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HomeMy WebLinkAbout219 WELLESLEY LN - Building Permits p CITY OF COSTA MESA 4 BUILDING DIVISION >w• ,,,,. ,r DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F I 11"...-2.10. IPI PERMIT �y,`° o,m�w 602-00150 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 219 WELLESLEY LN Status: ISSUED Suite: Applied: 01/31/2002 Vicinity: Issued: 01/31/2002 Parcel Number: 14139532 Zoning: Applicant: ZYCH, JEFF ISSUED BY: Address: 2519 BOWDOIN PL Phone: 714-366-7744 COSTA MESA,.CA - ' Zip: 92626 Owner: ZYCH,JEFF Address 2519 BOWDOIN PL Phone: 714-366-7744 COSTA MESA,CA Zip: 92626 Contractor: OWNER-BUILDER Address: Phone: Zip: License: 0 Arch : - Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT INTERIOR REMODEL OF 2 EXISTING BATHROOMS AND 6 WINDOW REPLACEMENTS(SAME SIZE)IN A SFD. FEE SUMMARY Plan Check: $0.00 Calc Valuation: $2,000.00 Permit: $69.25 • Claim Valuation: $2,000.00 SMIP Res: $0.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 • Total: $69.75 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front, 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days,or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 iSd 2446-46(6/00) a .._ V DECLARATIONSI WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty 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 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 are: Carrier: Polity Number: (This section need not be completed if the permit is valued at one hundred dollars($100)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 these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARE(S100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect.Lic.4 Class 4 Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: - Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5.Business and Professions Code:Any city or county which 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 pursuant to the provisions of the Contractors License Law(Chapter 9(commenting with Section 7000)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 sbjects the applicant to a civil penalty of not more than five hundred dollars($500).): I,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 property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.It,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 purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant t•the •ntractors License Laws.). ❑ I am . sec.; Business and Professions Code for this reason: Signature: , Date: 1-51-02, Owner ID ye".4' i s i•'Else. ❑Yes 0 No Driver's License No. . Expires: Vedficati• • by(typr • ..,. ment,I.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth Into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,talsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,An 2,Sec. 341,Title 8,Calitomla Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has e permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the Californla Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,ora volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ 2 Does or wit the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? LiYes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the Califomia Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application agerit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes A No (Section 65850.2 of the California Government Code requires that the requested intonation be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes',the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? 0 Yes 0 No B (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORI TION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with st: t I: s an ciy ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for' spec'• • •oses.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sighef :t..ee _ gad 11q\Mgne Date Am.Or ' t mit'peasant Date ONE t INSPECI1ONTYPF, J PEE MAU LODE( INSPECTIONTYPg PATE INIMAL6 rr 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention • 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Be 204 Final Demolition 250 Final Building/Occupancy �/.�/noZ • p4W M 9 CITY OF COSTA MESA • BUILDING DIVISION et r ,• \I DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 4 PERMIT. IIIPM E02-00085 Sbaltalli0#4. (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 219 WELLESLEY LN Status: ISSUED Suite No Applied: 01/31/2002 Vicinity: Issued: 01/31/2002 Parcel Nunmber: 14139532 Applicant: ZYCH, JEFF ISSUED BY: Address: 2519 BOWDOIN PL - Phone: 714-366-7744 COSTA MESA,CA: Zip: 92626 Owner: . ZYCH;JEFF ' ' - Address 2519 BOWDOIN PL Phone: 714-366-7744 ' COSTA MESA,CA Zip: 92626 , Contractor: OWNER-BUILDER Address: Phone: Zip: License: 0 SCOPE OF PERMIT ELEC PERMIT TO REPLACE 2 GFI INTERIOR REMODEL OF 2 EXISTING BATHROOMS IN A SFD.2 OUTLETS - - REF: B02-00150 FEE SUMMARY Quantity Quantity . ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa .$0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $0.00 0 - up to 50 kva/kw _ $0.00 0 Recept Outlets $2.20 . I- 2' up to 100 kva/kw '$0.00 0 Switches $0.00. - 0 over 100 kva/kw $0.00 0 , • Non Res Appl ' $0.00 ., 0 Low Voltage Equipment $0.00 0 Res Appl " $0.00 0.` , - Low Volt Wiring System/Ckt $0.00 - 0 -- Service to 200a $0.00 - _ 0' - Miso.Conduit $0.00 0 Service to 1000a ' . $0.00 , 0 Misc. Conductor $0.00 . 0 Service over 1000a $0.00 0' Circus(gen or ride) , ' $0.00 . 0'/ Motors to 1 hp $0.00 -- .0 . Circus(mech ride or lights) - $0.00 . ,0 Motors to 10hp $0.00 ' 0 Christmas Tree Stand $0.00. 0 Motors to 50hp $0.00 . 0 Fireworks Stand ' - ' $0.00 0 Motors to 100hp $0.00 ' - 0 ' - ' 'Other Electrical Fee $0.00 Motors over 100hp $0.00 - 0" Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $25.70 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days,or if work is suspended or abandoned fora period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 is; 2446-46(6/00) 4' • . DECLARATIONS 1 WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty 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 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 are: Carrier: Policy Number: (This section need not be completed if the permit is valued of one hundred dollars($100)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 these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST.AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.If Class R Contractor's Signature: _ Date: CONSTRUCTION LENDING AGENCY: o I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which 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 pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)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 the applicant to a civil penalty of not more than five hundred dollars($500).): I.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 property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within ono year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as ownor of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license p ua the ntractors License Laws.). ❑ I am ex mat 1 sec. Business and Professions Code for this reason: Signature: Expires: Verification n y(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Gm 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the Calif omia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? D Yes LJ No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that undor penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AN AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I :gree • c lyl th all sta ajaws and city ordinances relating to building construction,end authorize representatives of the City of Costa Mesa to enter upon the above-d:- ribed • •ce Yo inspecti urposes.I agree not to occupy or allow occupancy of any building authorized by this pe it until final inspection. I re Of Legal Owner(s) Date -nd/Or Authorized Applicant Date 000E I I11SPECT10NTYPE PATE MALE con! INSPECTION TYPE PATE RITITIALA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final -.8 Fi I Plumbing ..---- o 201 Final Re-Roof / 10 al Elect' I •i 201 Final Block/Retaining Wall Mar Inal Fi ventio 202 Final Factory Fire Place 220 Final ning Approval . 203 Final Sign _ 222 Final Site 204 Final Demolition .250 Final Building/Occupancy i • toll.M CITY OF COSTA MESA k` BUILDING DIVISION a q • DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F I � 'sa I k "K PERMIT E02-00085 Mit (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 219 WELLESLEY LN Status: ISSUED Suite No Applied: 01/31/2002 Vicinity: Issued: 01/31/2002 Parcel Nunmber: 14139532 Applicant: ZYCH, JEFF ISSUED BY: v 1 Address: 2519 BOWDOIN PL - ., - - Phone: 714-366-7744 COSTA MESA.CA - Zip: 92626 .. Owner ZYCH,JEFF Address 2519 BOWDOIN PL Phone: 714-366-7744 COSTA MESA,CA Zip: 92626 . Contractor: OWNER-BUILDER • ' Address: - • .--Phone: Zip: License: 0 - • SCOPE OF PERMIT ELEC PERMIT TO REPLACE 2 GFI INTERIOR REMODEL OF.2 EXISTING BATHROOMS IN A SFD.2 OUTLETS - - - -- - ." - -_ ' - REF:802-00150 4/16/02 SUPPLEMENTAL PERMIT:27 LIGHT FIXTURES,2 SWITCHES. FEE SUMMARY • Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 ' Standing Section $0.00 0 • New Res(1-2 units) $0.00 0 - Misc Electrical Equipment $0.00 0 New Res(3+units) . .. $0.00 0 : Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 _ _ 0 up to 10-kva/kw.._ $0.00 0 Lighting Fixts $27.11 . 27. up to 50 kva/kw $0.00 0 Recept Outlets $2.20 2 up to 100 kva/kw $0.00 0 Switches $2.20 2 over 100 kva/kw $0.00 0 Non Res Appl - $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 Service to 1000a $0.00, 0 Misc.Conductor '$0.00 0 Service over 1000a . $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 - 0 - ' Fireworks Stand $0.00 0 Motors to 100hp $0.00 0- Other Electrical Fee ' $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 . Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $55.01 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 7 i 264646(6/00) S . al • DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty 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. O 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 are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) O 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 Califomia,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 these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: • I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class# Contractor's Signature: _ Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which 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 pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)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 s jects the applicant to a civil penalty of not more than five hundred dollars($500).): I,as owner of the properly,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 property who builds or Improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement Is sold within one year of completi. ,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am XCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The con ac•s License .w does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) livens. - rsu. t'•t :Contrac•r-License Laws.). O I am-xemp m:r s•c. Business aria Professions Code for this reason: ZSigr tura: cDate: 4-1k,-0 g\ Owner ID verii:.b Sys lic- :r ❑Yes ❑No [Dover's License No.. Expires: _ Verification .f Ow :r ••.e of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes D No (Section 25505 of the California Health and Safely Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safely Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes I0 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If'ryes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: -t CERTIFICATE OF COMPLIANCE AND AUTHORIZA ON OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all Stas;I s and cit ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property f In :.ctiDrl es.I a Tee not to occupy or allow occupancy of any building authorized by this permit until fiplal inspection. : -e I own°(s) 1;Date:.:,- d/Oft ho ed p cant Date CODE I INSPECTION TYPE PANE JBIIDAL5 CODE( INSPECTION TYPE PATE KLEGALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing -. • 200 Final Re-Roof 210 Final Electrical 7e#. j Y 201 Final Block/Retaining Wall 212 Final Fire Prevention U 202 Final Factory Fire Place 220 Final Planning Approval . 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy - 051 A CITY OF COSTA MESA 4 BUILDING DIVISION Fo q4 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER ( rn.r I J 11004 PERMIT q "R,,...noe P02-00054 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 219 WELLESLEY LN Status: ISSUED Suite No Applied: 01/31/2002 Issued: 01/31/2002 Vicinity:Vicinity: C/L Parcel Nunmber: 14139532 - ISSUED BY: Applicant: ZYCH, JEFF Address: 2519 BOWDOIN PL - ' . Phone: 714-366-7744 - COSTA MESA,CA, Zip: 92626 - Owner: /ZYCH,JEFE- , Address 2519 BOWDOIN PL Phone: 714-366-7744 _ COSTANESA,CA Zip: 92626 ' Contractor: OWNER-BUILDERi- - Address: - - - . ` Phone: - Zip , License: 0 Arch / Eng : f - r - Address: . __ Phone: Zip: , - -- License: . " SCOPE OF PERMIT PLUMBING PERMIT FOR INTERIOR REMODEL OF BATHROOMS AND REPIPE FOR AN EXISTING SFD. 1 BATHTUB,4 GAS OUTLETS(1-4), 1 SHOWER,2 WASH BASINS,2 WATER CLOSETS, 1 WATER HEATERNENT, 1 WATER RE-PIPE. ,,,•, . ' " REF: B02-00 - " ' • FEE SUMMARY - . ' , - AMT QTY ... AMT QTY - , " AMT QTY ISSUE FEE $23.50' ' Laundry Tub/Washer - $0.00 0 - 'Sump Purnp $0.00 0 Backflow irrigation , ' $0.00 0 . Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer ' $0.00 0 "P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub , " $9.80 1 Pressure Regulator $0.00 0 Urinal . $0.00 0 Clarifier System $0.00 0 " , • Process Piping(per 10 ft) $0.00 0 . Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $19.60 2 Dishwasher $0.00 0 . Sewer Cap for Demo , $0.00 0 . Wash Basin Set $0.00 0 Drain, Floor $0.00 0 " ' " Sewer Connect $0.00 0 " . Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 - Sewer Private Line $0.00'' 0 Water Closet(Toilet) $19.60 2 Drain, Roof $0.00 0 Shower - $9.80 1 Water Heater/vent $12.30 1 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $9.80 1 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $24.60 4 Sink,kitchen $0.00 0 Water Softener $0.00 0 Gas(Over 4 outlets) $0.00 0 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $129.00 NOTICE: The work authorized by this permit sigtPAUghip hisfilgoALIGQNR1LLQN$requirements under California statutes and related regulations. (Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 244646(6/00) ii - DECLARATIONS 1 1 • WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,es 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 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 are: Carrier: Policy Number: (This section need not be completed i/the permit is valued et one hundred dollars($100)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 these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class# Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: • I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which 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 pursuant t0 the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)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 . sub'ects the applicant to a civil penalty of not more than five hundred dollars($500).): . I,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 property who builds or improves thereon,and who does such work 1\ himself or herself or through his or her own employees,provided 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 purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contra tors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) lice rsuer t• the Contractors License Laws.). ❑ I e • Iu •/el se.. Business and Professions Code for this reason: Signature: - Date: 1 -31- 0a. Owner ID vert'.: P'.`' 5 icense. ❑Yes 0 No Driver's License No. Expires: Verificat� of Aw ip•y ype of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth Into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,Califomia Administrative Code). ' ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑Yes ❑No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). n.need prepare RMPRkMan... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 0 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ' 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No 8 (if'yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: • Date: CERTIFICATE OF COMPLIANCE AND AUTH•-IZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to com• with all - ate laws .nil city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described pro.:My f• i ti e. in purpo•• I agree not to=cupy or allow occupancy of any building authorized by this permit until final inspection. LA -10 /4\ e• eg. Owners Date L •n. Or Au prized Applicant Date CODE t, I•• I-- PATE EMU CODE I INSPECTION TYPE DALE PALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing •.�! J 200 Final Re-Roof 210 Final Electrical VVUU 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. CITY OF COSTA MESA CONSTRUCTION PERMIT PERMIT NO. TRACT NO. LO 3 UNIT NO. A P # Zone oNO. �y 1-3�s — �2K I Project Address 219 WellesleyLane, Costa Mest 1 f � k�l S Main Building: Accessory Building: Applicant's Mailing Address 219 Wellesley Lane TYPE OF CONSTRUCTION IJ NEW It31 ADD reALTERATION ❑ REPAIR E Front ���yy���� ��qq" �� � Michael/Carin Howard) 0 CONVERSION 0 DEMOLISH 0 OTHER • T a/II-O rrt¢.Sk 0 Owner's Name one 540-6951 D S RIP 10 OORK/USE OF BLDa. I B Rear / N Address 219 Wellesley Lane, Costa Mesa / . . a. o �r� . 1f_Iin•Yit• Right � Zg ' N Arch/Eng. not applicable License No. TYPE OF PE RMITIs� La' t DING FOUNDATION STRUCTURAL K G Address ❑ TENANT H ELECTRICAL Q•PLUMBING ❑ MECHANICAL $ Left R Contractor's Name BYCON Phone 645-2251 ❑OTHER ^ 1Ping. Ref.# Parking Req./Provided E Address(mailing) 3300 W. Coast Hwy, PROJECT DESCRIPTION SQ. F7. (orb OCCUPAN Y p,. /_ r1 e Imo, )i-�2 _ - 0 •� y Newport Bcht Planning Notes: t/{'1 `a/-P•Ol Z(/ L.(FGRW"' M 00r 2. CONSTRUCTION TYPE • VALUATION$ ` � ni GG � s�1 T City License No. ZONE GRADING CU.YDS. ACRES LIMIA CA�.lN�•t11J.L' „YnO'D' M, �J 'db S. LICENSED of rmCOthat I licensedR DECLARATION V "" �'sR-OL •1 / fl i I hereby ion m 00) I am ion of the provisionsBusnandf Charterroi9 ns eandn9 Remarks: �dS n /� O 3 VQ� M t with section n full of a effect.3 of Business Professions Code, 7`'c- _(yY C.� C� t my license it in full force and -19 41 ELECTRICAL FEES License Class A License No.4-19#5.2.0 l `� ` ) t/ ' (— Date Signature hit)&f tyit,S PLUMBING FEES i Automatic Washer Transformer 0 15-50 KW WORKERS'COMPENSATION DECLARATIOrjBar Sink Showers Construction Pole Sub. ❑ 50+KW 1 heiby affirm that I have a certificate of consent to self-Insure or a certificate • r orkers' Compensation Insurance, or a certified copy thereof (SectionBackflow Preventer Service Sink Cooking Unit Meter Cup to 100 amps ' mob' ) I Dishwasher Meter Cover 100 Policy No. 0-13-4621-$Company State Farm amps Backflow Irrigation Sewer Cap _ Certified copy Is hereby furnished. I Dryers Gas ❑Electric Sub Panel— --4_ Certified copy Is filed with the cit yluil tlir�g vision. Bathtubs Sewer Connection Date Applicant RLQtRW tug] Fan Motors O0-1 HP ❑1h-8 EXEMPTION FROM WORKERS'COMPENSATIO DECLARATION Clarifiers Solar Collectors _ (This section need not be completed if the permit Is for one