HomeMy WebLinkAboutUntitled •
a
YE#
I (AP use only)
ACCOUNTS PAYABLE CHECK REQUEST
Request Date 07/27/2020 Department DSD - Development Services
k„ 7Check Payable to Triangle Services
p .,-�c)rYOF P.O. Box 153
:
.ClLC.t ADI A] Address
1 S El Monte, CA 91733
City,State,Zip Code
INVOICE NUMBER(S)
(if applicable)
ACCOUNT NUMBER(S) AMOUNT
714-2275 5 3,575.00
5
$
$
r
S
TOTAL CHECK AMOUNT $ 3,575.00
Reason for Payment:
Refund demolition bond to the above recipient for 925 Hampton Rd
Permit Demo-18-1910
APPROVED'BY(MUST BE SIGNED$Y'AUTHORIZED SIGNERS) „; •, n
Signature Date Approved
2nd SIGNATURE REQUIRE(}FDR ANY CHECK AMOUNT OVER$2;500 `j �,
• Signature Date Approved
ACCOUNTS PAYABLE USE ONLY
I
Check here if check is to be I I Reviewer's Initials
returned to Department
VR112019
r- City of Arcadia, CA _ Permit NO Demo 18 1910.
Development Services Department 1 Q }-r .� Y' 1 {zy4 °5... Permit Type Demolition.
n 240 West Huntington Drive,Post Office Box 60021 ! r t°E°E '? ''i 7
1 f- i ' i r =� 1 ( Work classification Demo Residential '
'� Arcadia,CA 91066-6021 �""} ( .) 4 ��
I , ."i (626)574-5416 - - _ ',Permit Status Issued
ARCADIA IssueAateb3/31/2020'1 p Expiration:
Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number \
925 Hampton RD Arcadia, CA 5769013036
Contacts
SPENCER,SHIRLEY CTR SHIRLEY SPENCER Owner Triangle Services _ Contractor
TRUST 2422 Durfee, El Monte,CA 91732
925 HAMPTONRD;ARCADIA CA,91006 (626)201-4840 830943
Description:DEMO HOUSE/DETACHED GARAGE,POOL, Valuation: $ 0.00 Tenant
REFUND BOND TO TRIANGLE SERVICES PO BOX 153 5 EL
MONTE,CA 91733 Total Sq Feet: 3.575.00 Plan Check N Plan tt
Fees Amount Payments Amount Paid
Bond for Demolition $3,575.00 Total Fees $3,800.75
Demo-Sewer Cap and/or Cesspool Fill $15.55 Cash/Receipt a REC-04178-20 $3,800.75
Demolition Permit $108.93
Amount Due: $0.00
Demolition Permit Issuance Fee $47.01
Plumbing Permit Issuance Fee $47.01
Solid Waste Management Fee $6.25 �f 302o 5ei�6„..0, __
Solid Waste Management Fee 2 $1.00
Total: $3,800.75 51 COMPLETED
/�/�'A/ CALLS FOR INSPECTIONS
�� �� ��; I) a7 a Request for inspection by telephone at 626-574-5450. Leave a message
/
WuV requesting the address,timeframe and what inspection item is needed.
This permit/plan review expires by time limitation and becomes null and
void if the work authorized by the permit is not commenced within 180 days
from the date of issuance or if the permit is not obtained within 180 days
from the date of plan submittal.This permit expires and becomes null and
void if any work authorized by this permit is suspended or abandoned for 180
consecutive days or if no progressive work has been verified by a City of
Arcadia building inspector for a period of 180 consecutive days.
5 el It
6' 'dee/
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March 31, 2020
Issued By: Date
March 31,2020 Page 1 of 1
.FAR
4 vyvoAq
• PERMIT/PLAN REVIEW APPLICATION
,.&.
SE .arum' _.' .
