The URL can be used to link to this page

Home My WebLink AboutB2001-2616 - PermitsCity of Newport Beach Building Department CIP Permit No: B2001-2616 PO Box 1768 Newport Beach, California 92658-8915 Permit Counter Telephone (949)644-3288 Inspection RequestsTelephone (949)644-3255 Job Address: 1 HOAG DR Floor: Inspector Area: 7 Owner: Address: Phone: Applicant: Address: Phone: Suite: HOAG MEMORIAL HOSPITAL 1 HOAG DR NEWPORT BEACH CA 92658 VILLANUEVA MIGUEL 4850 BARRANCA PKWY#203 IRVINE CA92604 949/552-2061 Code Edition : 97 Type of Construction: 11-1HR , Occupancy Group: B Added/New sq.ft. Bldg: 2263-TI Added/New sq. ft. Garage: No of Stories: 3 No of Units: Issued: Receipt # Bldg: 1 Legal Desc: Contractor: Address: Phone: Con State Lic: Lic Expire: Bus Lic: Lic Exp Date: WATSON INVES 18182 SERRANO AVENUE VILLA PARK CA � y. 714/974.6421 7 436023 03/31/2003 BT98038807 10/31 /2001 Workers' Compensation Insurance - - Carrier: STATE FUND Policy No: 229-0019928 Expire: 01/01/2002 Building Setbacks Rear: Front: Left: Right: Use Zone: Parking Spaces: Construction Valuation: $71,737.00 Building Permit Fee: $649.40 Plan Check Fee: $467.57 Supplemental: $0.00 Investigation Fee: $0.00 Clean Up Deposit: $1,100.00 Energy Compliance: $0.00 Fair Share: $0.00 ZONING APPROVAL' FIRE APPROVAL: - - GRADING APPROVAL: PUBLIC WORKS: Microfilm: Excise Tax : Park Ded: SJH Trans: San Dist: Ca Seismic Safety: Disabled Review: $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.74 TOTAL FEE :$3,004.81 1 1 PC FEES Description of Work: TENANT IMPROVE�Ij1�EENTICONFERENCE CTR 3RD FLR 2095-2001 rir1T8 � /y�"�� JACK WOOD "IC-ft 4850 BARRANCA#203 t IRVINE CA 949/552-2061 State Lic: C015130 Architect: Address: Phone: Engineer: Address: Phone: Designer: Address: Phone: State Lic: Special Conditions: Yf.3 NO/ Hazardous Mat: Add Fire Dep HMO: Other Fee: TOTAL PAYMENT :$362.88 $20.45 $0.00 $0.00 Fire Department: Plan Review Fee: Inspection Fee: Planning Department: Counter Review : Zoning Plan Check: OverTime Plan Check Fee: TOTAL DUE: $2,641.93 OTHER DEPARTMENT: PLAN CHECK BY; APPROVAL TO ISSUE: p&e ovt,/iv --- $187.03 $454.58 $0.00 $54.04 $0.00 WORK MUST BE STARTED WITH -A PERIOD OF 180 DAYS FROM THE DATE OF VALIDATION OR THIS PERMIT BECOMES NULL AND VOID. 0�3LP9,;3 APPROVALS FOUNDATION: ROUGH GRADE LINE & GRADE CERT/SETBACKS ERECTION PADS 'FOOTINGS SLAB ON GRADE DATE 8Y FRAMING - DECK SLAB CO ENTS //17/ eVL rf feAriitt, Wz o Ore 'j/htf IL 6 S 74i 14 ate *74 yt 7 8n-cjfC 3/ , Clyk /fj Lrr'9 41,/ /iwac /L-E ,so 4 �w ei coo G/YL dam- �jJfiu� p /7s • - //// C.4,c mf /r SUBFLOOR ROOF & BUILDING HT EXT, SHEAR/HOLD DOWNS GENERAL FRAMING FIREPLACE THROAT 1�/5/di g OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LICENSE LAW FOR THE FOLLOWNG REASON IBEC. 70315, BUSINESS AND PROFESSIONS CODE' ANY CRY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE, DENIUJSH, OR REPAIR ANY STRUCTURE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE AROVISIONL' OF THE CONTRACTORS LICENSE LAW (CHAPTER 9 (COMMENCING WITH SEC. 7000) OF DIV 3 OF THE BUSINESS ANO PROFESSIONS CODE)) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BAND FOR THE ALLEGED EXEMPTION. ANY VIOLATION OF SEC. 70315 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS ($5001: D 1„ AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WTH WAGES AS THEIR SOLE COMPENSATION, VALE DO THE WORK. AND THE STRUCTURE 13 NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSINESS AND PROFESSIONS COVE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND VVHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES PRONGED 