hundred($100)or F.A.U. Inc.Solar 09-15 HP ❑16-15+ less). Crs Solar Piping I certify that in the performance of the work for which this permit Is Issued, IFixtures Microwave shall not employ any person in any manner so as to become subject to the Solar Tank Workers' Compensation Laws of California. Date Signature r Drains Swimming Pool w/Spa Device Boxes Pole Light NOTICE: If,after making this declaration, you should become su a /6 Outlets Range Workers' Compensation provisions of the Labor Code, y• -•u fo Floor Sinks Urinal comply with such provisions or this permit Shall • e CONSTRUCTION LENDING • NCV Gas Service Outlets ' Water Closet 18 Switches Sign I hereby affirm that there is a ruction lendin• gent e performance of the work for w ch •i permit i (Sect 3097 Clv. C.) i Garbage Disposal Standing Sections Lender's Name - - ry Interceptors Water Heater Lender's Address SIM6 Kitchen Sin Water Service — Generator 00-5 KW 05-15 KWrTrash Compactor OWNER BUILDER DELLA- - I hereby affirm that I am exe • le Con. ctor's License Law for the I Lay ies Auto-Wash — following reason (Section 703 • . cess and Pr•fesslonal Code: A • or county which requires a perm)• - onstruct,alter,Improve,demol' - it P- 'Laundry Trays any structure, prior to its issue also requires the applicant for h per t to file a signed statement that -/she Is licensed pursuant to the •vision- •f rains the Contractor's License Law(Chapter 9(commencing with Sect • 000) — Division 3 of the Business and Professions Code) or that he/She • . • pt Reinspection Fee $15 Issue Fee $ 3 r' from and the basis for the alleged exemption. Any violation o • Ion 5 by any applicant for a permit subjects the applicant to civil t of not more than five hundred dollars($500). DEVELOPMENT SERVICES R IREMENTS: I, as owner of the property or my employees with wages as thea ole Reinspection Feb I $15 Issue Fee $ 3 Zoning Approved By Date V q•5'-91G1 - compensation, will do the work, and the structure Is not intended or of •red for sale (Section 7044, Business and Professional Code: The Contractor'sICAL FEES Building Approved By Date - License Law does not apply to an owner of a property who builds or Improves _ _ � thereon, and who does such work himself/herself or through his or her own '. H••d or Type I ❑ Application Issued By Date employees, provided that such improvements are not intended or offered for Boiler sale. If, however, the building or improvement Is sold within one year of com- Canopy Type II 0 SUMMARY Of..EEES pletion, the owner will have the burden of proving he/she did not build or Ica- Duct •-• 'v -7 64 prove for the purpose of sale). • - BUILDING PERMIT $ 3l SMIP $ L 0 I, as owner of the property, am exclusively contracting with lice c D • - Refrigeration System PLAN CHECK $ PERMIT tractors to construct the project (Section 7044,Business and Professi• The Contractor's License Law does not apply to an owner of prope D .14r-ntilating 00-100,000 BTU 0100,000 BTU PLUMBING $ ISSUANCE $ builds or improves thereon. and who contracts for such oroiects with — tractor(s) license pursuant to tne Contractor's License Law). I am aware Exhaust System ❑ Multiple❑ System Repair/Alteration PLAN CHECK 25% $ ENERGY P.C. $ proof of their Worker's Compensation insurance should be provided to .- ELECTRICAL $ GRADING $ ❑ I am exempt under Section B.& P.C.for this reason Firepl/Fact.Bit. ICBG ak Fire Dampers MICROFILM $ — PLAN CHECK 50% $ Date Owner Heating System& Ducting Registers MECHANICAL I hereby certify that I have read this application and state that the above 00-100,000 BTU 0100,000 BTU $ TOTAL FEE $ • Information is correct. I agree to comply with all city and county ordinances PLAN CHECK 25% $ and state laws relating to building construction, and hereby authorize repre- • sentatives of this city to enter upon the above-mentioned property for 93x1-1 2 3281 Inspection put180.1 el e 8 Signatures' �A W Date p 3 I 0865-46,rev. 5/88 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor CONSTRUCTION AND PLANNING Y. ' POOL' cPA r APPROVALS Permit Date Inspector APPROVALS Pe,....0-# Date Inspector 1. Temporary Electric& Service of Pole, 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement • 3. Electrical Conduit Utility-Undrgrnd. • 54. Forms ' 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding - Igoe, 5. Steel Reinforcement p 561RoughikrUing & Pressure Test • 6. Electrical UFER Grnd 57. APPROV�ALTO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. 61/Pipe, 0 Undrgrnd., Test to 9. Water Pipe-Undrgrnd. 60. 8 kwash Lines, P-Trap, 0 Undrgrnd. 10. Structural Floor System SAPPROVAL TO DECK 11. Property Sewer Line & House Connection �'- • 62.: Backwash & Receptor-Final 12. Sewer Cap '0 th63. Heater & Vi#Final 13. Roof Drains A X64. PlumbingSYstem?'zFinal t • 14. Rough Plumbing .7 X65. Electrical=Final v 15. Rough Electrical-Conduit 66. Solar System-Final -Lir 16. Rough Electric Wiring '/ �d f Y 67. Fencing & Access Approval 17. Rough.Wiring Sign itf'. 