BMCH2015-0085Date: Owner:
I certify that I have read this application and state that the above information is correct.
CONSTRUCTION LENDING AGENCY I agree to comply with all city and county ordinances and state laws relating to building
I hereby affirm under penalty of perjury that there is a construction lending agency for construction, and hereby authorize representatives of this city to enter upon the above•
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). mentioned property for inspection purposes.
Lender's Name: e: - r ;zt Il:7-" Signature (Applicant or Agent):
Lender's Address:
C�
Qum&VOICE (760) 777-7125
78-495 CALLE TAMPICO 0 i7
FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 COMMUNITY DEVELOPMENT
DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 3/24/2015
Application Number: BMCH2O15-0085
Owner: ;
Property Address: 44575 VIA DEL MONTE
CHARLES SHEPARDSON
APN: 604203011
44575 VIA DE NOPAL
Application Description: SHEPARDSON CHUCK HVAC- SPLIT SYSTEM
LA QUINTA, 92253
Property Zoning:
Application Valuation: $8,000.00.
D
Applicant:
MAR 24 215
TRUE AIR MECHANICAL
TRUE AIR MECHANICAL
0 OUTSIDE CITY LIMITS
0 OUTSIDE CITY LIMITS
LA QUINTA, CA 92253 CITYOFLAQUINTA
COMMUNITY DEVELOPMENT DEPARTMENT
LA QUINTA, CA 92253
(949)382-6340
Llc. No.: :LIC -0110617
-----------------------,----------------------------------------------------------------------,
LICENSED CONTRACTOR'S DECLARATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
I hereby affirm under penalty of perjury one of the following declarations:
9 (commencing with Section 7000) of Division 3 of the Business and Professions Code,
_ I have and will maintain a certificate of consent to self -insure for workers'
and my License is in full force and effect.
compensation, as provided for by Section 3700 of the Labor Code, for the performance
License Class: _ License No.: :LIC -0110617
of the work for which this permit is issued.
3 contractor:
I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the of the for which this
Date:
performance work permit
is issued. My workers' compensation insurance carrier and policy number are:
OWNER -BUILDER DECLARATION
Carrier: _ Policy Number: _
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State
I certify that in the performance of the work for which this permit is issued, I
License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
shall not employ any person in any manner so as to become subject to the workers'
city or county that requires a permit to construct, alter, improve, demolish, or repair
compensation laws of California, and agree that, if I should become subject to the
any structure, prior to its issuance, also requires the applicant for the permit to file a
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
signed statement that he or she is licensed pursuant to the provisions of the
comply with those provisions.
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3
% l11
of the Business and Professions Code) or that he or she is exempt therefrom and the
Da e: ` 2 1 Is Applicant: aQ/
basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for
permit subjects the applicant to a civil penalty of not more than five hundred dollars
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
($500).:
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES, AND CIVIL FINES UP TO '
(_) I, as owner of the property, or my employees with wages as their sole
ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF
compensation, will do the work, and the structure is not intended or offered for sale.
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
(Sec. 7044, Business and Professions Code: The Contractors' State License Law does not
INTEREST, AND ATTORNEY'S FEES. {
apply to an owner of property who builds or improves thereon, and who does the work
himself or herself through his or her own employees, provided that the improvements
APPLICANT ACKNOWLEDGEMENT
are not intended or offered for sale. If, however, the building or improvement is sold
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
within one year of completion, the owner -builder will have the burden of proving that
the conditions and restrictions set forth on this application.
he or she did not build or improve for the purpose of sale.).
1. Each person upon whose behalf this application is made, each person at whose
(_) I, as owner of the property, am exclusively contracting with licensed contractors
request and for whose benefit work is performed under or pursuant to any permit
to construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
issued as a result of this application , the owner, and the applicant, each agrees to, and
State License Law does not apply to an owner of property who builds or improves
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
employees for any act or omission related to the work being performed under or
the Contractors' State License Law.).
following issuance of this permit.