14:13:10,/ Development Services Department, 240 West Huntington Drive,Post Office Box 60021
Arcadia, CA 91066-6021, (626) 574-5416,Fax (626) 447-9173
City of
Arcadia C r/ COP Y
LICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
❑ I hereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under penalty of perjury one of the following:
Chapter 9(commencing with Section 7000,of Division 3 of the Business and
Professions C.,�,and my license is in full J e/,. e t ect. at/JR/22
0 I have•and will maintain a certificate of consent to self-insure for workers'
License Class .li
'ce No.�G!`l� xp. Datil/v� compensation, as provided for by Section 3700 of the Labor Code, for the
Signature of Contractor An. / performance of the work for which this permit is issued.
OWNER-BUILDER ARATION ❑ I have and will maintain workers'compensation insurance,as required by Section
❑ I hereby affirm under pen: .'perjury that I ant exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit
License Law for the folio . on(Section 7031.5,Business and Professions tis issued.M/ a s'c tpe s ' insurance carrier and policy numbers are:
Code.Any city or county which requires a permit to construct,alter,improve, Carrier
demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number U6 -9M Ss2 I ?o-I(�-20
for such permit to file a signed statement that he or she is licensed pursuant to the
provisions of the Contractors License Law(Chapter 9(commencing with Section r(This section need not be completed if the permit is for one hundred dollars or less)
7000)of Division 3 of the Business and Professions Code)or that he or she is
exempt there from and the basis for the alleged exemption. Any violation of 0 I certify that in the performance of the work for which this permit is issued,I shall
Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subject to the workers'
penalty of not more than five hundred dollars($500)): 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
❑I, as owner of the roe forthwith c mp with those provisio
property,rty, or my employees with wages as their sole
compensation,will do the work,and the structure is not intended or offered for
sale(Section 7044,Business and Professions Code:The Contractors License Date SOW Signature
Law does not apply to an owner of property who builds or improves thereon,
or who does such work himself or herself or through his or her own
employees,provided that such improvements are not intended or offered for WARNING::Failure to secure rs'Compensation coverageis unlawful,
sale.If,however,the building or improvement is sold within one(1)year of ,- ;and shall subject an employer to criminal penalties and civil fines up to one
completion,the owner-builder will have the burden of proving that he or she .. hundred thousand dollars($100,000),in addition to the cost of compensation,
did not build or improve for the purpose of sale). :damages as provided for in Section 3706 cif the Labor Code,interest, and
attorney's fees.
0 I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Section 7044,Business and Professions
Code:The Contractors License Law does not apply to an owner of property CONSTRUCTION LENDING AGENCY
who builds or improves thereon,and who contracts for such projects with a I hereby affirm under penalty of perjury that there is a construction lending agency
contractor(s)licensed pursuant to the Contractors License Law). for the performance of the work for which this permit is issued (Section 3097,
Civil Code).
❑ I am exempt under Section 7044,Business and Professions Code,for this reason:
Lender's Name
Date Signature Lender's Address
IMPORTANT: APPLICATION IS HEREBY MADE TO THE BUILDING OFFICIAL FOR A PERMIT SUBJECT TO THE CONDITIONS AND
RESTRICTIONS SET FORTH ON THIS APPLICATION AND THE FOLLOWING:
1. The City's approved plans and permit inspection card must remain on the job site for use by City inspection personnel.
2. Final inspection of the work authorized by this permit is required.A Certificate of Occupancy must be obtained prior to use and occupancy of new buildings
and structures.
3. Per South Coast Air Quality Management District(AQMD)regulations,renovation and remodeling work that results in the removal,stripping,or altering
of asbestos containing materials requires an asbestos survey and removal prior to disturbing the asbestos.Please contact AQMD at(909)396-2000 for
further information.'r /_C /`y ��p��
ante J V✓' �J/�(SU1/m� +Title �WfV�r`
PRINT NAME
I ertify that I have read this application and state that the above information is corkect and that I am the owner or duly authorized agent of the owner.
I agree to comply with all City ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of
Arcadia to enter upon the above-mentioned property for inspection purposes.