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 THE PURPOSE OF SALE). ❑ I, A3 OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WTH UOENSEO CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 1044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF THE PROPERTY WHO BUILDS OR IMPROVES THEREON, AND W4O CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(3) LICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW,). ❑ I AMEXEMPT UNDER SEC. B.S P.C. FOR THIS REASON DATE OWNER INTERIOR & EXTERIOR INSULATION ! //0 DRYWALL SUSPENDED CEILING SHOWER LATH ,y i EXTERIOR LATH SCRATCH (PLASTER) (2 DAY) MASONRY PRE -GROUT MISC. INSPECTIONS: PERMIT EXTENSION 1ST EXP. LETTER 2ND EXP. LETTER DECLARATION OF Ca4PLIANCF N17N LLph W FEDERAL REGULATIONS PART 61 or -TITLE 4u AND AORD RULE 1401 D 1 SUBMITTED ASBESTOS NOTIFICATION TO: D ROM ASBESTOS NOTIFICATION IS N SIGNATURE:)(1,JDJ,F—.,t BUILDING FINAL CERTIFICATE OF OCCUPANCY TENANT NAME: TYPE OF BUSINESS USE: i REFUNDED DATE ?i)7/cJs TO: &OG !T-40r 0(1,G,4 i-b4 )r&J ebb1 LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WTH SECTION 7000) OF LANNON 3 OF THE BUSINESS AND PROFESSIONS COO, AND MY LICENSE IS IN FULL FORCEAM) EFFECT LICENSE CLASS CIO. N0. // Q 1 1 1\ CATE� LO-'• D1 CONTRACTOR\y_�A.L.�WD7.73,. WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJORVONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAJNTAIN 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. XI HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION 3TOD OF THE LABOR CODE, FOR THE PERFORMANCE OP THE WORK FOR WHICH THIS PERMIT IS ISSUED, MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER ST' 1114 FOUL" NUMBER t''19-o5 Oolg12$& (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS (5100)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 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,IQ ' 1� ]... DATE: 1 O_`',• 01 _ _ APPLCANT_ V 'RAMC b.)J? � WARNING: FAILURE TO SECURE WORKERS' COMPEN ATION COVERAGE 13 UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PFNALTIES AND CIWL FINES UP TO ONE HUNDRED THOUSAND DOLLARS MMOI000'.IN ADD'PTN -0 THT COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3705 (F 11 E Ll3OR C )SE, I .T REST, AND AITORNEY'S FEES. CONSTRUCTION LENO)NG AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE ISA CONSTRUCTION LENDING AGENCY FOR THE PEEPORMARAL OF THE WORK NM WHICH MIS PEIAI 9ISSUED (SEC.309T,CIVC). LFNOFR'3•'AMr LENIER'S ACTRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATON IS CORRECT. I AGREE TO COMPLY WTTH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON -I SILL T ME 'TO' LED PF C'ERTY YR 113PECTION PURPOSES, l (l• r \4 ,• ' n$cro RMdTEE NAAE(.MIN.) °AKAR&WD�Sr 1.0'4401 SIGNATURE OF PERMITTEE DATE City of Newport Beach Building Department ELECTRICAL Permit No: E2001-1337 PO Sox 1768/3300 Newport Blvd, Newport Beach, California 92658 8015 Permit Counter Telephone (049)644-3288 Inspection RequestsTelephone (949)644-3255 Job Address:1 HOAG DR BIdg: 1 Inspector Area: 7 Owner: Address: Phone: Receipt t: Processed By: Floor: Suite: Code Edit: 96 Legal Desc.: HOAG MEMORIAL HOSPITAL 1 HOAG DR NEWPORT BEACH CA 92658 Description of Work: Contractor: WATSON INVESTMENT DEVELOPMENT Address: 18182 SERRANO AVENUE VILLA PARK CA Phone: 7141974-6421 Con. State Lic. 436023 Lic Expire: 03131/2003 Bus. Lic.: BT98038807 Lic. Exp Date: 1013112001 FEE New Construction Residential Multi -Family 1-2 Family Rec a ptacl elSwitchlOu l I ets Recep/Outlets 67 $46.19 0 $0.00 Fixtures 36 $28.52 0 $0.00 Sep Circuit 30 $112.50 Service Slcins 0 to 600V up to 200A 0 $0.00 Branch Circuit 0 to 600V over 200A 