HomeMy WebLinkAbout3301 Vivian DriveThe City of Wheat Ridge
Third Party Form Check List
Property Address 3301 Vivian Dr Wheat Ridge CO 80033
Permit Number 201803000
Permit Issued Date 11/13/2018
Owner Information
Property Owner Information Bernadette Whitney
Property Owner Address 3301 Vivian Dr
Inspector Information
Inspection Company Certified Building Consultants
Inspector Name Kraig Stanforth;Travis Stanforth
Inspector Contact info. 720-940-1180 TStanforthCBC aC 2gmail.com
Inspector Statement of Acknowledgemen#
*1 hereby acknowledge the roof I am inspecting is 6/12 or over. All roofs that are under
6/12 must be inspected by the City of Wheat Ridge Building Department.
*1 hereby acknowledge the roofing system for the referenced building has been
inspected and found to be in compliance with the minimum requirements of the 2012
IRC and 2012 IBC as well as the City of Wheat Ridge Policies and Procedures and
manufacturer's reco tionsa. i ions.
Inspector: lti Date:1'�
Pr Owner Statement of Acknowledgement
*1 hereby acknowledge that I am the owner of the building referenced above and I give
my consent for the listed third -party inspection company to perform my roof inspection
in lieu of the City of Wheat Rice Building vision inspection.
Property Owner/Agent: Date:
This original document, as well as the roo checklist, must be submitted to the Chief
Building Official within seven days of the final inspection.
Drop off in person
Permit Counter 2nd Floor
7500 W. 29th Ave
Wheat Ridge, CO 80033
Submit via Email
Kcooka-ci.wheatridge.co. us
CBC Wheat Ridge Roof Inspection Packet Page 2 of 6
N/A ❑ Pass ❑ Fail Metal roof shingles shall not be installed on slope less than 3:12
N/A ❑ Pass ❑ Fail Metal valley flashing shall be the same material as roof
N/A ❑ Pass ❑ Fail Metal valley flashing shall extend a min. of 8" from the
centerline with a min. of 3/4 " high splash diverter rib built-in at
the flow line with the sections overlapping a min. of 4"
Tile Roof Requirements
N/A ❑ Pass ❑ Fail Clay and concrete tile shall have a min. 2-1/2:12 slope
N/A ❑ Pass ❑ Fail Slopes 4:12 and under require double underlayment
CBC Wheat Ridge Roof Inspection Packet Page 3 of
6
The City of Wheat Ridge
Inspection Check List Notes
Mid-Roof
Roof Inspection
❑
N/A
Pass
❑
Fail
Structural roof components
❑
N/A
Pass
❑
Fail
Verify that no more than 2 layers of shingles exist
❑
N/A
Pass
❑
Fail
Flashing for roof and walls
N/A
❑ Pass
❑
Fail
If new sheathing is installed, verify that it is listed in the permit
description (Valuation must be adjusted)
N/A
❑ Pass
❑
Fail
Verify sheathing nail pattern (see Policy and Procedures)
❑
N/A
N/A
❑. Pass
Pass
❑
❑
Fail
Fail
Crickets and saddles where needed
Verify vent must have boot same gauge as pipe
❑
N/A
Pass
❑
Fail
Verify vent caps
❑
N/A
Pass
❑
Fail
Verify no flashings are damaged or rusted
❑
N/A
Pass
❑
Fail
Step flashing shall be min. of 4x4 piece per shingle
❑
N/A
Pass
❑
Fail
Verify scuppers allow for proper drainage
❑
N/A
Pass
❑
Fail
Ice and water shield 2' in heated wall spaces
❑
N/A
Pass
❑
Fail
Underlayments must follow 2012 IRC/2012 IBC
❑
N/A
Pass
❑
Fail
Verify roof slope for proper damage
❑
N/A
Pass
❑
Fail
Dripedge shall have min. of 2" overlap
❑
N/APass
ZK
❑
Fail
Dripedge should extend down min. 2" past roof deck
❑
N/A
X Pass
❑
Fail
Dripedge shall be mechanically fastened 12" OC
N/A
❑ Pass
❑
Fail
90 LB roof roofing shall not be applied to roof slopes less than
2:12 slope. Exception, detached garages, patios, carports, open
on three sides with min. slope of 1:12
N/A
❑ Pass
❑
Fail
Above roof insulation R-25
N/A
❑ Pass
❑
Fail
Below roof residential R-38
N/A
❑ Pass
❑
Fail
Below roof commercial R-32
N/A
❑ Pass
❑
Fail
Modified Bitumen, EPDM, TPO min. slope 1/4:12 slope must be
installed in accordance with the manufacturer's specifications.