` p1 ll7-\
\çure (::::::21(111 \ Date / /
C�
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(AP use only)
4 I tie
ACCOUNTS PAYABLE CHECK REQUEST
14 i
Request Date 07)27)2020 Department DSD - Development Services
Check Payable to Triangle Services
A �t IT OF P.O. Box 153
AtRCADIA Address
S El Monte, CA 91733
City,State,Zip Code
INVOICE NUMBER(S)
(if applicable)
. ACCOUNT NUMBER(S) AMOUNT
714-2275 $ 3,575.00
5
$
5
5
TOTAL CHECK AMOUNT $ 3,575.00
Reason for Payment:
Refund demolition bond to the above recipient for 925 Hampton Rd
Permit Demo-18-1910
APPROVED'BY(MUST BE SIGNED BY AUTHORIZED SIGNERS) ,
Signature Date Approved
2ndSIGNATURE,REQUIRED HFOR ANY CHECK AMOUNTOVER'$2,500 ' ,'" 1., :, a° :+
Signature Date Approved
ACCOUNTS PAYABLE+USE'ONLY
Check here if check is to be I-I Reviewer's Initials
returned to Department I I
VR112019
k '''_ t A PermitNO-Demo-18-1910
City of Arcadia, CA
Development Services Department 3 *'D 1 y' ""'+",7>^�re Permit Type Demolition_:
C 240 West Huntington Drive,Post Office Box 60021 f S; t {C' (1
!c,s , .v Arcadia,CA 91066-6021 _ f,`$ i i F�1i . t 3[4(9 k�Classification Demo Residential'
(626)574-5416 • _ - -. ` ry PermitSfotus:'Issued
ARCADIA Issue-Date:03/31/20201 Expiration
Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number
925 Hampton RD Arcadia,CA 5769013036
Contacts
SPENCER,SHIRLEY C TR SHIRLEY SPENCER Owner Triangle Services .. Contractor
TRUST 2422 Durfee, El Monte,CA 91732
925 HAMPTON RD:ARCADIA CA,91006 (626)201-4840 830943
Description:DEMO HOUSE/DETACHED GARAGE,POOL, •.(
Valuation: $ 0.00 Tenant
REFUND BOND TO TRIANGLE SERVICES PO BOX 153 5 EL
MONTE,CA 91733 Total Sq Feet: 3.575.00 Plan Check# Plan#
,------, a.:._.-.ate-.�.. ...., _ r.- :,.. ,aa
Fees Amount Payments Amount Paid
Bond for Demolition $3,575.00 Total Fees $3,800.75
Demo-Sewer Cap and/or Cesspool Fill $15.55 Cash/Receipt#REC-04178-20 $3,800.75
Demolition.Permit $108.93
Amount Due: $0.00
Demolition Permit Issuance Fee $47.01
Plumbing Permit Issuance Fee $47.01
Solid Waste Management Fee $6.25 1 f r3o20 $c/r Coe c5t___
Solid Waste Management Fee 2 $1.00
Total: $3,800.75 1151ert ,
CALLS FOR INSPECTIONS/VI
, ,�� ,, f el/, 'tel a7 /&MRequest for inspection by telephone at 626-574-5450. Leav i8liie's5 e.,
COLrequesting the address,timeframe and what inspection item is neW,:
This permit/plan review expires by time limitation and becomes null and
void if the work authorized by the permit is not commenced within 180 days
from the date of issuance or if the permit is not obtained within 180 days
from the date of plan submittal.This permit expires and becomes null and
void if any work authorized by this permit is suspended or abandoned for 180
consecutive days or if no progressive work has been verified by a City of
Arcadia building inspector for a period of 180 consecutive days.
