HomeMy WebLinkAbout039-100-022A.P. 39-10-22
ROBERT G. LOCEY
E/S Chico Ricer Rd. ,' lst hse. S.
of Morehead Ave.,
Chico
P"erm 't"137'4�74B--('r'er'oof")'-`------------ `v
39-10-22
2185 Chico River Rd, Chico
C Contr: Four Counties Roofing q
Permit#2641-88B(reroof/SF)
B07=2240;:
MISCELLANEOUS' SHV-AC Cha.nge'Out
CHANGE OUT HVAC UNIT ->�
21.85.-CHICO RIVER;'RD�: i�•w
,LOCEY ROBERT �G & HELEN
l
�r M cm
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BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT
24 HOUR INSPECTION #:(530) 538-7636 (OROVILLE) (530) 891-2834 (CHICO)
OFFICE #:(530) 538-7541 FAX#: (530) 538-2140
WEBSITE: www.buttecounty.net\dds
PROJECT INFORMATION
Site Address: 2185 CHICO RIVER RD
Owner:
Permit No: B07-2240
APN: 039-100-022
LOCEY ROBERT G & HELEN
Issued Date: 10/29/2007 By KCG
Permit type: MISCELLANEOUS
2185 CHICO RIVER ROAD
Subtype: HVAC Change Out
CHICO, CA 95928
Expiration Date: 10/28/2008
Description: CHANGE OUT HVAC UNIT
(530) 342-8111
Occupancy: Zoning: A10
Contractor
Applicant:
Square Footage:
GALLAGHER'S HEATING & AIR
GALLAGHER'S HEATING &,
Building Garage Remdl/Addn
PO BOX 35
PO BOX 35
LOS MOLINOS, CA 96055
LOS MOLINOS, CA 96055
Other Porch/Patio Total
(530) 384-2444
(530) 384-2444
FEE INFORMATION
DBM Heat Pump (Package Unit) $58.00
Total Charged: $58.00 Fees Paid: $58.00
Balance Due: $0.00 Receipt No: B5142
LICENSED CONTRACTOR'S DECLARATION
OWNER / BUILDER DECLARATION
Contractor (Name) State Contractors License No. / Class / Expires
I HEREBY AFFIRM UNDER PENALTY OF PERJURY that I am exempt from the Contractors License
GALLAGHER'S HEATING & AIF 777334 / C20 C38 / 04/30/2008
Law for the following reason (Sec. 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 such permit to file a signed statement that he or she is licensed
I HEREBY AFFIRM UNDER PENALTY OF PERJURY that I am licensed under provisions of Chapter 9
(commencing with Se ion 7000) of Division 3 of the Business and Professions Code, and my license
pursuant to the provisions of the Contractors License Law [Chapter 9 (commencing with Section 7000)
is i f r and a
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
10/29/2007
the applicant to a civil penalty of not more than five hundred dollars [$500];
Please check one of the following:
Contractor's S19jalure Date
-11, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE
COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR
OFFERED FOR SALE (Sec. 7044, Business and Professions Code: The Contractors License
Law does not apply to an owner of the property, who builds or improves thereon, and who does
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY one of the following declarations:
the work himself or herself or through his or her own employees, provided that such improvements
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR
are not intended or offered for sale. If, however, the building or improvement is sold within one
WORKERS' COMPENSATION, as provided for by Section 3700 of the Labor Code, for the
year of completion, the owner -builder will have the burden of proof that he or she did not build or
performance of the work for which this permit is issued.
improve for the purpose of sale.).
n,N'iAVE AND WILL MAINTAIN WORKER'S COMPENSATION INSURANCE, as required by
❑ I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED
CONTRACTORS TO CONSTRUCT THE PROJECT (Sec. 7044, Business and Provessions Code:
L_FJ Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers' Compensation insurance
The Contractors License Law dows not apply to an owner of the property who builds or improves
carrier and policy number are;
thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the
State Fund 713-0013855 05/01/2008
Carrier: Policy Number: Exp. Date:
Contractors License Law.).