68. APPROVED4FR PLASTERING/42%;Y.'. PG4 ; 18. Rough Electrical-T Bar Ceiling ,a - if�• � 69. POOL/SPA SYSTEMS FINAL + '�, ` 19. Rough Heating & Air Conditioning f `•'• FIFfE DEPT. REQUIREMENT ,^ 20. Rough,Factory Fireplace ''`�' APPROVALS Permit# r y 21. Ducts, in Structure 'r oP' 70. UPderground Hydro �,.,,� 22.'Ducts, Ventilating 1 71. Product Piping 0 Gas C3:0,i1"'' 23. Gas Pi a-Rou h & Test -: P e:Rough _ 72. Underground Flush lX;•�' 24. Roof Framing 73. Undergrnd.Storage'TankaD Gas 0 Oil 25. Roof Sheathing u� 74. Overhead Hydro tj'` 26. T-Bar Ceiling (Structural)•.8j Monocoat 75. Dry Chemical Z:' 37;Frame and Flashing ,I r 76. Dry Standpipe ice ,•' 28. Lathing-8r Siding j77. FIXED SYSTEM FINAL y 29.,Insulation 78. FIRE PREY. FINAL 30. DrywallNailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat`, 79. FINAL INSPECTION I 32. Electrical,Power Meter-Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning- 35. Final Gas Pipe-Test 4 i; - '36. Hood or Canopy G - • , - -37. Final Factory•Fireplacet, - ' - 438. Final Plumbing _ ' .r, '39. Water.Service-Final ' .40. Gas'Service-Final . '41. Solar Domestic-Fina (.., 42. Backflow Preventer'"• 4 43. Backflow Irrigation>. !i, � 44. Landscape I;rigationSystem ^ • 45. Sound Attenuation-,':Jr 46. Handicap'Regulatiolns t -) • 47. FINALLSTRUCTURE &'BUILDING 48. Special Requirements Completed ' ..49. Electitic Release to'Edison' • '50. Gas/Release to Soutliern•;California Gas Co f //al 51. CERTIFICATE OF OCCUPANCY ,i No. / Date w 12(10 Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. CAF_ �� s�� — PERMIT NO. TRACT NO. LOT NO. UNIT NO. CITY OF COSTA Mr,AfiCOnRU TIOtERMIT / 87 � 3 Project Address �C l 1 v�l�7f //65 t5 ( , /U B L 9 S 2 8 ,p �i \\ Applicant's Mallin Add(r�ens a/9 Lit I� IEY`/r}/��'.1^ TYPE OF CONSTRUCTION I_ NEW ADD u ALTERATION ❑ REPAIR f /F-C / !\FA Phone/ e WCt ❑ CONVERSION ❑ DEMOLISH ❑ OTHER kr!, Ilii .5(� 5 -32- I e7/ Owner's Name O M A.P.# { _/J J 2one/G /! ' ^ DESCRIPTION OF WORK/USE OF BLDG.MOdr'r/''c./ Address ry��I �L/I�5 I� w J S Main Building: Accessory'/Build,��i((��g: Y s� E ("flit Z Arch/Eng. J License Na. TYPE OF PERMIT ❑ GRADING ❑ FOUNDATION yx STRUCTURAL T Front 0 Address - ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL B Rear G N 6 . Contractor's Name O•� Phone ❑ OTHER C Right A �� N PROJECT DESCRIPTION SQ. FT. OCCUPAN V Address(mailing) JC`}� • CONSTRUCTION TYPE VALUATION $ ! "JtJor• S Left G City License No. ZONE GRAOI NG CU.YDS. ACRES R LICENSED CONTRACTOR DECLARATION Ping. Ref.# r Req./Provided E I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: Planning Note : Q with section 7000) of Division 3 of the Business and Professions Code, and M my license is in full force and effect. C7 c, i( �.s — Q Ts S License Class License No. P. L 8 O 1 Date Signature PLUMBING FEES WORKERS' COMPENSATION DECLARATION Bar Sink Showers `ereby affirm that I have a certificate of consent to self-insure or a certificate ELECTRICAL FEES Workers' Compensation Insurance, or a certified copy thereof (Section .00, Lab. C.) Backflow Preventer Service Sink Automatic Washer Transformer 0 15-50 KW Policy No. Company Backflow Irrigation Sewer Cap050+KW Construction Pole Sub. 8 Certified copy is hereby furnished.hcity • copy is filed with the city Builtling Division. Bathtubs Sewer Connection Cooking Unit Meter pup to 100 amps Date Applicant EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Clarifiers Solar Collectors Dishwasher Meter Dover 100 amps (This section need not be completed if the permit is for one hundred ($100)or less). Dishwasher Solar Piping Dryers ❑Gas ❑Electric Sub Panel I certify that in the performance of the work for which this permit i ued, I shall not eloy ny person in any man so as t ecome subj c to the Drinking Fountains Solar Tan Fan Workers fom/gPgn la, Laws of CalifomMotors 00-1 ❑1%-B i�'�t ( ' Y Date / / Signature 1 - Floor Drains Swim ng Pool w/Spa F.A.U. NOTICE: II afte// making this declaration,, ou ou should ecome subj¢ to the Inc.601- ■9-15 HP 016-15+ Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks nal Fixtures comply with such provisions or this permit shall be deemed revoked. M.