Must have manufacturer's letter of warranty with the address
on the letter for final inspection
Metal Roof Shingles Requirements
N/A ❑ Pass ❑ Fail Metal roof shingles shall not be installed on slope less than 3:12
N/A ❑ Pass ❑ Fail Metal valley flashing shall be the same material as roof
N/A ❑ Pass ❑ Fail Metal valley flashing shall extend a min. of 8" from the
centerline with a min. of 3/4 " high splash diverter rib built-in at
the flow line with the sections overlapping a min. of 4"
Tile Roof Requirements
N/A ❑ Pass ❑ Fail Clay and concrete tile shall have a min. 2-1/2:12 slope
N/A ❑ Pass ❑ Fail Slopes 4:12 and under require double underlayment
CBC Wheat Ridge Roof Inspection Packet Page 3 of
6
Company Name:
Inspector Signature:
Date of Inspection:
The City of Wheat Ridge
Inspection Check List Notes
Mid -Roof
Certified Buil
Notes
CBC Wheat Ridge Roof Inspection Packet Page 4 of
6
The City of Wheat Ridge
Inspection Check List Notes
Final Roof
Roof Inspection
❑
N/A
Pass
❑
Fail
Structural roof components
❑
N/A
Pass
❑
Fail
Verify that no more than 2 layers of shingles exist
❑
N/A
Pass
❑
Fail
Flashing for roof and walls
❑
N/A
D( Pass
❑
Fail
Structural roof components
(
N/A
❑ Pass
❑
Fail
If new sheathing is installed verify that it is listed in the
permit description (Valuation must be adjusted)
y,
N/A
❑ Pass
❑
Fail
Verify sheathing nail pattern (See Policy and Procedures)
N/A
❑ Pass
❑
Fail
Crickets and saddles where needed
❑
N/A
Pass
❑
Fail
Verify B vent must have boot same gauge as pipe
❑
N/A
Pass
❑
Fail
Verify vent caps
❑
N/A
Pass
❑
Fail
Verify no flashings are damaged or rusted
❑
N/A
Pass
❑
Fail
Step flashing shall be min. of 4x4 piece per shingle
❑
N/A
Pass
❑
Fail
Verify scuppers allow for proper drainage
❑
N/A
Pass
❑
Fail
Ice and water shield 2' in heated wall spaces
❑
N/A
Pass
❑
Fail
Underlayments must follow 2012 IRC/2012 IBC
❑
N/A
Pass
❑
Fail
Verify roof slope for proper drainage
❑
N/A
Pass
❑
Fail
Dripedge shall have min. 2" of overlap
❑
N/A
Pass
❑
Fail
Dripedge should extend down min. 2" past roof deck
❑
N/A
Pass
❑
Fail
Dripedge shall be mechanically fastened 12" OC
N/A
❑ Pass
❑
Fail
90 LB roll roofing shall not be applied to roof slopes less than
/
2:12 slope: Exception, detached garages, patios, carports, open
on three sides with min. slope of 1:12
N/A
❑ Pass
❑
Fail
Modified Bitumen, EPDM, TPO min. slope 1/4:12 slope must be
installed in accordance with the manufacturer's letter of
warranty with the address on the letter for final inspection
Metal Roof Shingles
Requirements
N/A ❑ Pass ❑ Fail Metal roof shingles shall not be installed on slope less than 3:12
N/A ❑ Pass ❑ Fail Metal valley flashing shall be the same material as roof
N/A ❑ Pass ❑ Fail Metal valley flashing shall extend a min. of 8" from the
centerline with a min. of 3/4 " high splash diverter rib built-in at
the flow line with the sections overlapping a min. of 4"
Tile Roof Requirements
N/A ❑ Pass ❑ Fail Clay and concrete tile shall have a min. 2-1/2:12 slope
N/A ❑ Pass ❑ Fail Slopes 4:12 and under require double underlayment
CBC Wheat Ridge Roof Inspection Packet Page 5 of
6
The City of Wheat Ridge
Inspection Check List Notes
Final Roof
Notes
Company Name: Certified Building Consultants
Inspector Signature:
Date of Inspection:
CBC Wheat Ridge Roof Inspection Packet Page 6 of
6
City of Wheat Ridge
Residential Roofing PERMIT - 201803000
PERMIT NO: 201803000 ISSUED: 11/13/2018
JOB ADDRESS: 3301 Vivian Dr EXPIRES: 11/13/2019
JOB DESCRIPTION: Reroof remove and install GAF Timberline HD Asphalt Shingles with 31
squares. Pitch 4/12. House.