(This section nee not be completed if the permit is or ons a ui— ndr%d dollars ($loo) or less.
E] IAM EXEMPT under Section B. 8 P.C. for this reason:
❑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'
X 10/29/2007
compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those
Owners Signature Date
provisions.
X 10/29/2007
I hereby certify that I have read this application and state that the above information is correct. I agree
to comply with all City and County ordinances, rules, regulations, and State laws relating to building
Signat a Date
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
construction, and with any and all conditions of permit. I agree to defend, indemnify, and hold harmless
Butte County, its officers, agents and employees from any and all claims and liability for personal
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,
injury, including death, and property damage roused t is arising out of, or in any way connected with
o,o
the issuance of this permit. I hereby acknowledge that issuance of this permit does not authorize the
DAMAGES AS PROVIDED FOR INSECTION 3706 OF THE LABOR CODE, INTEREST AND
ATTORNEY'S FEES.
use or occupancy of any sidewalk, street, or subsidewalk. I hereby authorize representatives of Butte
County to e�above property for inspection purposes. I hereby certify that 1 am the
roperty.o ct on the property o Hers be If/9'/2007
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY that there is a construction lending agency for
ame Priot Date
the performance of the work for which this permit is issued. (3097 civ. code)
❑ Owner ❑ Contractor OR: Agent for Owner Agent for Contractor
FILE COPY
Lender's Address City State Zip
l Las( Na -le
t -tanner
BUTTE COUNTY
DEPARTMENT OF DEVELOPMENT SERVICES
BUILDING PERMIT APPLICATION
24 HOUR MSPECISONIt O OVILLE: UBMITTAL REQUIREMENTS 30) - 6 - O: 530 284
OFFICE #: (530) 538-7541 (' 891 �ti +�
A FEF_ rvILI_ 6E REQUIRED AT TIME OFAPPIICATION
Wcbsitc: wNvw.buttecounty.net/dds
**PLEASE PRINT CLEARLY**
IAT/ON
Fir N e PROJECT LOCATION
� fAP4
°
OVER FOR SUBMITTAL REQUIREMENTS
K:T0RMSI8UILDING F0RMS1BldgApplSubRgmts.doc
Page 1 of 2
Cross sire—el
WORKER'S COMPENS /TA pN
Policy Number
Carrier
PURAZT1-
Np.l
If hiring anyone other than license contractors, a certificate of worker's
compensation must be shown at the time of permit issuance.
LENDING AGENCY
Name
Address
Description or Scope of Work:
_, ,. _
Sq FT- Living Garage 9 Open Cov
❑ Structure Built without Permits
❑ Proposed Change of Occupancy
(Note previous use):
EXPIRATION OF APPLICATION
Applications for which a permit has not hecn issued gill cNhi1-e title
Year after the date of application. In order, to rcni.,a ;lclion tilt ,111
application after expiration, a new application, I,)Ivu and fee twill he
feuired.UEST FOR REFUNDS
Refunds can only be made upon written requcsl by the I,c,-son \\ho
paid the fee. 1 -he request must be made prior to the expiration of, (Ile
pennil and no construction work has been done. r ilinr, Ices. 1)1;111
check fees for work plan checked and other deparinicnl cots are not
refundable.
Received by: Amount: 0-0
_ SRA
Receipt #: ,
-----.._..-- - —..... - ... ..... Sheriff
rid
Dale:
Total
REV 8-12-05
COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS
7 County Center Drive - Oroville, (Oliforni 95965 - Telephone: 9.16/538-7541
APPLICATION AND PERMIT
PERMIT NO.
ASSESSOR PARCEL NUMFUR— e,
ZONING
BUILDING PERMIT
OWNER
TELEPHONE 7
SQ. FT. OCC.1 BUILDING VALUATION
OWNER'S MAILING ADDRESS ,
;i)
CONTRACTOR'S NAME
TELEPHONE
CONTRACTOR'S MAILING ADDRESS
Fireplace
CONSTRUCTION LENDER
UNKNOWN
Total Valuation $
Filing Fee
$ 10,00
LENDER'S MAILING ADDRESS
Permit Fee
$ �-
ARCHITECT OR ENGINEER
LICENSE NO.