(_) I am exempt under Sec. B.&P.C. for this reason
2. Any permit issued as a result of this application becomes null and void if work is
not commenced within 180 days from date of issuance of such permit, or cessation of
Date: Owner:
I certify that I have read this application and state that the above information is correct.
CONSTRUCTION LENDING AGENCY I agree to comply with all city and county ordinances and state laws relating to building
I hereby affirm under penalty of perjury that there is a construction lending agency for construction, and hereby authorize representatives of this city to enter upon the above•
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). mentioned property for inspection purposes.
Lender's Name: e: - r ;zt Il:7-" Signature (Applicant or Agent):
Lender's Address:
FINANCIAL ,• .,
5 1+- i^ su'• tY. _. 4;i Ai � .3 :[ '. ♦:.if -
yDESCRIPTIOyi`1ar 3 !?tKs fACCOUNT ,;fix t C `tQTY
rikgN�r
ly 5 v,+ S - ...
,yr"AMOUNTt;< "PAID PAID'DATE`
.BSAS SB1473 FEE 101-0000-20t3g06 0
$1.00 $0.00
t' -r } h !� r� `T_ � ... • t x.:.K.
t
PAIDBY < + x aMETHOD,,=a r{. c„kRECEIP,T;# M �: .CHECK# +
-�, .,
CLTD.BY`v
,
Total Paid forBUILDING STANDARDS ADMINISTRATION BSA: $1.00 $0.00
i°`, r DESCRIPTION ,r;wz
"�'�M�4',A000.UNT t' w
Fp QTY�T;
h
+ AMOUN
i- PAID; xd
d
PAID DATE
HVAC CHANGEOUT - SPLIT -SYSTEM
101-0000-42402
0
$72.52
$0.00
L>, . ter +
e s, aux wPAIDBY ''fes 1 �:�:n .”
�._ ..�. ... YH µ
" �w4 + 5 R.METHOD .«`�' ^ x
t f + —w
".`.i,;RECEIPT:#4
_«CHECK#
CLTD ABY
i< a+s;b DESCRIPTIONS
r ."ACCOUNT' '�
...•_: , - Y'f ..� x;.
�. QTYf
AMOUNTS ' ':
xx� PAID' '
5..2 1,. , .�C,",:+:
4 PAID DATE
HVAC CHANGEOUT - SPLIT -SYSTEM PC
101=0000-42600
0
$36.26
$0.00
BY;RECEIPT:#r
t :'
�k .10 CHECK # �jj
CLTD BYJ
�. Total Paid forCHANGEOUT: $108.78 $0.00
xN�DESCRIPTIONx...O,, ,,, - 1
s • d� ;A000UNT t j
TY
MOUNT'PAID,PAID?DATE
M
PERMIT ISSUANCE
101-000042404
0
$91.85
$0.00
r .x� : Y• PAID'iBY?t{a..t ;�? s ,c
c a,: METHOD ,r; .+t
l .;7 tyRECEIPT,# ' r:
aCHECK'# Tt:
��CLTD BY
Total Paid for PERMIT ISSUANCE: $91.85 $0.00
TOTALS:00
f
,
•
t
t
•
M
)
•
t
M
)
Description: SHEPARDSON CHUCK HVAC SPLIT SYSTEM
Type: MECHANICAL Subtype: Status: UNDER REVIEW
Applied: 3/24/2015 PJU
Approved: r
Parcel No: 604203011 Site Address: 44575 -VIA DEL MONTE LA QUINTA,CA 92253
Subdivision: TR 23971-1' Block: Lot: 78
Issued: "
Lot Sq Ft: 0 Building Sq Ft: 0 Zoning:
Finaled: ,
Valuation: $8,000.00 Occupancy Type: Construction Type:
Expired:
No. Buildings: 0 No. Stories: 0 No. Unites: 0
r< PAID
Details: REPLACEMENT OF SPLIT SYSTEM A/C NEATING COIL PER 2013 MECHANICAL CODES 2013 ENERGY) CARBON MONOXIDE ALARM(S)
TO BE INSTALLED PRIOR TO FINAL INSPECTION.