*** CONTACTS ***
OWNER OSTERTAG LIVING TRUST
CON (3 03) 842 -77 68 Bernadette Whitney
SUB (303)332-6224 Chuck Gardner 021423 Gardner Contracting LLC
*** PARCEL INFO ***
ZONE CODE: UA / Unassigned USE: UA / Unassigned
SUBDIVISION CODE: 2403 / APPLEWOOD VILLAGES, PROSPECT V BLOCK/LOT#: 0 /
*** FEE SUMMARY *** ESTIMATED PROJECT VALUATION: 10,075.00
FEES
Total Valuation 0.00
Use Tax 211.58
Permit Fee 220.15
** TOTAL ** 431.73
*** COMMENTS ***
*** CONDITIONS ***
Midroof & Final Roof inspections for ROOFS 6/12 PITCH & OVER: 3rd party inspection will be
required for both the midroof and final inspections. The 3rd party inspection report AND
THE ORIGINAL PERMIT CARD needs to be dropped off to the Permit Desk at the City of Wheat
Ridge. The report MUST BE SIGNED by the Homeowner.
REGARDING ROOF VENTILATION: Roof ventilation shall comply with IBC Sec. 1203.2 or IRC Sec.
R806. The installation of ridge venting requires the installation or existence of soffit
venting. For calculation purposes, one hat or turtle vent equal to one-half of one square
foot of opening.
Effective December 1, 2014, asphalt shingle installations require an approved midroof
inspection, conducted when 25-75% of the roof covering is installed, prior to final
approval. Installation of roof sheathing (new or overlay) is required on the entire roof
when spaced or board sheathing with ANY gap exceeding one half inch exists. Sheathing and
mid -roofs may be called in at the same time, one hundred percent of the sheathing must be
complete and 25-75% of the mid -roof may be complete. Asphalt shingles are required to be
fastened to the roof deck with a minimum of 6 nails per shingle. Ice and water shield is
required. Eave and rake metal is required. A ladder extending 3 feet above the roof eave
and secured in place is required to be provided for all roof inspections. Roof ventilation
is required to comply with applicable codes and/or manufacturer installation instructions,
whichever is more stringent. In order to pass a final inspection of elastomeric or similar
type roof coverings, a letter of inspection and approval from the manufacturer technical
representative stating that "the application of the roof at (project address) has been
applied in accordance with the installation instruction for (roof material brand name) roof
covering" is required to be on site at the time of final inspection.
City of Wheat Ridge
Residential Roofing PERMIT - 201803000
PERMIT NO: 201803000 ISSUED: 11/13/2018
JOB ADDRESS: 3301 Vivian Dr EXPIRES: 11/13/2019
JOB DESCRIPTION: Reroof remove and install GAF Timberline HD Asphalt Shingles with 31
squares. Pitch 4/12. House.
I, by my signature, do hereby attest that the work to be performed shall comply with all accompanying approved plans and specifications,
applicable building codes, and all applicable municipal codes, policies and procedures, and that I am the legal owner or have been authorized
by the legal owner of the property and am authorized to obtain this permit and perform the work described and approved in conjunction with
this�ppermit. I further attest that I am legally authorized to include all entities named within this document as parties to the work to be
pertgrn�ed anan'd/t/h all w rk to perform is disclosed in this document and/or its' accompanying approved plans and specifications.
Signature of OWNER or CVNTRACTOR (Circle one) Date
l . This pen -nit was issued bas'`ed on the information provided in the permit application and accompanying plans and specifications and is
subject to the compliance with those documents, and all applicable statutes, ordinances, regulations, policies and procedures.
2. This permit shall expire 365 days after the date of issuance regardless of activity. Requests for extension must be made in writing and
received prior to the date of expiration. An extension of no more than 180 days made be granted at the discretion of the Chief Building
Official and may be subject to a fee equal to one-half of the originalpermit fee.