Seel i(
6' 'deet
Aall
Ac
March 31, 2020
Issued By: Date
March 31,2020 Page 1 of 1
. PERMIT/PLAN REVIEW APPLICATION
•f ,.
a'41b. Development Services Department,240 West Huntington Drive,Post Office Box 60021
%Ph,et-* Arcadia, CA 91066-6021, (626) 574-5416, Fax (626) 447-9173
City of
Arcadia C m y C OF Y
LICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
❑ I hereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under penalty of perjury one of the following:
Chapter 9(commencing with Section 7000,of Division 3 of the Business and
Professions C,)�,and my license is in full r e/:,'' e t ect. [/` ❑ I have and will maintain a certificate of consent to self-insure for workers'
License Class . "ce,;'No.�f�`J1 xp. Da[A/�I zZ compensation, as provided for by Section 3700 of the Labor Code, for the
Signature of Contractor A?". I performance of the work for which this permit is issued.
OWNER-BUILDER 'i
ARATION 0 I have and will maintain workers'compensation insurance,as required by Section
I hereby affirm under pen: r'perjury that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit
0
License Law for the folio . on(Section 7031.5,Business and Professions is Mprpe s insurance carrier and policy numbers are:
Code.Any city or county which requires a permit to construct,alter,improve, Carrier / /��/J �j �/��
demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number t/6 _"!r- t 56-27 ZQ-/ -K/
for such permit to file a signed statement that he or she is licensed pursuant to the
provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less)
7000)of Division 3 of the Business and Professions Code)or that he or she is
exempt there from and the basis for the alleged exemption. Any violation of ❑ I certify that in the performance of the work for which this permit is issued,I shall
Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subject to the workers'
penalty of not more than five hundred dollars($500)): 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
❑I, as owner of the property, forthwith mp with those provisio
or my employees with wages as their sole
compensation,will do the work,and the structure is not intended or offered for
sale(Section 7044,Business and Professions Code:The Contractors License Date Signature
Law does not apply to an owner of property who builds or improves thereon,
or who does such work himself or herself or through his or her own
employees,provided that such improvements are not intended or offered for WARNING: Failure to secure ers'.Compensation coverage is unlawful,
sale.ff,however,the building or improvement is sold within one(1)year of , - and shall subject an employer to criminal penalties and civil fines up to one
completion,the owner-builder will have the burden of proving that he or she _ hundred thousand dollars($100,000),in addition to the cost of compensation,
did not build or improve for the purpose of sale). - 'damages as provided for in Section 3706 of the Labor Code, interest, and
attorney's fees.
❑I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Section 7044,Business and Professions
Code:The Contractors License Law does not apply to an owner of property CONSTRUCTION LENDING AGENCY
who builds or improves thereon,and who contracts for such projects with a I hereby affirm under penalty of perjury that there is a construction lending agency
contractor(s)licensed pursuant to the Contractors License Law). for the performance of the work for which this permit is issued (Section 3097,
Civil Code).
0 I am exempt under Section 7044,Business and Professions Code,for this reason:
Lender's Name
' Date Signature Lender's Address
IMPORTANT:APPLICATION IS HEREBY MADE TO THE BUILDING OFFICIAL FOR A PERMIT SUBJECT TO THE CONDITIONS AND
RESTRICTIONS SET FORTH ON THIS APPLICATION AND THE FOLLOWING:
I. The City's approved plans and permit inspection card must remain on the job site for use by City inspection personnel.
2. Final inspection of the work authorized by this permit is required.A Certificate of Occupancy must be obtained prior to use and occupancy of new buildings
and structures.
3. Per South Coast Air Quality Management District(AQMD)regulations,renovation and remodeling work that results in the removal,stripping,or altering
of asbestos containing materials requires an asbestos survey and removal prior to disturbing the asbestos.Please contact AQMD at(909)396-2000 for
further information.
are J V v't hel tis'—'3 Title
PRINT NAME
I ertify that I have read this application and state that the above information is corhect and that I am the owner or duly authorized agent of the owner.
