HomeMy Public PortalAbout9548 Las Tunas Dr_Plumbing_3/13/2014_COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
TR: 6561 LT: 638 BL: .001
ASSESSOR INFORMATION NUMBER:
8587-015-019
TENANT:
OWNER:
TEL.
NO:
LI, JEN KAO
-
923 S 6TH AVENUE
ARCADIA CA 91006
APPLICANT:
TEL.
NO:
FANG, KEN
(909) 569-2069-
18888 LABIN CT B 213
ROWLAND HEIGHTS
CONTRACTOR:
TEL.
NO:
CHAPPOS CONSTRUCTION INC
(818)
253-6728-
23518 BALMORAL LN
LIC. NO
WEST HILLS CA 91307
714085
ARCHITECT OR ENGINEER:
TEL.
NO:
KECHUNG CHOU
(626)
826-0055-
18888 LABIN CT B 213
LIC. NO:
ROWLAND HEIGHTS CA
C27103
TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
FEES PAID
FEE DESCRIPTION: QUANTITY: UOM:
OW PLANCHECK FEE 0.00
01 PERMIT ISSUANCE FEE
11 CLOTHESWASHER(S) 1.00 FIX
25 LAVATORIES/SINKS 1.00 FIX
47 WATER HEATER(S) 1.00 WTH
60 DWV REPAIR OR ALTER 1.00 SYS
64 WATER PIPNG ¢= 1 1/2 1.00 LIN
TOTAL FEES
I
REPORT ID: DPR263
ROUTE TO: BS0508
PLUMBING PERMIT
PL 0508 1401160021
BUILDING ADDRESS:
9548 LAS TUNAS DR
AMOUNT:l TEMP CA 917802106
NEAREST CROSS STREET:
164.10 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY CA
27.80
16.20 JISSUED ON: PROCESSED BY: PLAN BY:
16.20 03/13/14 SR
16.20
16.20 IFINAL DATE� FIN BY: CODE:
16.20 1Z
272.90 1kSCRIPTION
OF WORK
TENANT IMPROVEMENT - PLUMBING - CLOTHESWASHER, SINK, WATER
HEATER, DRAINAGE AND WATER LINE
(SPECIAL CONDITIONS:
APPROVALS
UNDER SLAB WORK
WATER SERVICE
PLASTIC YIN METAL YIN
ROUGH PLUMBING
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
LAWN SPRINKLERS
GAS TEST
UTILITY COMPANY NOTIFIED
jCWV
GRAY WATER SYSTEM
DATE INSPECTOR SIGNATURE
OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I JOB ADDRESS
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, Improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure 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 properly, or my employees with wages as
their sole compensation, will do (,�) all of or U portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the 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 it was not built or
improved for the purpose of sale.).
U i, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contre?tor pursuant -to the Contractors' State License
Law).
I hereby affirm under penalty of perjury that I 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 and effect.
License Class License No.
Date b ,a'{/,'',(" Contractor Sig e _
2ORKERS'COMPEN ON
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 DOLLARS ($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.
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, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
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' compensation insurance carrier and policy number are:
Carder Policy Number Expiration Date
Name of Agent Phone Number
L) I am exemlJt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year priori to completion of the improvements covered
this permit, I cqnnot legally sell a structure that I have built as
owner -builder If it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: htto:l/www.leoinfo.ce.cov/celaw.html.
Date:
Signature of Property Owner or Authorized Agent
—k I certiy 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
�nde tSfiaffoi�Tv�i[frs ply with those provisions
�21S�4
tura-efAppucc(n' Date I
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ N o ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter 220
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lenders Address
By my signature below, I certify to,each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified property for inspection purposes.
re o roptthorized Agent
Applicant (Print Name) Applicant Signature ��te ey ,
at �(
Company Name Date >
COUNTY OF -LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
TR: 6561 LT: 638 BL: .001
ASSESSOR INFORMATION NUMBER:
8587-015-019
TENANT:
OWNER:
TEL. NO:
LI, JEN KAO
(626) 446-2358-
923 S 6TH AVENUE
ARCADIA CA 91006
APPLICANT:
TEL. NO:
CHEN, MAN LIANG
(626) 390-5858-
893 N WHITE HOUSE CI
WALNUT CA 91789
CONTRACTOR:
TEL. NO:
MLC CONSTRUCTION, INC.
(626) 390-5858-
893 N WHITE HORSE CIRCLE
LIC. NO
WALNUT CA 91789
928009
ARCHITECT OR ENGINEER:
TEL. NO:
KECHUNG CHOU
(626) 826-0055-
18888 LABIN CT B 213
LIC. NO:
ROWLAND HEIGHTS CA
C27103
TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
FEES PAID
lFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:
!
