� 1300{{-1'j 131 < construc an ereby a horize representatives of this ou y ISSUANCE FEE _ - - —'- -• toe p0n t ve-m Toned property for inspecti0 rpo e �� S" I3 ° Ik j INVESTIGATION FEE TOTAL FEE / ^ sre�ew or.arn o,n9em Dace SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS COM)ENSATIION DECLARATION r l t I„hereey,'cifirm that I have a certificate of consent to self r�sure or a certificate of Workers Compensation Insurance APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company ❑ Cert"ified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING ❑ ADDRESS Certified copy is filed with the county building inspec BUILDING tion department ADDRESS �1(y �j T Date Applicant CITY ZIP 17 a0 LOCALITY ✓ CERTIFICATE OF EXEMPTION FROM WORKERS N OF BLDGS NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST1�— (This section need not be completed if the permit is for one TRACT BLOCK LOT NO ASSESSOR hundred dollars ($100)or less ) MAP BOOK PAGE PARCEL TEL USE N P I certify that in the performance of the work for which this OWNER Fi E NO ►y/z7[-� Ei NO permit is i sued I shall not employ any pe in any manner r /1 I SPECIAL so as to coin subject to the Work r o pensat n Laws ADDRESS fV —25 G• CONDITIONS 0 U Date Applicant CITY ZIP 1 ARCHITECT OR �A TEL NOTIC TO APPLICANT If after making this Certificate of &NC NO DISTRICT G OUP TYPE FIRE P CESSED BY O Exemption you should become subject to the Workers ENGINEER CONST ZONE U Compensation provisions of the Labor Code you must forth ADDRESSv31 _5W with comply with such provisions or this permit shall be L I t deemed revoked CONTRACTOR NO STATISTICAL CLASSIFICATION APT NDO Z LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code and my license is in full force and effect CITY CLASS BK PG VA&Z►1I�I60 A SQ FT NO OFNO OF CHECK License Number Lic Class SIZE STORIES FAMILIES ONE # 0 0 0 o e 1 VALUATION Contractor Date DESCRIPTION OF WORK • NEW C]NEWLUCOQ s - 5925 ❑ 1 am exempt under Sec NETS ti/ E_ ADD LJ0 e o 5 9 2 5 5 ALTER v B&P C for this reason art-TI @'1111.3, REPAIR ❑ $ -88123-�8 8 USE OF 5 t " ` -4 Date EXISTING BLDG DEMOL ❑ `� - i j Signature APPLICANT TEL FINAL OWNER BUILDER DECLARATION (PRINT) NO DATE I hereby affirm that I am exempt from the Contractor s License 1 Law for the following reason (Section 7031 5 Business and ADDRESS FINAL l �+ Pro essions Code) PRESENT By BUILDING I as owner of the property or my employees with ADDRESS wages as their sole compensation will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044 Business and Professions Code) MOVING TEL ❑ I as owner of the property am exclusively contracting CONTRACTOR NO ✓ with licensed contractors to construct the project (Sec ADDRESS tion 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCYREQUIRED YARD HWY TOTAL SETBACK SET BACK PROP LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P L (Sec 3097 Civ C ) SIDE PL Lender s Name LDMA Ref # P C Fee$ Permit Fee Lender sAddress JS) I certify that I have re this application and state that the t Issuance Fee LDMA P/C# above informationisorretIagree to comply with all County Investigation Fee It ordinancesand Sta la s relating to building construction Total FeeLDMA Perm # R and her y author e r resentohves of this County to enter up n t abov me h ed pro arty for inspection rpos a SEE REVERSE FOR EXPLANATORY LANGUAGE r Signature of Applicant or Agent Date - r r { COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS RESIDENTIAL ADD/ALT/REP BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 0308120055 PHONE (626) 285 0488 EXT LEGAL ID NO 16F CONST- DR TR 6561 LT 437 SQ FT STORIES TYPE OCCUP GROUP 5843 AGNES AV STRUCTURE 931 1 VN R3 TEMP CA 917802216 ASSESSOR INFORMATION GARAGE NEAREST CROSS STREET LAS TUNAS 8587 027 010 OTHER THOMAS PAGE 597 GRID A3 LOCALITY TEMPLE CITY EXISTTENANT BLDG USE USE ZONES R C SS S ON EXIST OCC GRP 10/14/03 JK 10/08/04 OWNER TEL NO BL GS NOW ON LOT VALUATION r'Y NAL BY CODE SHEHEE KEVIN JOLYNN M (626) 285 6753 73,735 5843 AGNES AV C TEMP 917802216 FEES-5 DBCRIPTION FEE DESCRIPTION QUANTITY UOM AMOUNT ADD 2BDRM, 1BATH LAUNDRY, 8 FAMILY RM APPLICANT TEL NO SAME AS OWNER B1 PLANCHECK W/ENERGY 73735 00 VAL 970 95 AA BLDG PERMIT ISSUANCE 27 75 SPECIAL CONDITIONS AC STRONG MOTION:RESID�73735 00 VAL 7 37 82 PERM IT�W/ENERGY--73735 00 VAL 1,142 30 ����� tlTOTAL�FEES 2,148 37 SAMECONTRASTOWNER OR TEL NO ��� APPROVALS DATE INSPECTOR SIGNATURE LIC NO 6 LOCATION AND SETBACKS XSO L ENGINEERA PROVAL R R TEL NO /// � FOUNDATION/TRENCH FORMS LIC fN/l/Of I 1111111 ` SLAB/ DER FLOOR ( 7 RAISED FLOOR FRAMING MAP NO SEWER MAP BOOK PAGE FIRE ZONE �I CM �n0r� UNDERFLOOR LA ON K 3 SFLOOR SHEATH NO OF FAMILIES CLASS — NO 21��� ND LEVEL FLOOR S E TH T N HAZARDOUS \ D O 1 - np' AIR QUALITY 1000 FEET MATERIALS SHEATHING J� NO NO NO FIRE DEPT FRAME INSPECT REQUIRED TOTAL SETBACK FROM EXISTGy, BLDG P SP SET BACK YARD HWY PROP LINE WIDTH O ❑ ®¢ 6 FSONT PLIDE PL `�ervoce V��� SHEA PANELS INSULATION/WEATHERRIP f�� IN RIOR LAT /DRYWALL 7 EXTERiOR LATH � �y T DRAINAGE SMOKE DETECTION DEVICES FIRE DEPARTMENT PPROVAL REPORT ID DPR261 ROUTE TO BS0508 ' COUNTY OF LOS ANGELES TEMPLE CITY # 0508 BUILDING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS RESIDENTIAL ADD BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 BL 0508 1101050009 PHONE (626) 285 0488 EXT I ILEGAL ID I NO OF CONST NEW BUILDING ADDRESS I ITR 6561 LT 437 I SQ FT STORIES TYPE OCCUP GROUPI 5843 AGNES AV I ISTRUCTURE 306 1 V B U I TEMP CA 917802216 I (ASSESSOR INFORMATION NUMBER I GARAGE I NEAREST CROSS STREET LAS TUNAS I 18587 027 010 I OTHER I THOMAS PAGE 597 GRID A3 LOCALITY TEMPLE CITY Cl I I I I ITENANT (EXIST BLDG USE USE ZONE (ISSUED ON PROCESSED BY IEXIST OCC GRP 101/13/11 SR I I I I (OWNER TEL NO IBLDGS NOW ON LOT VALUATION IF 'ATE FIN CODE I ISHEHEE KEVIN JOLYNN M 1 ' 6 120 1 //1 15843 AGNES AV I_ 1 / (/ ► I ITEMP 917802216 FEES PAID ID RI TIO OF WORK 1 117 X18 ,ATTACHED SOLID COVER PATIO I IFEE DESCRIPTION QUANTITY UOM AMOUNT I (APPLICANT TEL NO I I 1 10 LEARY TOM ID1 PLANCHECK W/O EN HC 6120 00 VAL 141 60 1 1 15823 AGNES AVE IAA BLDG PERMIT ISSUANCE 27 80 ISPECIALiCONDITIONS I ITEMPLE CITY CA 91780 IAB STATE GREEN BLDG FEE 6120 00 VAL 1 00 1 1 IAC STRONG MOTION RESID 6120 00 VAL 0 60 I I 1 ID2 PERMIT W/O EN HC 6120 00 VAL 166 60 1 1 (CONTRACTOR TEL NO I TOTAL FEES 337 60 IAPPROVA-S DATE INSPECTOR SIGNATURE ITOM 0 LEARY CONSTRUCTION (626) 287 0927 1 1 I 15823 AGNES AVENUE LIC NO I ILOCATION AND SETBACKS I ITEMPLE CITY CA 91780 489354 B 1 1 1 1 1 1 ISOILS ENGINEER APPROVAL I I I I I I t I I I (ARCHITECT OR ENGINEER TEL NO I IFOUNDATTON/TRENCH FORMS 1 1 ISAWAYA RAMZY (213) 479 0978 1 I I 1 11960 SANTA ANITA AVE LIC NO 1 (SLAB/UNDER FLOOR I 1 ISIERRA MADRE CA S 3974 1 1 I I I i IRAISED FLOOR FRAMING IMAP NO SEWER MAP BOOK PAGE FIRE ZONE CMP ) (UNDERFLOOR