Plan Checking Fee
$
Energy Plan Checking Fee
$
ARCHITECT OR ENGINEER'S MAILING ADDRESS
Penalty
$
BUILDING ADDRESS
Permit fee
$ 1
PLUMBING PERMIT
Filing Fee 10.00
Each Trap. 1
1 2.00
Solar or heat pump water heater
20.00
LOT NO.
SUBDIVISION NAME PARCEL MAP
Water piping
5.00
Each qas water heater or vent
5.00
USE OF STRUCTURE
SF ❑ Duplex❑ Mobilehome❑ Other
SPECIFY
Gas piping system 1 - 5 outlets
5.00
Building sewer
5.00
Mobile Home S I G I W
0.00ea
TYPE OF WORK
New ❑ Addition ❑ Remodel ❑ Utilities ❑ Installation❑ Other ❑.
Describe work: _
Permit Fee
$
Contractor
ELECTRICAL PERMIT
Filing Fee 10.00
Main service 100V DR LESS
100 AMP OR LESS
10.00
Main service EA. ADO'L 100 AMP
2.50
CONTRACTORS LICENSE LAW
I declare under penalty of perjury (Check One):
❑. I am licensed under provisions of Chapt. 9, Div. 3 of the' Busines$
and Professions Code and my license is in full force .and effect.
� 11
'— �
License No. Classification
El 1, as the owner, or my employees with wages as their sole compen-
sation, will do the work,and the structure is not intended or offered
for sale. (Sec. 7044)
❑ I, as the owner, am exclusively contracting with licensed contract-
ors. (Sec. 7044)
❑ I am exempt under Sec. , Business and Professions Code
for this reason
NEW CONST. DWELLING OCCUP.51) '/zQsgft
OR ADONS. ACC. BLDGS.
NEW CONSTR.MULTI-OUTLET 2,50 ea
NON.RESID BRANCH CIRC TS
POWER APPARATUS e)
SINGLE OUTLET CIR.
OUTLETS OR FIXTURES
Ex. Occup .0 90
FIXED PR
Ex. Occup. OUTLETS (RESID )EA.? 2.00
Temporary service 10.00
Mobile Home Facilities 15.00
Misc. Wiring 15.00
Permit Fee $
Contractor
MECHANICAL PERMIT
Filing Fee 10.00
WORKMEN'S COMPENSATION INSURANCE
I declare under penalty of perjury (check one):
❑ The permit is for $100.00 (valuation) or less.
❑I have placed on file with the County of Butte Building Department
a Certificate of Workmen's Compensation Insurance or a Certificate
of Consent to Self -Insure.
❑ I shall not employ any person in any manner so as to become subject
to the W. C. laws of California.
Notice to Applicant: If after making this statement, should you become subject
to the W. C. provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked.
Heating
Cooling
Hood
3.00
Ventilation
permit Fee
$
Contractor
I certify that I have read this application and state that the above information
is correct. I agree to comply to all County Ordinances and State Laws relating
to building construction, and hereby authorize representatives of the Countyot
Butte to enter upon the above-mentioned property for inspection purposes.
I also agree to save, indemnify and keep harmless the County of Butte against
all liabilities, judgments, costs, and expenses which may in any way accrue
against said County in,conseq/ue/R/`ce of the granting of this permit.
X /k%+ %V( r,,! lL.�
Signature of Applicant – Owner E]Contractor ElAgentF-1work
An OSHA permit is required for excavations over 5'0" deep and demolition or construct-
ion of structures over 3 stories in height.
Mobile Home Installation Fee
$
Energy Inspection Fee $
TOTAL PERMIT FEE $ J1, , .1.
Occup.