101 PERMIT ISSUANCE FEE 27.80
1 TOTAL FEES 27.80
REPORT ID: DPR263 ROUTE TO: BS0508
PLUMBING PERMIT
PL 0508 1405280022
BUILDING ADDRESS:
9548 LAS TUNAS DR
TEMP CA 917802106
NEAREST CROSS STREET:
THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY CA
ISSUED ON: PROCESSED BY: PLAN BY:
05/28/14 SR
FFINAL DATE FIN BY: CODE:
lASCRIPtloN OF WORK
CHANGE CONTRACTOR SEE ALSO PL 1401160021 -TENANT IMPROVEMENT
PLUMBING - CLOTHESWASHER, SINK, WATER HEATER, DRAINAGE AND
WATER LINE
SPECIAL CONDITIONS:
APPROVALS DATE INSPECTOR SIGNATURE
UNDER SLAB WORK ,
L
WATER SERVICE '
PLASTIC YIN METAL YIN
ROUGH PLUMBING
!
lGAS PIPING
lGAS VENT !
! !
lHOT WATER HEATER !
! !
PLUMBING FIXTURES !
LAWN SPRINKLERS
lGAS TEST
!
UTILITY COMPANY NOTIFIED i
!
lCWV
!
GRAY WATER SYSTEM
OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I JOB ADDRESS
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure 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).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (J) all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the 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 it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contractor pursuant.to the Contractors' State License
Law). '
(_): I am exemdt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in whicf I must have resided for at least
one year priorlto completion of the improvements covered by
this permit, I cnnot legally sell a structure that I have built as an
i
owner -builder f it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of'the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: htto://www.lecinfo.ca.aov/calaw.html.
Date:
Signature of Property Owner or Authorized Agent
I hereby affirm under penalty of perjury that I 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 and effect.
License Class License No.
Date C6 rector Signature
(
ORKERS' COMPENSATION DECLARATION
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 DOLLARS ($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.
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, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
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' compensation insurance carder and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone Number
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 s all forthwith comply with those provisions
Signature of Applicant Dater / f
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ No ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter 220'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lender's Address
By my signature below, I certify to each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified property for inspection purposes.
Signature of P%mperty Owner or Auutj�(�toorized Agent
Date
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
ITR: 6561 LT: 638 BL: .001
ASSESSOR INFORMATION NUMBER:
8587-015-019
1
TENANT:
OWNER:
ILI, JEN KAO
1923 S 6TH AVENUE
JARCADIA CA 91006
(APPLICANT:
ICHEN, MAN LIANG
1893 N WHITE HOUSE CI
WALNUT CA 91789
CONTRACTOR:
MLC CONSTRUCTION, INC.
893 N WHITE HORSE CIRCLE
WALNUT CA 91789
ARCHITECT OR ENGINEER:
IKECHUNG CHOU
18888 LABIN CT B 213
IROWLAND HEIGHTS CA
TEL. NO:
(626) 446 -2358 -
TEL. NO:
(626) 390 -5858 -
TEL. NO:
(626) 390 -5858 -
LIC. NO
928009
TEL. NO:
(626) 826 -0055 -
LIC. NO:
C27103
TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
FEES PAID
FEE DESCRIPTION: QUANTITY: UOM:
O1 PERMIT ISSUANCE FEE
25 LAVATORIES/SINKS 4.00 FIX
TOTAL FEES
IREPORT ID: DPR263
ROUTE TO: BS0508
PLUMBING PERMIT
PL 0508 1405010029
BUILDING ADDRESS:
9548 LAS TUNAS DR
AMOUNT:l TEMP CA 917802106
NEAREST CROSS STREET:
27.80 ( THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY CAI
64.80
92.60 JISSUED ON: PROCESSED BY: PLAN BY:
105/28/14 SR
FINAL DATEr FINAL ^BY: CODE:
ID$SCRIPTION OF WORK VVV
INSTALL FOUR SINKS IN THE FOUR FACIAL ROOMS AND ONE IN
RECEPTION
ISPECIAL CONDITIONS: I
APPROVALS
UNDER SLAB WORK
WATER SERVICE
PLASTIC Y/N METAL Y/N
ROUGH PLUMBING
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
LAWN SPRINKLERS
GAS TEST
UTILITY COMPANY NOTIFIED
CWV
GRAY WATER SYSTEM I
DATE INSPECTOR SIGNATURE
OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I JOB ADDRESS
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure 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).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (,')all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the 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 it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The ContractorsState License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contrga for pursuant .to the Contractors' State License
Law).
L. I am exemdt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year prior) to completion} of the improvements covered by
this permit, I cannot legally sell a structure that I have built as an
owner -builder If it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of'the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: httD://www.leoinfo.ca.aov/calaw.html.
Date:
Signature of Property Owner or Authorized Agent
I hereby affirm under penalty of perjury that 1 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 and effect.
I—License`C/las_s % [ License No. ��4 009
Late 1 /� X /rLfoptractor Signature
WORKERS' COMPENSATION DECLARATION
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 DOLLARS ($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.
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, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
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' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent
Phone Number
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 those provisions
�Sign`ature of Applicant Date r
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself compiled and will continue
to comply therewith through the application process.
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ N o ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ No ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requiremgnts
under the Los Angeles County Code Title 2, Chapter 220'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lender's Address
By my signature below, I certify to each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified property for inspection purposes.
Signature
/of/Pfo�perty Owner or A/y}J��orized Agent
Applicant (Print Name) Applicant Signature
Company NameDate xDate jt/, �4