3. If this permit expires, a new permit may be required to be obtained. Issuance of a new permit shall be subject to the standard
requirements, fees and procedures for approval of any new permit. Re -issuance or extension of expired permits is at the sole discretion of
the Chief Building Official and is not guaranteed.
4. No work of any manner shall be performed that shall results in a change of the natural flow of water without prior and specific approval.
5. The permit holder shall notify the Building and Inspection Services Division in accordance with established policy of aIl required
inspections and shall not proceed or conceal work without written approval of such work from the Building and Inspection Services
Division.
6. The issuance or granting of a permit shall not be construed to be a permit for, or an approval of, an violation of any provision of any
applicable code or a'y ordinance or regulation of this jurisdiction. Approval of work is subject to field inspection.
Signature of Chief Building Official Date
REQUESTS MUST BE MADE BY 11:59PM ANY BUSINESS DAY FOR INSPECTION THE FOLLOWING BUSINESS DAY.
From: no-reply@ci.wheatridge.co.us
Sent: Tuesday, November 13, 2018 12:38 PM
To: CommDev Permits
Subject: Online Form Submittal: Residential Roofing Permit Application
Categories: Gina
Residential Roofing Permit Application
This application is exclusively for new permits for residential roofs and for licensed
contractors only. This type of permit is ONLY being processed online --do not come
to City Hall to submit an application in person. Permits are processed and issued in
the order they are received and due to the volume of requests, time to process
varies and is subject to change. YOU WILL BE CONTACTED WHEN YOUR
PERMIT IS READY FOR PICK-UP AND WILL BE GIVEN A SPECIFIC DATE
AND TIME WINDOW TO COMPLETE THE TRANSACTION. You will be notified if
your contractor's license or insurance has expired, and you may update those
documents at the time you are issued your permit.
For all other requests:
Homeowners wishing to obtain a roofing permit must apply for the permit in person
at City Hall. Revisions to existing permits (for example, to add redecking) must be
completed in person at City Hall. The Building Division permit counter is open from
7:30 am to 3:30 pm, Monday through Friday to process these types of requests.
THIS APPLICATION DOES NOT CONSTITUTE A PERMIT. DO NOT BEGIN
REROOFING UNTIL PERMIT HAS BEEN ISSUED.
Is this application for a Yes
residential roof?
How many dwelling units Single Family Home
are on the property?
PROPERTY INFORMATION
Property Address
Property Owner Name
3301 Vivian Dr
Bernadette Whitney
Property Owner Phone 303-842-7768
Number (enter WITH
dashes, eg 303-123-4567) S43'1J�
Property Owner Email
heathers@gardner-contracting.com
Address
Do you have a signed
Yes
contract to reroof this
property?
Applications cannot be
submitted without an
executed contract
attached below.
Attach Copy of Executed
signed contract.pdf
Contract
CONTRACTOR INFORMATION
Contractor Business
Gardner Contracting
Name
Contractor's License
021423
Number (This is a 5 or 6
digit number for the City
of Wheat Ridge)
Contractor Phone
3033326224
Number (enter WITH
dashes, eg 303-123-4567)
Contractor Address
909 Telluride St aurora co 80011
(Primary address of your
business)
Contractor Email Address
production@gardner-contracting.com
Retype Contractor Email
production@gardner-contracting.com
Address
DESCRIPTION OF WORK
TOTAL SQUARES of
31
the entire scope of work:
Project Value (contract
10075
value or cost of ALL
materials and labor)
Are you re -decking the
No
roof?
Is the permit for a flat
Pitched roof (2:12 pitch or greater)
roof, pitched roof, or
2
both? (check all that
apply)
What is the specific pitch
of the PITCHED roof?
How many squares are
part of the PITCHED
roof?
Describe the roofing
materials for the
PITCHED roof:
Type of material for the
PITCHED roof.
Provide any additional
detail here on the
description of work. (Is
this for a house or
garage? Etc)
4:12
31 �--
GAF Timberline HD
Asphalt
Tear off and reroof house
SIGNATURE OF UNDERSTANDING AND AGREEMENT
I assume full Yes
responsibility for
compliance with
applicable City of Wheat
Ridge codes and
ordinances for work
under any permit
issued based on this
application.