CONST.TYPC
SCHOOL
FLOOD
PARCEL
P11
I No
I 13SUE
Vol,
This permit is hereby issued under the applicable provi-
sions of the Butte Count Code and/or resolutions to do
indicated above for which fees have been paid.
r DIRECTOR OF PUBLIC WORKS
. �, , Date U - a
BY Xr
PERMIT EXPIRES rDate Y r7 - /
. - .
Receipt No.�i
WHITE-D.P.W.. YELLOW -ASSESSOR, PINK -INSPECTOR. GOLDENROD-AP►LI CANT
COUNTY OF BUTTE - DEPARTMENT OF PUBLIC WORKS
7 County Center Drive - Oroville, CaliforNa 95965 - Telephone: 916/538-7541
APPLICATION AND PERMIT
I
P IT O.
ASSE}S,Oj\PARCEL NN MBER�
ZONING
BUILDING PERMIT
OWNER
Robert Lo
TELEPHONE
342-811
SO. FT. DCC- BUILDING VALUATION
OWNER'S MAILING ADDRES
2185 Chico River Rd., Chico
3
t' n
CONTRACTOR'S NAME
Four Counties Roofing
TELEPHONE
343-141
'
CONTRACTOR'S MAILING ADDRESS
3 Crusader Ct . Chico CA
Fireplace
CONSTRUCTION LENDER
UNKNOWN'
Total Valuation $ 1.8Q0.00
Filing Fee
$ 10.00
LENDER'S MAILING ADDRESS
Permit Fee
$
ARCHITECT OR ENGINEER
LICENSE NO.
Plan Checking Fee
$
Energy Plan Checking Fee
$
ARCHITECT OR ENGINEER'S MAILING ADDRESS
Penalty
$
BUILDING ADDRESS
Permit fee
$
PLUMBING PERMIT
Filing Fee 10.00
2185 Chico River Rd. , Chico
Each Trap
2.00
Solar or heat pump water heater
20.00
LOT NO.
SUBDIVISION NAME
PARCEL MAP
Water piping
5.00
Each qas water heater or vent
5.00
USE OF STRUCTURE
SF[2 Duplex[] Mobilehome❑ Other
SPECIFY
Gas piping system 1 - 5 outlets
5.00
Building sewer
5.00
Mobile Home S G W
O.00ea
TYPE OF WORK
New ❑ Addition ❑ Remodel ❑ Utilities ❑ Installation[] Other [
Describe work:
Re -roof
Permit Fee
$
Contractor
ELECTRICAL PERMIT.
Filing Fee 10.00
V OR L
Main service 100 AMP ORSLESS
10.00
Main service EA. ADD'L 100 AMP
2.50
CONTRACTORS LICENSE LAW
I declare under penalty of perjury (check one):
❑� I am licensed under provisions of Chapt. 9, Div. 3 of the Business
and Professions Code and my license is in full force and effect.
489246 C-39
License No. Classification
I, as the owner, or my employees with wages as their sole compen-
sation, will do the work,and the structure is not intended or offered
for sale. (Sec. 7044)
'
❑ I, as the owner, am exclusively contracting with licensed contract-
ors. (Sec. 7044)
❑ I am exempt under Sec. , Business and Professions Code
for this reason
NEW CONST. DWELLING OCCUR
OR ADDNS. ( ACC. SLOGS. , /20sgft
NEW CONSTR. MU TI.OUTLET 2,50 ea
NON-RESID BRANCH CIRC ITS
POWER APPARATUS e
(SINGLE OUTLET CIR. I
Ex. Occup(OUTLETS OR FIXTURES 5AL03t
ewL030
FIXED❑
Ex. DCCUp. OUTLETS P(RESID )REA.I 2.00
Temporary service 10.00
Mobile Home Facilities 15.00
Misc. Wiring 15.00
Permit Fee $
Contractor
WORKMEN'S COMPENSATION INSURANCE
I declare under penalty of perjury (check one):
❑ The permit is for $100.00 (valuation) or less.