INSULATION I I I 1 3 001 I 1-1- I 1 I I 11ST LEVEL FLOOR SHEATH 1 1 INO OF FAMILIES DWELLING UNITS APT/COND STAT CLASS I I NO 21 1 12ND LEVEL FLOOR SHEATH I SCHOOL WITHIN HAZARDOUS I IROOF SHEATHING I I I (AIR QUALITY 1000 FEET MATERIALS I I Ilevv I NO NO NO I IFIRE DEPT FRAME INSPEC I 1 I I I I I I 1 I IBLDG DEPT FRAME INSPECTI I I I 1 11 1 I ISHEAR PANELS I I I I I I I (INSULATION/WEATHER STRIPI I I 1 I I I (INTERIOR LATH/DRYWALL I I 1 (EXTERIOR LATH I I I I I I I ILOT DRAINAGE I I I I I I I I ISMOKE DETECTION DEVICES I I I I I I IFIRE DLPARTMENT APPROVAL( I I I I I I I I I I I I I (REPORT ID DPR261 ROUTE TO BS0508 I I 1 I I I I I I F ✓ � ti k WORKERS COMPENSATION DECLARATION 76A663 0/81 APPLICATION EOR ELECTRICAL PERMIT Y- y � hereby�afi,�rm that t have a certificate of consent to self insure APPLICATION , FOR a per, to of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec 3800 Lab C) 7 Policy No > 'r Company FOR,APPLICANT TO FILL IN JOB ❑ Certified copy ishereby,furnished New Residential Bldgs & Pools EACH NO FEE .ADDRESS �1<i ❑ Certified copy is filed`with the county building inspection 1 & 2 Family Sq Ft $ — $ LOCALITY iNEAREST I-PtI department r < i k+ + y Multi family Sq Ft a — + S J CROSS ST TU NJ h5 VIM_ Date Applicant ' Residential Swimming Pools 4 OWNER OR I ; /n I FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec ja Light SwMAIL ivd COMPENSATION INSURANCE r , v , I a r O-C) ADDRESS �^ (This section need not be completed if the work involved by the First 20 n� permit is for one hundred dollars($100)or less) Total No Additional- CITY _ r' V Tel No I certify that in the performance of the work for which this permit 1" PLAN CHECK ,is issued I shall,not employan i APPLICANT , y person in�a manner so as to w e become su ject to the Workers Corn nsa ws Lighting Fixtures First 20 A ADDRESS - w t (ya ZfoAdditional + Date Applicant Total No i , CITY Tel No 'Date TO APPLICANT If after along this, Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption iyou should become subject to the Workers Compensation Range_ eater DW / APPLICANT • provisions4of the Labor Code you must forthwith comply with such e Oven _ Dryer _ W M ADDRESS provisions or this permit shall be deemed revoked Top _ FAU __WH__ a LICENSED CONTRACTORS DECLARATION v Hood Fan _ Other_ //'' CITY Tel No_Z.V 53 d hereby affirm that I am f licensed under provisions of Chapter 9 Disp Room Air Cond U LICENSE OR Class (commencing with Section 7,000) of Division 3 of the Business and REG NUMBER Professions Code and my license is in' ull force and effect r LL DISTRICT NO _ PROCESSED Y Power Apparatus& Large Appliances o/ w Size& Type HP KW KVA or KVAR 41 _J Q License Number Lic ClassU> Up to 1 Incl FINAL + { Over 1 to 10 Incl DATE " VA ATION Contractor - Date ❑ , Over 10 to 50 Incl FINAL ~ I am exempt under Sec Over 50 to 100 Inc r BY j W1 T B&PC for this reason Over 100 t Cn { r Services Swbd MCC& Panelboards" f ` Z h ' "Date 0 200 Amp Under 600 V Signature 201 1000`Amp Under 600 V _s1 ,1 y^ +" Over 1000 Amp or Over 600 V a Exemption for Reg Maint Elect r # o o to 0 0 2 r SINGLE FAMILY+ Temp Power Pole& Appurtenances 1 ­ 4 41 50 HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractors License Law ' ; o 0 o4 1 5 Ox for the following reason(Section 7031 5 Business and Professions Additional Sign Branch Circuits 4 co ) V � i1123F`88 ` * - A I as owner of the property will do the