I agree to comply with all City ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of
Arcadia to enter upon the above-mentioned property for inspection purposes. p1 ide..,-)
C::::Matjf.-------:-----
\ amre ` \ Date 4/
YE if
(AP use only)
ACCOUNTS PAYABLE CHECK REQUEST
Request Date 07/27/2020 Department DSD - Development Services
Check Payable to Triangle Services
CtryopAddress P.O. Box 153
.AR.CADIA
S El-Monte, CA 91733
City,State,Zip Code
INVOICE NUMBERS)
(if applicable)
ACCOUNT NUMBER(S) AMOUNT
714-2275 $ 3,575.00
$
$
$
$
TOTAL CHECK AMOUNT $ 3,575.00
Reason for Payment:
, Refund demolition bond to the above recipient for 925 Hampton Rd
Permit Demo-18-1910
APPROVED BY(MUST BE SIGNED'BY AUTHORIZED SIGNERS) "`
Signature Date Approved
2nd SIGNATURE REQUIRED lOB ANY CHECK AMOUNT OVER$2,500
Signature Date Approved
ACCOUNTS PAYABLE;USE ONLY -
Check here if check is to be Reviewer's Initials
returned to Department
VR112019
f s ,, City of Arcadia, CA Permit NO Demo 18 1910
Development Services Department r
i F „ Y epr '-h Fr rG� r= Permit Type Demohron
\4k4
240 West Huntington Drive,Post Office Box 60021 { 11 e !a i , �j' { I
r Arcadia,CA 91066-6021 1 c--. , c-1) E' Hat.
Iti Work Classification Demo-Residential
;i .. t - L
(626)574-5416 --- . mit-Status:Issued
I � _ . x . : Per
_
ARCADIA - Issue Date:03/3i/262o 1 Expiration:
Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number
925 Hampton RD Arcadia, CA 5769013036
Contacts.«.
SPENCER,SHIRLEY C TR SHIRLEY SPENCER Owner Triangle Services _ Contractor
TRUST 2422 Durfee,El Monte,CA 91732
925 HAMPTON RD,ARCADIA CA,91006 (626)201-4840 830943
Description:DEMO HOUSE/DETACHED GARAGE,POOL, t Valuation: $ 0.00 Tenant
REFUND BOND TO TRIANGLE SERVICES PO BOX 153 5 EL
MONTE,CA 91733 Total 5q Feet:
d 3.575.00 Plan Check N Plan N
t ,
Fees Amount Payments Amount Paid
Bond for Demolition $3,575.00 Total Fees $3,800.75
Demo-Sewer Cap and/or Cesspool Fill $15.55 Cash/Receipt k REC-04178-20 $3,800.75
Demolition Permit $108.93
Amount Due: $0.00
Demolition Permit Issuance Fee $47.01
Plumbing Permit Issuance Fee $47.01
Solid Waste Management Fee $6.25 c-{-'
r,3�0 ��'c."ss_c_
Solid Waste Management Fee 2 $1.00
Total: $3,800.75 0. compiETEDOr 4
-
hi �1�f �/ �1/�/ CALLS FOR INSPECTIONS Np
'�� I r'. at,, i/ oc•f "" `-'Request for inspection by telephone at 626-574-5450. Leave's s5Age.,
/ DE requesting the address,timeframe and what inspection item is ne it d '
This permit/plan review expires by time limitation and becomes null and
void if the work authorized by the permit is not commenced within 180 days
from the date of issuance or if the permit is not obtained within 180 days
from the date of plan submittal.This permit expires and becomes null and
void if any work authorized by this permit is suspended or abandoned for 180
consecutive days or if no progressive work has been verified by a City of
Arcadia building inspector for a period of 180 consecutive days.