I understand that this Yes
application is NOT a
permit. I understand I will
be contacted by the City
to pay for and pick up the
permit for this property.
I understand that work Yes
may not begin on this
property until a permit
has been issued and
posted on the property.
I certify that I have been Yes
authorized by the legal
3
owner of the property to
submit this application
and to perform the work
described above.
I attest that everything Yes
stated in this application
is true and correct and
that falsifying
information in this
application is an act of
fraud and may be
punishable by fine,
imprisonment, or both.
Person Applying for Heather Sutcliffe
Permit
Email not displaying correctly? View it in your browser.
11/23/2009 MON 10:15 FAX 303 237 8929 303 Best Way
01002 /002
INSPECTION RECORD OccupancVlType
'INSPECTION LINE: (303) 234 -5933
Inspections will not be made unless this card is posted on the building site
Call by 3:00 PM to receive inspection the following business day.
4 INSPECTOR MUST SIGN ALL SPACES PERTAINING TO THIS JOB
ION INSPECTIONS
DATE
INSPECTOR
INITIALS
COMMENTS:
aissons
ie
W INSPECTIONS
(CEG) Concrete round
Mid-Roof
or Monolithic
rvice
=PJum
of / French Drain
ric
ice Lines
bing__.._..
.. _... _.._ ..... _. _. _ .....
Water Service Lines
Gas Pipin g
CONCRETE SLAB FLOOR
Electrical (Underground)
Plumbing (Underground)
Heating (Underground)
I ROUGHS
ie
Mid-Roof
rvice
=PJum
ric
bing__.._..
.. _... _.._ ..... _. _. _ .....
_ ..
Gas Pipin g
Rough Mechanical
ABOVE INSPECTIONS i0 BE SIGNED PRIOR TO :'rC
'::i::i.v ;'r:'.;
Framing
_
CITY OF NNEAT RiliBE
Insulation
%` 11/23703 8:04 AN edbh
Drywall Screw
n _...._ ___....__ ...._...__._.
Casey CB1Yirt
. - RECEIPT NO:C]IM396 _- ......ANOWT.
FINALS
SPSP Reroof 41 sqs
47505
-....
Electrical
--
Permit Fee _ _.
272.19
-- - -..Use Tax- ..__.. ...
202.95
Plumbing
Mechanical
PAMT RECEIM _
MOUNT
5177 . ..
. 475.05_ .:
Roof
._ -- ...4S. _ .... ..
puth Code:
. _..........086768.. _ -... - _- ......._
........ .... _:
Building Final
TOTAL
475.05
Fire Department
R.O:W & Drainage - INSPECTIONS FOR PLANNING & ZONING FIRE AND PUBLICE WORKS
Parking & Landscaping I SHOULD BE CALLED AT LEAST ONE WEEK PRIOR TO FINAL INSPECTIONS.
"NOTE: ALL ITEMS MUST BE COMPLETED AND APPROVED BY PLANNING AND ZONING, BUILDING AND PUBLIC WORKS BEFORE A i
CERTIFICATE OF OCCUPANCY IS ISSUED. FINAL INSPECTION BY THE BUILDING DIVISION DOES NOT CONSTITUTE AUTHORIZATION
OFA CERTIFICATE OF OCCUPANCY NOR PERMISSION FOR OCCUPANCY.
OCCUPANCY NOT PERMITTED UNTIL CERTIFICATE OF OCCUPANCY.IS ISSUED
♦ i CITY OF WHEAT RIDGE
Building Inspection Division
I (303) 234 -5933 Inspection line
(303) 235 -2855 Office • (303) 237 -8929 Fax
INSPECTION NOTICE
Inspection Type: Mll
' •IrP6
Job Address: 3)1N M'ul'l rn Vr
Permit Number: CITg
flJli(y o
El No one available for inspection: Time ;C) AM�PM
Re- Inspection required: Yes Mo
*When corrections have been made, call for re -ins ection at 303 - 234 -5933
Date: 1 r�, f q q Inspector: r
DO NOT REMOVE THIS NOTICE
~L nom.
p ♦ i CITY OF WHEAT RIDGE
- Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 237-8929 Fax
INSPECTION NOTICE
Inspection Type: ~swrL Job Address: -M)l
Permit Number: O9?2
I
i
i
I
I ;,W AM/PM
❑ No one available for inspection: Time ~~!°=1
Re-Inspection required: Yes No.1
*When corrections have been made, calf for re -inspection at 303-234-5933
Date: in Inspector: _
DO NOT REMOVE THIS NOTICE
w! r ern . r•'
INSPECTION RECORD OccupancvlType
INSPECTION LINE: (303) 234-5933
inspections-will not-be-made unless this card-is posted off-the building site
Call by 3:00 PM to receive inspection the following business day.