.'_z?.. -'� .I..,..
CHRONOLOGY
'u''. ...i4. .... .� .,. `, ` A: '.+ `,!'
CONDITIONS
;'''..
.. ',' .,
:r - =r7' ."'.'i .y
'BY
DESCRIPTION tFs
;ACCOUNT _ '�,?
a QTY ..�'AMOUNTr'
r< PAID
PAIDDATE
,•RECEIPTr# {CHECK#` :
CONTACTS
t. PAID
nNAME TYPE *NAME '� _ t �'
_._-.su-^..,,.ZZm. .4 . ::. u. a.ti�'c _'`+t w r.. +��.,!' .»=:..� :
�'ADDRESSlCITY'$TATEt
zc`tiw .i:>: ;_,-•bcs.-..+�,'�.s.'H
-!a.'��i;-..r.
.-s..a
T`ZIP -'- PHONE:
-.t^^:.'. Se:S. .f.
FAX: 4YEMAIL+ 3"
cNet _r'3,',.-°- "`�.•+:
APPLICANT TRUE AIR MECHANICAL
0 OUTSIDE CITY LIMITS
LA QUINTA
CA
92253 (760)801-6580
0
CONTRACTOR TRUE AIR MECHANICAL
0 OUTSIDE CITY LIMITS
LA QUINTA
CA
92253 (760)801-6580
OWNER ` CHARLES SHEPARDSON
• 44575 VIA DE NOPAL•
LA QUINTA
92253 (760)801-6580
.'_z?.. -'� .I..,..
:.+'. sr:•a c., .-� h't_,.•
'u''. ...i4. .... .� .,. `, ` A: '.+ `,!'
.,,. -
;'''..
.. ',' .,
:r - =r7' ."'.'i .y
'BY
DESCRIPTION tFs
;ACCOUNT _ '�,?
a QTY ..�'AMOUNTr'
r< PAID
PAIDDATE
,•RECEIPTr# {CHECK#` :
METHOD
t. PAID
...
.: '
BY
BSAS SB1473 FEE
101-0000-20306
0
$1.00
$0.00
Total Paid forBUILDING STANDARDS ADMINISTRATION
$1.00
$0.00'
BSA:
r;.
Printed: Tuesday, March 24, 2015 1:53:45 PM 1 of 2 F
SYSTEMS
INSPECTIONS
EQIW "';';'INSPECTION TYPE- -k SPE, 0 SCHEDUL
MECHANICAL FINAL" BLD
I PARENT PROJECTS
BOND
INFORMATION
RECEIPT
101-0000-42402
0
$ 72.52
$0.00
SPLIT -SYSTEM
.
HVACCHANGEOUT-
101-0 000-42600 T
07
$36.26
$0.00
SPLIT -SYSTEM P
Total Paid forCHANGEOUT: $108.78 $0.00
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$0.00
T77
Total Paid for PERMIT ISSUANCE: $91.85 $0.00
TOTALS: $201.63 $0.00
INSPECTIONS
EQIW "';';'INSPECTION TYPE- -k SPE, 0 SCHEDUL
MECHANICAL FINAL" BLD
I PARENT PROJECTS
' .
Printed: Tuesday, March 24, 2015 153:45 PM - 2 ofZ - _
BOND
INFORMATION
' .