I have placed on file with the County of Butte Building Department
a Certificate of Workmen's Compensation Insurance or a Certificate
of Consent to Self -Insure.
❑ I shall not employ any person in any manner so as to become subject
to the W. C. laws of California.
Notice to Applicant: If after making this statement, .should you become subject
to the W. C. provisions of the Labor Code, you must forthwith comply with such
provisions or this permit. shall be deemed revoked.
MECHANICAL PERMIT
Filing Fee 10.00
Heating
lin
Cooling
Hood
3.00
Ventilation
permit Fee
Contractor
$
I certify that I have read this application and state that the above information
is correct. I agree to comply to all County Ordinances and State Laws relating
to building construction, and hereby authorize representatives of the County of
Butte to enter upon the above-mentioned property for inspection purposes.
1 also agree to save, indemnify and keep harmless the County of Butte against
-all liabilities, judgments, costs, and expenses which may in any way accrue
ag t said County 'n cons 4ue ce t e granting of this permit.
X Date 8-16-88
Si nature of Applicant — Owner ❑ Contractor ❑ Agent B
An OSHA permit is required for excavations over 5'0" deep and demolition or construct-
ion of structures over 3 stories in height.
Mobile Home Installation Fee $
Energy Inspection Fee $
TOTAL PERMIT FEE $ 39.50
occuP.
CONST.TYPEJ
SCHOOL
FLOOD
PARCEL
PD
HD
se
This permit is hereby issued under
sions of the Butte County Code and/or
work Indicated above for which
DIRECTO O PUBLIC
By
44
PERMIT EXPIRES Date— '7—
the applicable provi-
resolutions to do
fees have been paid.
WORKS
Date
r/J
— ��
Receipt No. a
WHITE-O.P.W.. YELLOW -ASSESSOR, PINK -INSPECTOR, GOLDENROD -APPLICANT
*(0 �'� 3° .,so
uN0°°
PERMIT NO. 1374-74B
P
E
M
MH UTIL.
PERMIT NO.
PERMIT EXPIRES
OWNER Robert G. Locey
CONTR.'� Owner
LOCATION (A.P. 39-10-22 )
E/S Chico River Rd., lst.hse.
S. of Morehead Ave, Chico
q
l
Temp. Power Pole
Called PG&E
Temp. Elea Serv.
Called PG&E
Temp. Gas Serv.
Called PG&E
a JOB _ , / /
FINALED Z V
(Date)
(Signature)
Setback
Forms
Main Bldg.
Footings
Stemwal I
Slab
Piers
Garage
Footings
Stemwa I I
Slab
Carport
Footings
Slab
Patio
Footings
Masonry Walls
Reinf. Steel
Bond Beam
Framing
Stucco
Mesh
Scratch
Brown
Finish
Interior Lath
Door Closer
DATE
COUNTY OF BUTTE'.—' DEPARTMENT OF PUBLIC WORKS
BUILDING INSPECTION RECORD
UILDING BUILDING (Cont'd)
PLUMBING
Firewall
Soil Piping
Parapets
1st Floor
Restroom Finish
2nd Floor
Windows
3rd Floor
Siding
To out
Roof Sheathing
Water Piping
Roofing
Sewer
Fdn. Vents
Fixtures
Garage Vents
Water Htr.
Prov. for physically
handicapped
Heaters
Appliances
Conformance of ex.
structure
Gas Piping & Test
Temp. Gas
Final
Sanitation
FIREPLACE
Final
Footing I ELECTRICAL
FIRE SPRINKLERS
Test
Final
MECHANICAL
Heating
Cooling
Ducts
Ventilation
Final
REMARKS OR CORRECTIONS
6
Motors
Water Htr.
Subpanels
Grd. Fault Prot.
Service
Temp. Pole
Underground
Permanent
Final
COUNTY OF BUTTE — DEPARTMENT OF PUBLIC WORK
7 County Center Driver Orville, California 95965 ^�
Telephone: 534-4541 j
APPLICATION AND PERMIT
authorize representatives of the County of t3utte to enter upon the
above-mentioned property for inspection purposes.