- Owave CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet Device Boxes I hereby affirm that there is a construction lending agency for the performance Pole Light of the work for which this permit is issued (Section 3097 Civ. C.) interceptors , Water Heater Outlets Lender's Name _ Range Lender's Address Kitchen Sink - Water Service Switches Sign OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories - ' Auto-Wash ' following reason (Section 7031.5 Business and Professional Code: Any city or Garbage Disposal Standing Sections county which requires a permit to construct,alter,improve,demolish or repair P—Trap :fLaundryGenerator Trays ❑0-. W ❑5-15 KW any structure, prior tb its issuance, also requires toe applicant for such permit - Trash Compactor to file a signed statement that he/she is licensed pursuant to the provisions of Roof Dra ' the Contractor's License Law (Chapter 9(commencing with Section 7000) of - --simian 3 of the Business and Professions Code) or that he/she is exempt . irefrom and the basis for the alleged exemption. Any violation of Section 31.5 by any applicant for a permit subjects the applicant to a civil N,.gnalty of not more than five hundred dollars ($500). `' t,_'as owner of the property or my employees with wages as their sole rReinspection Fee I $15 Issue Fee $ 3 mpensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL Reinspection Fee $15 Issue Fee $ 3 FEES License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own DEVELOPMENT SERVICES REQUIREMENTS: employees, provided that such improvements are not intended or offered for Boiler Hood or Type I 0 Lie nt • sale. If, however, the building or Improvement is sold within one year of com- — Canopy Type II • Zoning Approved By ts..1-0 "' Date 0 •4 pletion, the owner will have the burden of proving he/she did not build or im- Duct- Under Ground Building Approved By Date prove for the purpose of sale). ❑ I, as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeratio - stem Application Issued ByDat• , tractors to construct the project (Section 7044,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who Duct-Ventilating 00-101,•10 BTU ❑100,000 BTU SUMMARY OF FEES builds or improves thereon,and who contracts for such projects with a con- _ tractor(s) license pursuant to the Contractor's License Law). I am aware Multiplethat ' BUILDING PERMIT $ 2.5 -00 SMTP $ 0•50 proof of their Worker's Compensation insurance should be provided to me. —E%haust System ❑ ❑ = stem Repair/Alteration ❑ I am exe pt under Section & B.& P.C.fo this reason Firepl/Fact.BIt. ICBG# Fire Dampers PLAN CHECK $ i 6 Z 5 PERMIT PLUMBING $ ISSUANCE $ X Date Owner 11:an AMJr Heating System& Ductin• Registers. ENERGY P.C. $ PLAN CHECK 25% $ I hereby ertify that I have read this application and state that he above 0o-100,000 BTU 10,000 BT GRADING $ information is correct. I agree to comply wi • all city and county ordinances - ELECTRICAL $ and state laws relating to buckling construe io , and hereby authorize repre- MICROFILM $ sentatives of this t to e er upon t-e a•ove-mentioned pr�Cp.�pertttyyy Rfor PLAN CHECK 50% $ • Inspection purpo•:-.i�"/1 •�/ / MECHANICAL $ ' 75 Signature 111.10.1.� • Date •L � . TOTAL FEE $ �� Reinspection Fee $15 Issue Fee $ 3 PLAN CHECK 25% 7( Drivers' License •.r SS • _ $ CMF 0865-46,rev. 10/84 White - Building; Canary - Applicant; Pink -Accounting; Goldenrod - Assessor CONSTRUCTION AND PLANNING POOL & SPA APPROVALS Permit # Date Inspector APPROVALS Permit# Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement • 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings • 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, D Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, 0 Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK • 11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final 12. Sewer Cap 63. Heater & Vent-Final • 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical-Final ^' 15. Rough Electrical-Conduit 66. Solar System-Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT 20. Rough Factory Fireplace APPROVALS Permit# _ • 21. Ducts, in Structure 70. Underground Hydro • 22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro 26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing /;7/87 G 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 44 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing . HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION - • 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED • 33. Final Electric Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe-Test . 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service-Final 40. Gas Service-Final 41. Solar Domestic-Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING r0/��� 4.„."/ 48. Special Requirements Completed 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co r 51. CERTIFICATE OF OCCUPANCY. • No. Date OWNER COLLEGE PARK NO. 4 DATE 9-26-57 ' JOB ADDRESS 219 Wellesley Lane BUILDING PERMIT NO. 5767 GENERAL CONTRACTOR Harbor Construction VALUE $ 11,200.00 AP. No. - LOT 33 TRACT 3187 FIRE ZONE DESCRIPTION OF WORK Res. w/att. -gar. -'>y_ ,,-tip I & d TYPE V ZONE Rl PLAN NO. 5748 PERMITS ISSUED INSPECTIONS DATE SUBCONTRACTOR DATE NUMBER Trenches' Forms Steel /p-/S-.S, Floor System Steel Reinforce Chimney'Re-Rod Bond Beam Frame and Flashing 4✓P./& /5.