0 $0.00 each Add Circuit Over 600A/1,000A 0 $0.00 Time Clocks TOTAL: $254.96 0 0 0 $0.00 $0.00 $0.00 INSPECTOR NOTES: ELECTRICAL/3RD FLR,"CONFERENCE CIO B2001-2616 / f1 jfi »•o ' 41_ / O Motors/Transformers (HP/KVA' 0 to 1 HP/KW/KVA 1 to 10 HP/KW/KVA 10 to 50 HP/KW/KVA 50 to 100 HP/KW/KVA over 100 HPIKWIKVA Piggy Back I Temp Power PAYMENT: $46.80 Temp Power Pole Temp Underground Sub Panel Record Managment Fee: Investigation Fee $0.00 Plan Check Issuance Supplemental Fee BALANCE: $208.16 $0.00 $0-00 $0.00 $0.00 $0.00 0 0 0 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.50 $0.00 $46.80 $20-45 $0.00 / IICENS D CONTRACTORS DECLARATION Alssieh eby affirm under penalty of perjury that I am licensed under provisions of Chaplet 9 (commencingm/1h Section 701b) of Division 3 of the Business and Professions code, my license is In tulllorce and effect. No: 436023 Class: Contractor. WATSON INVFSTMENT DEVFIOPMENT WORKERS' COMPENSATION DECLARATION I hereby affrm under penalty of perjury one of the following declarations: 1 have and will maintain a cerlilcole of consent lo sett -Insure for workers' compensallan, cs provided for by Section 3100 of the labor code. for the performance of the work for which thls penult is issued. I hove and will maintain workers compensation insurance, as required by Section 37C0 of the labor code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers is: Carrier: STATE FUND Policy number: 2,29-00I 9920 Expire :01/01/2002 This section need not be completed if the permit is for one hundred dollars ($1001 or less. 1 certify That in the performJnce of 6 !e wfvrk for which this permit is ¢sued, I shall nor employ any person in any manner se as to became subject to the workers' compensation laws of ealifornia, nd Hat i 1 sho-tld'w "corm s'bjecbb the workers' compensation provisions of Section 3700 of the labor code, I)shalt forthwith comply with those provisions. Date: aV-at Applicant Signature. 7`�^-rL W Warning: Failure to secure workers' compensation coverage is unlawful, and shall subject an em toyer to atminal penalties and civil fines up to one hundred I$100,00nt',;n addition to she iesr e(compensctioh,d^mrge-as p'avdad for in Section 3706 of the labor code, Interest, and atforney's fees. I hereby doknowlcage thq' I Gas=read this appildrlion: ihst the i formation given is correct: and that I am the owner, ar duly authorized agent of the owner. I agree lo comply with city and state laws regulating construction; and In dung the work authorized thereby, no person will be employed in violation of the labor code of the state or California retorting to workmen's compensation Insurance. Permittee Namf-(f (flint) > . tA1 r k ufm.TSot., Address : Signature of petjnidee:_,. "�.,�ar . t,Jc JAr. Date: Approvals Grounding Electrode Underground Underslab/Floor Rough Conduit Walls Rough Wiring Ceilings Rough Service Temp Power Utility Co. Notified Final InspectorlDate WORK MUST 8E STARTED WITHIN A PERIOD OF i8Q DAYS FROM THE DATE OF VALIDATION OR THIS PERMIT BECOMES NULL AND VOID.. 09'Cad 3 City of Newport Beach Building Department MECHANICAL Permit No: H2001-1088 PC Box 1768/3300 Newport Blvd., Newport Beach, California 92658 891 Permit Counter Telephone (040)644-3288 Inspection RequestsTelephone (949)644-3255 Job Address: 1 HOAG DR Bldg: 1 Inspector Area: 7 Code Edit: 97 Owner: Address: Phone: Issued : Processed By: HOAG MEMORIAL HOSPITAL 1 HOAG DR NEWPORT BEACH CA92658 Floor Suite: Legal Desc.: Contractor: Address: Phone: Con. State Lic Lic Expire: Bus. Lic.: Lic. Exp Date: WATSON INVESTMENT DEVELOPMENT 18182 SERRANO AVENUE VILLA PARK CA 714/974-6421 436023 03/31/2003 BT98038807 10/31/2001 FEES Description of Work: MECHANICAL/ RD FLR CONFERENCE CTR B2001-2616 /.M193L3- /to- O7j9�iC94 INSPECTOR NOTES 4SitiG� CfOp ,s4i/. 