Printed: Tuesday, March 24, 2015 153:45 PM - 2 ofZ - _
STATE OF CALIFORNIA
ALTERATIONS - MVAC
CEC-CFIR-ALT-04-E Revised 06/14 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CF111-ALT-04-E
Alterations - HVAC CZ 2, and 8-15 (formerly CF -IR -ALT -HVAC) (Page 1 of 1)
Site Address:
'I 41X75- Ocl
Enforcement Agency:
Date Prepared:
Permit#:
m #A
Equipment Type
Equipment Efficiency
New Ducting, Plenums, Lineset:
Required R -value
Conditoned
Floor Frea (sq ft)
Thermostat
❑ Packaged System
Evaporator Coil
AFUE
COP
❑ R-6 (CZ 2, 8-13) Ducting
Served by system
❑ Setback
getSplit System
Condensing Unit
❑ R-8' (CZ 11, 14, 15) Ducting
rM sgft
(If not already
❑ Mini Split
❑ Compressor
SEER
HSPF❑
'
R-6 (all CZs ) Plenums
present, must
❑ Furnace
❑ Lineset
EER
❑ R-5 or R7.5) Lineset°
be installed)
❑ TXV
HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options below. At permit application this
form is allowed to be filled out by hand. For final inspection all forms are to be registered (no hand filled forms allowed) and a copy left on site.
'PL1. HVAC Changeout/Repair
Required Compliance Documents to be left. on site for Final:
All Equipment,
CFIR-ALT-02-E
Condenser Unit, Evaporator Coil,
CF2R: MECH-01, MECH-20-HERS, MECH-(23 or 24)' -HERS, MECH-25-HERS'
Compressor, TXV, Lineset,
CF3R: MECH-20-HERS, MECH-(23 or 24) -HERS', MECH-25-HERS'
Air Handler/Furnace' (Can include new ducting)
Installer Requirement: Dud leakage (< 15%, or < 10% to outside, or seal all accessible leaks), Air Flow 2 300 CFM/ton, Refrigerant Charge.
.Exempted from duct leakage testing if:
❑ 1. Duct system registered with HERS provider as previously sealed, or ❑ 2. There is less than 40 linear feet of duct in. unconditioned space, or
❑ 3. Existing duct systems are constructed, insulated or sealed with asbestos (list manufacture date of building 1
❑ 2. New HVAC System Required Compliance Documents to be left on site for Final:
All new equipment and. All New Ducts' CF1R-ALT-02-E
including Mini Split CF2R: MECH-01, MECH-20-HERS, MECH-22-HERS, MECH-(23 or 24) -HERS', MECH-25-HERS'
CF3R: MECH-20-HERS, MECH-22-HERS, MECH-(23 or 24) -HERS', ME=H-25-HERS'
Mini Splits require CF1R-ALT-02-E, CF2R-MECH-01, and (CF2R-CF3R) MECH-25-HERS
Installer Requirement: Dud leakage < 6%, Fan Efficacy (.58W/CFM), Air Flow >: 350 CFM/ton (or alternative), Refrigerant Charge
❑ 3. All New Ducts with Replacement Required Compliance Documents to be left on site for Final:
All New Ducts' and one or more of the following CF1R-ALT-02-E
replaced: Condenser Unit, Evaporator Coil, CF2R: MECH-01, MECH-20-HERS, MECH-(23 or 24) -HERS, MECH-25--IERS
Compressor, TXV, Lineset,.Furnace' CF3R: MECH-20-HERS, MECH-(23 or 24) -HERS, MECH-25-HERS
Installer Requirement: Duct leakage < 6%, Air Flow >_ 350 CFM/ton (or alternative), Refrigerant Charge
Exempted from duct leakage testing if; ❑ 1. Existing dud•systems are constructed, insulated or sealed with asbestos
❑ 4. New Ducting over 40 feet Required Compliance Documents to be left on site for Final:
New ducting but less than All New Ducts' CFIR-ALT-02-E, CF2R: MECH-20-HERS, CF3R: MECH-20-HERS.
Installer Required to: Duct leakage (< 15% or, < 10% to outside or, or seal all accessible leaks)
❑ EXCEPTION: Existing duct systems constructed, insulated or sealed with asbestos.
' All new ducting R-8 required when more than 40 ft installed and R-6 when less than 40 ft installed. This includes in walls, between floors etc.