-a-{^1 Lathing, In Out -.L k /A -R/-S F Plaster, brown all 8 6'-f- 1 -31-SW Underground soil w.c4W/G Pipe T1 &$ /0--/D-S7 Top Out p y Furnace ]L t'jey t ,[ , . . Jo-v-4-7 Ii'# 94- v - Gas Vents. J Rough Plumbing /W//1 ii-'j-r7�P --ecobz. u e ^ 7 / / / .TC I/ / Cesspool Septic Tank i Q"n'� Prop. Swr. Line4,f,House Con St.,St 5 //•e-9-�f•7 .tte4t.0 Jo—.2r—n_ // 7,25 n/ 10 Sprinkling System A He •^",g Final /Dins '-I -/0-4-P1 fQ P.f. nq Fixtures, Final /WAS 4-id-.f er / Final Gas Test /S 44M( k'-'o-&-r '` Construction Pole Underground Power k Rough Wiring /4-/l-JJ' fq-.�.. , -Pe-s/r .12-9-5'� 5_: S-// ll Fixtures, Final /4 /S-S lie,-OCCUPANCY 7 g -/6-45 \cc / Form 210-5M-1-57 / FEE RECEIVED r ' 5748 SEP 13 1957 COSTA MESA BUILDING DEPARTMENT FINANCE DEPT. P.O. BOX 317 CITY OF COSTA MESA COSTA MESA. CALIFORNIA i FOR APPLICANT TO FILL IN APPLICATION FOR PERMIT ADDRESS 219 WELLESLEY LANE BUILDING COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY RECEIPT NO. G11Id/�L]K7 OWNER fOI I ES PARK No . 1. �,J MAIL RECEIVED BY DATE RECEIVED DATE ISSV91 ADDRESS 2 1 1 6 SO. MAIN Si . / / 7-7,7-,s7 SEP 2 G 195 TEL. BUILDING CITY SANTA ANA, CALIF . NO. KI 55577 ADDRESS ARCHITECT LIC. OR '"'NEER NO. COSTA MESA. CALIFORNIA ^,cis FIRE ADDR E.> /7 .Jf ZONE ZONE PNO.OF LANS TYPE / GROUP C Y LIC. n PLANS (/// CONTRALTO A�'Oy NO. {� TEL. APPROVED _ADDRESS NO. BY DATE LEGAL LOT DESCRIPTION NO. 33 BLOCK TRACT 3 187 CORRECTIONS A.P.NO. SIZE NO.OF BLDG. OF LOT ALI X I 15 NOW ON LOT USE OF JAI EXISTING BLDG. l.''LII11 SETBACK LINE FROM CENTER OF STREET 0REAR YARD 35 SIDE YARD RIGHT 5 LEFT 5 DESCRIPTION OF WORK NEW X ALTERATION ADDITION I. „it, MOVING DEMOLISH BUILDING NO.OF SIZEI 379 ROOMS STORIES EXTERIOR WALL ROOF I _COVERING COVERING USE OF NEW ��y�-' BUILDING RESIDENCE & $ TACHED GARAGE HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING BUILDING CONSTRUC. TION. VALUATION SIGNATURE OF PERMIT FEE $ Ca PERMITTE C• LEGE PARK No . LL PLAN CHECK 5 /ILS II2OO. , AUT =-I�• q.' _ TOTAL FEE S 567 - `w` OWNER STEWART, NORMAN DATE 2-6-62 JOB ADDRESS 219 Wellsley Dr. BUILDING PERMIT NO. 163_ -- GENERAL CONTRACTOR Owner-Bldr. VALUE 5,360.00 AP No. 113-395.04 LOT TRACT FIRE ZONE DESCRIPTION OF WORKAdd Den to Res I 'ECTIONS Signature DATE GROUP I TYPE V ZONE R1 Soil PERMITS ISSUED Gas 4/9-5 3-2-7-02- SUBCONTRACTOR DATE NUMBER Water Rough Corn. Refrig. 0 Air Cond. ❑ Rough Heating ,44,LS 3-26-62- _ Rough Plumbing " n Miscellaneous �c-�-G�" a2`� — Prop.Swr.Line ❑ House Con. 0 St.Swr. 0 Sprinkling System Construction Pole Underground 0 Power El y� Rough Wiring '"lam Y24.c1.-12/4"��p re --- :L,�-G, z- /W9.7V Trenches ❑rC Forms IB' Steel Reinf. ❑ C. 4 3 -/ -.41 f Floor System C Bond Beam 0 Steel Reinforce 0 Sheathing / es 5.. e-61..- Frame . e-6LFrame and Flashing C._/' rgj . 7,; A..- ---1.7-- 1 ci ,, ---1.7-417 Lathing — In ❑ Out CIE/ r% - _ P 'q brown coat L g. 0 Air Cond. 0 Final ' Heating, Final if-1 $' I f.'/-Cd' Plumbing Fixtures, Final Final Gas Test Cr- 441.0 3=2-7-42,Electric Fixtures, Final / h' 1 I it' /;e I Building, Final / r# ,`-'e OCCUPANCY FORM PIl6.SM — 7.51 16169 1 69 FE RECEIVED FEB 6 1962 COSTA MESA BUILDING-SAFETY DEPARTMENT igeFINANCE DEPT. P. O. BOX S77 COSTA MESA. CALIFORNIA CITY OF COSTA MESA For Applicant to Fill In Completely APPLICATION FOR PERMIT TYPE OR PRINT BUILDING BUILDING /� �J I `l j (` / FII gotgart&a n i faC- ADDRESS COSTA MESA. CALIFORNIA (' For Office Use Only OWNER A_I1t4 A-41 - S'rEfra n.r/te. I RECEIPT NO. 1 /S/ Ty& ., ADDRESS 2/.Y Platt/ LI_Y c f ( RECELYn/ 0 j I D=T;R=CE7PCD IDATE:ISSUED CITY'G'o f j L# /y EPA. N°TELiSlin ADDREEESSTSS /44 i4/N deed�AA �J 6 ORCENGI EER ay/30 /LD(/e' NOLht Aian COSTA MESA. CCAA+LIIF0A7" IA ADDRESS �q/ IRE CONTRACTOR "�/(3'�I7p �ro /�d�Jm/`�/,��yr•n ZONE TYTAT GR�OjUP `� �/✓J%,%1 �/T e.,44. ' / A/0. APPROVED ^ `�ADDRESSS5,37.4pr 8, /3 ele,V4v in ,. n CITY ` LI �T • / •/ A . .0/}L_ ZONE 1/I i I NO.OF ^ I USE OP NEW ,P `[ /” '�(\ I PLANS (/i/� BUILDING (�pi Cl."--,4� STA ND. x(,7(0 CO (n No:4 If tLq4G DEEecRSCR IPrION 8,/-- 33 , TAI 318.7 SIZE (�a� J H. OF SLOGS. OctOF LOT sic / �� NOW ON LOT !/ A.P.NO. 1/3 —3 7s- ct ESE OF �JI�E, / �K /LL YARDS EVES EXISTING BLDGAPPROVED ALLOWED SETBACK LINE PR (CENTER LINE ST.) /�.�� //CENTER OP STREdial-E //t - REAR YARDYA /� FRONT /.12,6 ;F �/,O I IN, SIDE YARD I LEFT / , I RIGHT S2 / R.SIDE --11 2 FT. - IN. DESCRIPTION OF WORK L.SIDE / 9 FT. P IN. NEW I II ALTERATION I II ADDITION I✓ REAR )aa. FT. IN. REPAIR I II MOVING I II DEMOLISH I APpROVED Iv 1 Z'( 0 / DATE SbY :Tr NG J// I�7 (� ROOMS / STORIES I eira "J EXTERIOR WALL r� ./�A� ROOF q ,. I COVERING ( l1LL.(l COVERING J Lti Re c,(c F BUILDING AND WORK TO BE PER OR USE D e .. MA/A-t-c_ I4C-- R DOi�c , bski c 'D 5_ sle ,ffldCWlyit„ Gfi A al A.Ef I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM• PURPOSE OP ESTABLISHING A PERMIT FEE ONLY. PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING BUILDING eoNBrnU ION. 9Q'7 !Et1_ VALUATIONSIGNATURE OFPERMIT FEE $ PERMITTEF o-"- $ �'A PLAN dHECK $ O (! — AUTHORIZ AGENT `/ /OCC O F � TOTAL FEE $