3R,C Par ,. li- 19,eg� /�'jc HVAC Items Furnaces up to 100k Stu/hr 0 $0.00 over 100k Btu/hr 0 $0.00 Wall/Floor Heaters 0 $0.00 Heat Pumps & Package Units up to 100k Btu/hr 0 $0.00 up to 500k Btu/hr 0 $0.00 up to 1M Btu/hr 0 $0.00 up to 1.75M Btu/hr 0 $0.00 over 1.75M Btu/hr 0 $0.00 ONTRACTORS DECLARATION Boilers & Compressors up to 3HP over 3HP to 15HP over 15HP to 30HP over 30HP to 50HP over 50HP Misc Items Fire Dampers Gas Line Metal Fireplace ICBO App.#- o $0.00 0 $0.00 0 $0.00 0 $0.00 o $0.00 0 $0.00 0 $0.00 0 $0.00 TOTAL: $35.14 PAYMENT : $0.00 Ventilation Bathroom Fan Exhaust Fan Attic Fan Down -Draft Fan Residential Hood Commercial Hood Repair/Alter/Add Air Handling Units up to 10k cfm over 10k cfm BALANCE: $35.14 0 $0.00 O $0.00 O $0.00 O $0.00 O $0.00 O $0.00 1 $11.35 O $0.00 O $0.00 by 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, my license is In full force and effect, nse No: 436023 Class: Dale: /V 0"'%• O% Contractor: WATSON INVESTMENT DEVELOPMENT WORKERS COMPENSATION DECLARATION: I hereby affirm under penally 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 bySection 3700 of the labor code, for the performance of the work for which this peril is issued. My worker's compensation insurance carer an9 popry re -trier is : Corder: STATE FUND Policy numifee 22.e01,92L Ekoire: 0l/01i2002 (This section need not be conpletec if 1he I..cr.nit is for one hundred dollars ($100 or less). I certify that in the performance of the work sor which thly re-mlt Is Issued, I shall not employ any person in any manner se as to become subject to the workers' compensation laws of Califo la, and agree that if l should become subject to the workers' compensation provisions a Sectlnn 100ptlhe labor code, l shall forthwith comply with those provisions. Dote: O•tt-01 Applicant Signature. Y 1,1 -ta-- Warning: Failure to s..cure xm.cers'.:on,pensabon coverage is unlawful and Fhall subject an employer to criminal penalties and chill fines up to one hundred thousand dollars ($11•0,0001, in additon to the cnst of conpensa1on.dat Inez as provided for In Section 3706 of the labor code, Interest, and attorney's fees. I hereby acknowledge that' Lave read .his application; that the Information given Is correct; and that I am the owner, or duly authorized agent of the owner. I agree to comply with city and state laws regulating construction and in doing the work authorized thereby, no person will be employed In violation of the labor code of the state of California relating to workmen's compensation Insurance. Permittee Name (Prins OrN. ft\%K. V✓. Cc . Address : Signature ofpermitteu:Ti--- ,� -re' Date: i' /0-4'-o7 l"d3 VAV Box Other Record Management Reef Investigation fee Plan Check Issuance Supplemental Fee a $0.00 $0.00 $0.00 $o.50 $0.00 $2.84 $20.45 $0-00 Approvals Inspector/Date Underslab/Floor HVAC/Hood - Rough /!//7/l '/ �/ er Fireplace -Rough Gas Test Fireplace - Final HVAC/Hood - Final I///44-1.