' Heating only systems and Air Handler/Furnace changes do not require Air Flow MECH-(23 or 24), or Refrigerant Charge verification MECH-25
' All New Ducts is when at least 75 percent of the duct system is new duct material, and up to 25 percent may consist of reused parts from the
dwelling unit's existing duct system (e.g., registers, grilles, boots, air handler, coil, plenums, duct material)
R-5 (1" thick insulation) for linesets 1" and less. R-7.5 (1.5" thick insulation) for linesets over 1 inch. Most mfg will require Suction line Diameter
with insulation as the following 1.5-2T-2%", 2.5-3T-2'/.", 3.5 to 4T-2%", 5T-4%"
Contractor (Documentation Author's /Responsible Designer's Declaration Statement)
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Compliance is true and correct.
2. 1 am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the information on this document.
3. That the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the
requirements of Title 24, Parts 1 and 6 of the California Code of Regulations (CCR).
4. That the energy features and performance specifications, materials, components, and manufactured devices for the building design or
system design identified on this Certificate of Compliance conform to the requirements.of Title 24, Part 1 and Part 5 of the CCR.
5. The building design features or system design features identified on this Certificate of Compliance are consistent vith the information
provided on other applicable compliance documents, worksheets, calculations, plans and specifications submitted to the enforcement
agency for approval with this building permit application.
Responsi I Designer Nam
�s Sfe.1efSvh
Responsible Designer Signatu e:
' /�--
Date Signed:
3/z�rl��
License:
�s617�
Company:
Tue A'r i
Address:
City/State/Zip:
618
Phoie:
,�,9
�� ��
a����
v,'ONe
For assistance or questions regarding the Energy Standards, contact the Energy Hotline at: i-tsuu-r/[-ssuu
:.
Clay'of La QuInta
.Buttdtng ez Safety Dlvisfon
P.O. Box IS04,�78-495 Calle TamPtco
La.Qidnta, CA 922S3 •:(760) 7774012
Buffi ing Pennit-Application and Tracking Sheet
Permit U
Pmje«Addtrss: V [,4,,
%. , je Ownce,Nane:
A. P. Number. ' •
Addrem:
Legal don:
City, ST, Zip: /–A v 22�Z,•
Contractor. �
Addm--.
� Telephone: (sp –
Project Description:
City,ST,?rp:
/ //Cls ,
Telephone: 'j
State Ija N :
Ard, , 8W•, Dia:
e0tL, 141 -JI
Address:
Lc Wil(. U-s's –/7L-
/7
City, ST, Zip:
city,
Telephone:
State Lia N:
Name of Contact Person: (�'(
CIf: Y •..
Construction Type:. Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.: 2–S6U d Stores: S UniW
Tdcphonc t7 of Contact Person:
Z_ i / Estimated Value of Project(7t',E�
APPLICANT: DO NOT WRITE BELOW THIS UNE
Y Submittal Req'd 'Reed TRACKING PERMU FRES
Plan Sets
Plan Check submitted Item Amount
Stmetaral Cates.
Reviewed. ready for cormllon Pian Cbedc Deposit. .
Truss Cala.
Called Contact Perera Pian Check Balance.
Mrie za alp
Plans picked upConstrnedon
Mond plain plan
Pians resubmltted:. Machadlai
Ginding plan
V Review, ready for correetloaeltaue Fdeetsial
Sabcoatactor List
Called CootactPersoo Ptutnbtng
Grant Deed
Plans picked up SILL
H.O.A. Approval
Fla as resabmftd Grading
61 HOISE:•
Review, ready for c arrecdoustWue Developer Impact Fee
Planning Approval •
Called Contact Person A.LP.P. '
Pub. WkL Appr
Date of permttktite
School Fees
Total Permit Fees
B1n.B
Cl y 0'fla Quihta
Building ar Safety Duron
P.O. Box I SO4, •78-495 Calle Tampico
La.QufttCk CA 92253 • (760) 7774012
Building Pertnit -Application and Tracking Sheet
Perinit #
Project.Addrcss; `bk
h c -c—
Owner'sNama.