INSPECTOR MUST SIGN ALL SPACES PERTAINING TO THIS JOB
FOUNDATION INSPECTIONS DATE INSPECTOR
INITIALS
COMMENTS:
Footings/Caissons
Stemwall / (CEG) Concrete
Encased Ground
Reinforcing or Monolithic
Weatherproof/ French Drain
Sewer Service Lines
Water Service Lines
CONCRETE SLAB FLOOR
Electrical (Undergroun,
Plumbing (Undergroun
Heating (Underground)
ROUGHS
Sheathing
Lath / Wall tie
Mid-Roof
Electrical Service
Rough Electric
Rough Plumbing
Gas Piping
Rough Mechanical
Framing
Insulation
Drywall Screw
FINALS
Electrical
UNTIL ABOVE HAS BEEN
UNTIL
TO BE SIGNED PRIOR TO
CITY OF WHEAT RIDGE
11/23109 8:04 HN edbb
Casey Colvin
RECEIPT NO:CD0003396 AMOUNT
RPSP Reroof 41 sqs 475.05
094200
Permit Fee 272.10
Use Tax 202.95 _
Mechanical PAYMENT RECEIVED - AMOUNT
Roof VS 5177 475.05
8uth Code:
Building Final - -086788
TOTAL 475.05
_
Fire Department
R.O:W & Drainage INSPECTIONS FOR PLANNING S ZONING, FIRE AND PUBLICE WORKS
Parking & Landscaping SHOULD BE CALLED AT LEAST ONE WEEK PRIOR TO FINAL INSPECTIONS.
`NOTE: ALL ITEMS MUST BE COMPLETED AND APPROVED BY PLANNING AND ZONING, BUILDING AND PUBLIC WORKS BEFORE A
CERTIFICATE OF OCCUPANCY IS ISSUED. FINAL INSPECTION BY THE BUILDING DIVISION DOES NOT CONSTITUTE AUTHORIZATION
OF A CERTIFICATE OF OCCUPANCY NOR PERMISSION FOR OCCUPANCY.
OCCUPANCY NOT PERMITTED UNTIL CERTIFICATE OF OCCUPANCY IS ISSUED
`1, A41
City of
-16
,VrWh6atfUdge
CCIAAM1TMTTv ntArPrnDAd"C nr'r
Building Division
7500 W. 29th Ave., Wheat Ridge, CO 80033
Office: 303-235-2855' Fax: 303-237-8929
Inspection Line: 303-234-5933
Property. Address:
Property Owner (pte
Mailing Address; (if different than property address)
Address:
Date:
Permit
State,
Contractor:
Contractor License #:0770 1 -25 -7 V Phone: 303 g-~= 7 76(oS
Use of space (description):
Description of work:
Ptan Review (due at time of submittal): 3
Sq, Ft./L.Ft added: Squares_qj_ BTU's Gallons Amps
OWNERICONTRAOTORSIGNATURE OF UNDERSTANDING AND AGREEMENT
I hereby certify that the setback distances proposed by this penult application art accurate, and do not violate applicable ordinances,
rules or regulations of the City of Wheat Ridge or covenants, easements or restrictions of record; that all measurements shown, and
allegations made are accurate; that I have read and aggree to abide by all conditions printed on this application and that I assume full
responsibility for compliance with the Wheat Ridge Building Code (I.B.C) and all other applicable Wheat Ridge Ordinances, for work
under this permit. Plans subiec lion.
CIRLCE ONE:: (OWNER) (CONTRACTOR) or PERSONAL REP SAEN,TATIVE of (OWNER) (CONTRATOR) o+ Q
PRINT NAM SIGNATURE: Al-l Date: IQ /
Credit Card ayment: Use credit card listed on fit Date: 0.I I L I
Print name. Signature: it
Ze/Ze 39ttd d]]IW3bd L8EEZGZC0C LT:LO 600ZICZITT
Facsimile Building Permit Application