6' 'dee/
`----ai %2'
/6 III
Ac
March 31, 2020
Issued By: Date
March 31,2020 Page 1 of 1
,FAR
0,JFOR%.44# .
ilii PERMIT/PLAN REVIEW APPLICATION
•,%,: Development Services Department,240 West Huntington Drive, Post Office Box 60021
c> Arcadia, CA 91066-6021, (626) 574-5416,Fax (626) 447-9173
City of
Arcadia C r l C 617Y
LICENSED CONTRACTOR'S DECLARATION / WORKERS'COMPENSATION DECLARATION
❑ I hereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under penalty of perjury one of the following:
Chapter 9(commencing with Section 7000,of Division 3 of the Business and
Professions C.1i,and my license is in full e//�'. e i ect. // ❑ I have and will maintain a certificate of consent to self-insure for workers'
License Class i •ce.�7 No. E+_�JI xp. Dat /�/ ZZ compensation, as provided for by Section 3700 of the Labor Code, for the
Signature of Contractor 1 Ii. performance of the work for which this permit is issued.
OWNER-BUILDER ARATION ❑ I have and will maintain workers'compensation insurance,as required by Section
❑ I hereby affirm under pen: .'perjury that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit
License Law for the folio • • -. on(Section 7031.5,Business and Professions is issued.M%tvi
is' •c pe s insurance carrier and policy numbers are:
Code.Any city or county which requires a permit to construct,alter,improve, Carrier ''22 /J �7�/�
demolish,or repair any structure,prior to its issuance,also required the applicant U/J -%M sc2 ! l(/9-to
for such permit to file a signed statement that he or she is licensed pursuant to the Policy Number
provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less)
7000)of Division 3 of the Business and Professions Code)or that he or she is
exempt there from and the basis for the alleged exemption. Any violation of ❑ I certify that in the performance of the work for which this permit is issued,I shall
Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subject to the workers'
penalty of not more than five hundred dollars($500)): 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
0 I, as owner of the roe forthwith c mp with those provisio
property,rty, or my employees with wages as their sole
compensation,will do the work,and the structure is not intended or offered forZa
sale(Section 7044,Business and Professions Code:The Contractors License Daze I Signature
Law does not apply to an owner of property who builds or improves thereon,
or who does such work himself or herself or through his or her own
employees,provided that such improvements are not intended or offered for WARNING: Failure to secure ers'.Compeusation coverage is unlawful; 1
sale.If,however,the building or improvement is sold within one(1)year of c_ • ,and shall subject an employer to criminal penalties and civil fines up to one
completion,the owner-builder will have the burden of proving that he,or she _ -hundred thousand dollars($100,000);in addition to the cost of compensation,
did not build or improve for the purpose of sale). - _ - 'damages as provided for in Section 3706 of the Labor Code,..interest, and
attorney's fees.
0 I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Section 7044, Business and Professions
Code:The Contractors License Law does not apply to an owner of property CONSTRUCTION LENDING AGENCY
who builds or improves thereon,and who contracts for such projects with a I hereby affirm under penalty of perjury that there is a construction lending agency
contractor(s)licensed pursuant to the Contractors License Law). for the performance of the work for which this permit is issued (Section 3097,
Civil Code).
❑ I am exempt under Section 7044,Business and Professions Code,for this reason:
Lender's Name
Date Signature Lender's Address
IMPORTANT: APPLICATION IS HEREBY MADE TO THE BUILDING OFFICIAL FOR A PERMIT SUBJECT TO THE CONDITIONS AND
RESTRICTIONS SET FORTH ON THIS APPLICATION AND THE FOLLOWING:
1. The City's approved plans and permit inspection card must remain on the job site for use by City inspection personnel.
2. Final inspection of the work authorized by this permit is required.A Certificate of Occupancy must be obtained prior to use and occupancy of new buildings
and structures.
3. Per South Coast Air Quality Management District(AQMD)regulations,renovation and remodeling work that results in the removal,stripping,or altering
of asbestos containing materials requires an asbestos survey and removal prior to disturbing the asbestos.Please contact AQMD at(909)396-2000 for
further information. 6-6(2-#3-73yy ��tt ���
ame J �� be/ Title L�7..//t�t5r`
PRINT NAME
I ertify that I have read this application and state that the above information is cor ct and that I am the owner or duly authorized agent of the owner.
I agree to comply with all City ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of
Arcadia to enter upon the above-mentioned property for inspection purposes. 167.)7-)'gn `ature \Da /te �