A. P. Number.
Address:
Legal tion;
Contntotor
City. ST, Zip:. JrfjA
telephone.. � —
ProjectDescription:
Adi: c .
City, $T. Zip:..
/
!
Telepho-5-
State lac t7:: 7 `SSG! • 7(
Arch.,':" ,Designer:
City Lic fl .. f o O ..
.. ,•
eo ; 71"(
City, ST. Zip:
Telephone:
State Lia B:
Construction Type:. Occupancy.
Project type (circle ono): New Add'n Aller Repair Demo
Name of Contact Person: G'/ j
Sq. FL: � -{� $ Stnrits: Z H (kut3 f
Tel c F of Contact Person:
Z- % /
Estimated Value of Project
APPLICANT: DO NOT WRITE BELow THIS LINE
Submittal Req,d 'Reed TRA47MG PERI rr Ens
Pian Seb
Ptah Cheek submitted Item Amount
titmdutat Carie.
Rtvkwed, rndy for eomecttons Plan Check Deposit, .
Truss Cala.
. 64ed Contact Person Pian Oteek lWance.
mile 24 CakL
Pians picked up Construedou
Flood plain plan
Pians rtsnbmittM.. Mechatikal
Gindtea plan
V Review, ready for correctlaadhaue Electrical
Sobeontactor List
Called ContactPtraoa Pluatblas
Gnat Dad
Plans pieced ap S MI
H.O.A. Approval
Pians rtsabmftd Grading
W HOUSE:-
sa hauteur; ready for cerrections/issue Developer Impact Fee
Punning Approval.
Called Contact Person A I P.P. '
Pub. WkL Appr '
Dalt of permitisaue
School Fen
Total Permit Fees
Buffft lit Safety DWY M
P.O. Box 1504,78495 Caffe TaM000
4.Qi*4 CA.92253 •.-(760) 7777012
Building Permit -Application and Tracking Sheet
P+erinit
'/
PMj"t Ad I=: q7T 7< V J
,, t
/ �i� l� .O-na', N.. C S ,.xv�►..
A P: Number l _
Address: �/SFSI$� 1!/k— f r4JfE
XAW Description:.
Contractor AL
Ad&=
CIO', ST, Zip: CA,- 7 22,S'
Tolophonc: (gyp
PmjectDescription:
City. $r. zip:
/ /T7S C, j'azi
4a.
r�itpnatt�5 -38-Z - G337
•
-
stateI:tap: /J�ti� 7�
CiryLic i3; la1j,l( .. S L -u�
Arab, Bug:, Desigter
:.. .;
Addros
`c GtJrl(• (&g �7,&— '`
City, ST, Zipi
?eieptwpe:
State MQ S:.
Construction Types • Oc6pamcr
Project type (circle one): New Add'n Alta Repak Demo
Name of Contact Peraoa:
Sq. Ft: 2-s-60-{% Storlis: 2-. • 1 S Unita
Telephone # of Contact Person:
y_ '7 / Estimebcd Valut of Project gbnp .,
APPLICANT: DO NOT WRITE BELOW THIS UNE
Y Submittal Sega
Reed Tt3ACMG PERM T I=
Plan Seb,
Pian Cheek submitted - Item Amount
St'oetural wes.
Rtviewed, ready for correcttou Plan Check Deposit. .
Thm Gala.. ,
Called Contact Perann Pula Chert Ralance.
title 24 C"
Pians picked up Conatrncdon
Flood Plain plan
Plana resubmitted.' MecAariiul
Gradiug pian
2'`• Review, ready for correedounnue Elemial
Subentaetor List
Called Contact Person Ptumblui ,
Grant Deed
Plans picked up S.M.I.
H.OAL Approval
Plans resubmitted Grading
10 HOUSE:•
r'' gevtev , ready for correeUouAcsue Developer.Impact Bee
Piaoulag Approval.
Called Contact Person AI.P.P.
Pub. Wks. Appr
Date of permit Issue
School Fees
Total Permit Fees _