--- WORK MUST BE STARTED WITHIN A PERIOD OF 180 DAYS FROM THE DATE OF VALIDATION OR THIS PERMIT BECOMES NULL AND VOID. City of Newport Beach Building Department PLUMBING Permit No: P2001-1203 i` PO Box 1768/3300 Newport Blvd., Newport Beach, California 92658-8915 Permit Counter Telephone (949)644-3288 inspection RequestsTelephone (949)644-3255 Job Address:1 HOAG DR Bldg: 1 Floor: Suite. Inspector Area: 7 Code Edit: 97 Owner Address: Phone: Issued : Processed By: HOAG MEMORIAL HOSPITAL 1 HOAG OR NEWPORT BEACH CA92658 LNA- Legal Desc.: Contractor: Address: Phone: Con. State Lic. : Lic Expire: Bus. Lic.: Lic. Exp Date: WATSON INVESTMENT DEVELOPMENT 18182 SERRANO AVENUE VILLA PARK CA 714/974-6421 436023 03131/2003 BT98038807 10131/2001 Bathroom Fixtures Toilet Bidet Urinal Bath Tub Shower Stall Wash Basin Hydro -Mass Tub Floor Sink 0 0 0 0 0 0 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 D CONTRACTORS DECLARATION Floor Drain Kitchen Fixtures Kitchen Sink: Garbage Disp Bar Sink Vegetable Sink ice Maker Dishwasher Lndry/Trap 0 $0.00 1 $7.95 0 $0.00 1 $7.95 0 $0.00 0 $0.00 0 $0.00 0 $0.00 FEES Description of Work: PLUMBING/3R0 F CONFERCE CTR ,/� B2001-2616 Ching-. �Lo-. �Aci- INSPECTOR NOTES: .a /Olt/ 00- ar's 6nr Regulator 0 $0.00 Lawn Sprinkler 0 $0.00 Mist Water Piping 0 $0.00 Water Softener 0 $0.00 Water Heater 0 $0.00 Gas up to 4 outlets 0 $0.00 Gas over 4 outlets 0 $0.00 Backflow up to 2" 0 $0.00 TOTAL: $40.83 PAYMENT: $3.98 Backflow over 2" 0 Hose Bibb 0 Drinking Fountain 0 Roof Drain 0 Grease Trap 0 Grease Interceptor 0 P-Trap 0 Other BALANCE: $36.85 eby affirm under penalty of penury that I am licensed under provisions a1 Chapter 9 {commencing wilh Section 70001 of Division 3 of the Business and Professions code, d my license is in full force and effect. License No: 436023 Class: Dale: ID'Li- D I Contractor: WAISON INVESTMENT DEVELOPMENT WORKERS' COMPENSATION DECLARATION'. I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consenl to self -Insure for workers' compensation, as provided for by Section 3700 of the labor code, for the performance of the work for whlck 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' compensation insurance carrier and policy number is: Carder: STATE FUND Policy number: 229-0019974 Expire ' DIM /7002 (This section need not be completed if the permit is for one hundred dollars ($1001 or less. I certify that in the performance of ihn work farwhic': thli pencil is issued. I shall not employ any person In any manner so as to become subject to the workers' compensation lows of califor la and agree that if I shoW,s become sulnhcl'a tl.e workers' compensation provisions of Secli 37 of 11 lab- ortc e,, 1 shalt icdhwifh comply with (hose provisions. Date: 1-1- DI Applicant Signature: W blaming: Failure to secure workers' compensalion coverage is unlawful, and shall subject an employer lo cdminal penalties and civil fines up to one hundred thousand dollars l$100,0W). in addition lo the cast of er-pens ationd.1 mays, us provided far in Section 3706 of the tabor code, interest. and attorneys Fees. hereby acknowledge that I have rend 'his hpp:ication: neat the Infnrmelio^ 3iven is correct: and that I am the owner. orduly authorized agent of the owner. I agree to comply with city am. _tote ,aws regusanng cnnslrudion and ir.doing.he woi< authorized thereby, no person will be employed in violation of the labor code of the stale of California relating lo workmen's compensation insurance. Permittee-Name-(Print(X--R�LK--Vdmcts.ask. -.Address Signature of permittee ;^"'& Us}a�:�..- Date: /o-4-ol $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Sewer Sewer 0 Sewer AlterlRepair 0 Sewer Abandon 0 $0.00 $0.00 $0.00 $0.00 Record Management Fee: $0.50 Investigation $0.00 Plan Check $3.98 $0-00 Issuance $20A5 Supplemental Fee $0.00 Approvals Soil Pipe (ground) Sewer Water Pipe (ground) Gas Pipe (ground) Plumbing (rough} Gas Plpe (rough) Water Heater Gas PSI Test Gas Co Notified Final Inspector/Date _ WORK MUST BE STARTED WITHIN A PER{ OF 8 Q DAYS FROM THE DATE OF VALIDATION OR THIS PERMIT BECOMES NULL AND VOID. � (093