work and the structure Misc ti Conduits& Conductors is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) r and Professions Code) r t r CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the - A performance of the work for which this permit is issued(Sec 3097 PERMIT FEE - a-� (Sub Total) - c Civ C) PLAN CHECKING FEE '%Lenders'Name P r w , * PERMIT ISSUING FEE Lenders Address ' # t I certify that I have read this application and state that the above TOTAL FEE i information is correct I agree to comply with all County ordinances i ; c and State laws regulating ytrical wiring and hereby authorize f represent, ves of this Co my to enter upon the abo e mentioned prop ty r inspection pu es a t _ SEE REVERSE FOR EXPLANATORY LANGUAGE r JS,gieof Permittee r Date " WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 76A663 APPLICATION FOR ELECTRICAL PERMIT 1 hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy th*reof(Sec. 3800 Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB /��Q �r_/ •/moi ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE $ $ LOCALITY FCM � c!r x/78 ❑ Certified co s filed with the count building inspection 1&2-Family,Sq.Ft. Y 9 P y q — CRA T. REST department. Multi-famil S Ft. LA,�;, 711t q6 Date Applicant Residential Swimming Pools i -MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. ht Lig Sw. OWNER OR COMPENSATION INSURANCE r (/O /5 FIRM NAME First 20 c �/ MAIL (This section need not be completed if the work involved by the Total No. Additional ADDRESS permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY Tel.No. is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 PLAN CHECK Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with such PERMIT P p y NT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICA LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000) of Division 3.of the Business and CITY Tel.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. Over 50 to 100 Incl. REGNNUM ER Class.SE OR a- Over 100 DISTRICT NO. P SED BY O License Number Lic.Class p Q Services,Swbd.,MCC&Panelboards p p CC Contractor Date 0-399 Amp. Under 600 V❑ DATE �J O I am exempt under Sec. 400-1000 Amp.Under 600 V `%3 W VALIDATION Over 1000 Amp.or Over 600 V FINAL B.&P.C.for this reasonBRANCH CIRCUIT FEES BY Cn Z Date: 15A,or 20A,120V,Lighting or Recept. 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuitsx ACCT. ❑ 41 Or More Branch Circuits Exemption for Reg.Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits t. y'3 _wi T ._V SINGLE FAMILY Temp.Power Pole&Appurtenances -T ' HOME OWNER-BUILDER DECLARATION ITEMS I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits TOTAL AL 46 _ 20 Code): CHECK if?,��I Misc.Conduits&Conductors I, as owner of the property,will do the work and the structure f,� is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) CHANGE -0F. and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the 7. {` 9 a performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) jJ �'�r f yrl 11;03 Civ. C.) PLAN CHECKING FEE i' Lender's Name k` PERMIT ISSUING FEE Lender's Address I certify that I Zre on and under penalty of purjury state TOTAL FEE that the abovorrec. I agree to comply with all County ordinances anati Electrical wiring,and hereby authorize representativeenter upon the above-mentioned property for insp C' SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATUR OF PERMITTEE DA