Xu—Date, 9��
Signature of Permitee or Agent
Receipt No.� l q
White-D.P.W. — Yellow-Assessor'f— Pink -Inspector — Goldenrod -Applicant
This permit is hereby issued under the applicable provisions of
the Butte County Code and/or resolutions to do work indicated
above for which fees have been paid.
DIRECTOR/0F PUBLIC WORKS
By Date moi/ -3 u— 7 5F
B ding permit expires Date ............... Y.�7.? 7A
BUILDIN
Owner
SQ. FT. I OCC. BUILDING VALUATION
Mailing Address G 3v
-
Telephone No.
2
Fireplace
Contractor
Total Valuation
Mailing Address ,
Permit Fee
Plan Checking Fee &/or Penalty
Telephone No.
Permit Fee
$
Building Address�. �'VC
PLUMBING
No.
@ FEE
PERMIT FILING FEE $2.00
/
,o.
Each Trap 1.50
Repair drainage or vent piping
1.50
Water piping 1.50
Each gas water heater or vent 1.50
A. P. No.Gas
— lQ Z
Zoning & Planning
piping system 1 - 5 outlets
1.50
Each additional outlet .30
s
S
Fire Dept.
FireZone
Use Permit
Building sewer 5.00
EQA
Parking
Plans
Parcel
Declaration
Parcel Ma P
60' R/W
Improvements
P
Lawn sprinkler system 2.00
Bldg. Plans Rec'd
Parcel Approval
Plans Approval
Permit Fee
$
$
NEW ❑ ADDITION ❑ UTILITIES ❑ OTHER ❑
ELECTRICAL
No.1
@ FEE
PERMIT FILING FEE $3.00
Main service incl. 1 meter
Additional meters, each
1.00
Sub -panel (12 or less) (more than 12)
Single Family ® Duplex ❑ Mobil Home ❑ Others ❑
Range, Cook -top or Oven 1.00
Water Heater or Space Heater
1.00
Light fixtures20 bal_�fd10
Receps., switches & fix outlets 120 25
CONTRACTORS LICENSE LAW
I am licensed under the provisions of Chapter 9, Div. 3, of the
State of California Business & Professions Code under the name
style of:
Hood, Ex. FanorF.A. Furn. Motor
1.00
Evap. cooler, gar. disp. or D.W. 1.00
Air conditioner or heat pump
Water pump
Mobil Home Facilities 5.00
Temp. Power Pole 5.00
License No. Classification
Misc. wiring
I am exempt from the Contractors License Laws of the State of California.
Permit Fee
$
$
WORKMEN'S COMPENSATION INSURANCE
1 am aware of the provisions of Section3700 of the California Labor
Code which requires every employer to be insured against liability
for Workmen's Compensation.
❑ I have placed on file with the County of Butte a certificate of
Workmen's Compensation Insurance.
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 Workmen's Compensation Laws of
California.
MECHANICAL
No.
@ FEE
PERMIT FILING FEE $3.00
Heating
Cooling
Ventilation
Hood 2.00
Permit Fee $
$
I certify that I have read this application and state that the above
information is correct. I agree to comply to all County Ordinances
and State Laws relating to building construction, and hereby
TOTAL PERMIT FEE
$ O
authorize representatives of the County of t3utte to enter upon the
above-mentioned property for inspection purposes.
Xu—Date, 9��
Signature of Permitee or Agent
Receipt No.� l q
White-D.P.W. — Yellow-Assessor'f— Pink -Inspector — Goldenrod -Applicant
This permit is hereby issued under the applicable provisions of
the Butte County Code and/or resolutions to do work indicated
above for which fees have been paid.
DIRECTOR/0F PUBLIC WORKS
By Date moi/ -3 u— 7 5F
B ding permit expires Date ............... Y.�7.? 7A