HomeMy WebLinkAbout1103 VICTORIA ST - Building Permits CITY OF COSTA MESA
ti oBUILDING DIVISION
Fa 4 11 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.0
V%imm+r'� FOR INSPECTIONS CALL: (714)754-5626
PERMIT NUMBER. M07-00565
PERMIT TYPE MECH STATUS: ISSUED
DATE ISSUED: 12/12/2007
ISSUED BY: RMD
JOB ADDRESS: 1103 VICTORIA ST CM Suite/Unit:
Vicinity:
SQ. FT: 0
SCOPE OF WORK: WALL FURANCE CHANGE OUT< 100 K BTU FOR A SFD.
•
OWNER: DAVIS, RACHEL M Address: 1103 VICTORIA ST Unit:
PHONE: 949-631-4330 City/State/Zip: COSTA MESA,CA
APPLICANT: RODRIGUEZ.ILDEFONSO Address: 7050 LAMPSON AVE Unit:
PHONE: 714-530-7320 City/State/zZip: GARDEN GROVE,CA
CONTRACTOR: EMPIRE PLUMBING HEATING AND AIR CONDITIONING License No. 794154
Address: 7050 LAMPSON AVUnit: PHONE: 714-530-7320
City/Slate: GARDEN GROVE,CA ZipCode: 92841 CELL:
•
MECHANICAL PERMIT FEE SUMMARY
MECH ITEM FEE: $38.30
PLAN CHECK FEE: $0.00.0 0
INVESTIGATION FEE: $0.005
REINSPECTION FEE: $0.00
TOTAL FEES: $38.30 Itt‘t
lieL
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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
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.
CODE/ INSPFC110N TYPE PACE INTITULS CODE( INSPECTION TYPE, p.
1616 Fixed System Final Fire Prevention 206 Final Mechanical re"Zi 1)1
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 Site
\ 204 Final Demolition 250 Final Building/Occupancy
WORKERS'COMPENSATION DECLARATIONla Owner ID verified by driv at_ J. ❑Yes ❑No
I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires:
❑ I have and will maintain a certificate o1 consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed):
compensation, as provided for by section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
ZI have and will maintain workers'compensation insurance,as required by
ion 3700 of the Labor Code,for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a
number are: person is required to descend,will be made in connection with work authorized
CC by this permit,and that no building structure,scaffolding,falsework,or demolition
Carrier--ind i..rn HGG or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp
inert need not 0e completed/tile pemNY valued at are hundred doWrs(5100)ar less) 2 Art 2,Sec.341,Title 6,California Administrative Code).
Policy�Number.- W F.unOlo.RiErg)
1 ❑ As owner-builder, I will not employ anyone to do work which would
❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless
issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California, and agree that if I should
become subject to the workers'compensation provisions of Section 3700 of gppimnrs Signature ogle
the Labor Code,I shall forthwith comply with these provisions.
269-/,‘9 7 Division of Industrial Safety Permit Number:
P�m's�S"g"nature _ r�°� HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑Yes ❑No
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST,AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. 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
LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons,or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is
in full force and effect. a registration form for acutely hazardous materials? ❑Yes ❑No
•Li=-#-- 17 9�/'/5 9 rClaS i-E?l7/0 .,2 M, (Section 25533 of the California Health and Safety Code, with some
/� � �, exceptions, requires registration with the Costa Mesa Fire Department by
d `�/iceii i// _ A IA-07 each business which at any one time has on hand a quantity of acutely
LCoprocmts signature-"/ / Dar to I hazardous materials equal to or greater than a weight of 500 pounds. or a
v �-_.l volume of 55 gallons, or 200 cubic feet of compressed gas at standard
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit's issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name: hazardous materials)? ❑Yes ❑No
(Section 25534 of the California Health and Safety Cade provides that the
Lender's Address: Costa Mesa Fire Department may require the preparation, certification and
fling with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
Signature - Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safely Code been fully complied with? ❑Yes ❑No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 1031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish. or repair any structure, prior to its ‘any other air pollution control district or agency? ❑Yes ❑No
issuance.also requires the applicant for such permit to file a signed statement ,(Section 65850.2 of the California Govemment Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors information be fumished on applications for non-residential building permits).
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 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes ❑ No
applicant for a permit subjects the applicant to a civil penally of not more than (If'yes the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec.7044, Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? ❑Yes ❑No
thereon,and who does such work himself or herself or through his or her own 8 (If yes attach certificate of compliance from the appropriate air pollution
control
employees. provided that such improvements are not intended or offered for officer
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 CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale,), information given above is correct. I agree to comply with all state laws and
❑ I, as owner of the property. am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions.
LICENSED CONTRACTORS to construct the project(Sec.7044,Business and
Professbns Code: The contractors License Law does not apply to an owner of Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that t have read this application and state that
❑ I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described property for
inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permit until final inspection.
/Signature of Legal Owner(s) Date
3057-46(107) Signature Date —4-P r /9 _/P of _0 7
rAnClnr..omwized A-.._qm -®`v Oc_e e=�,
1
wr `s,,, >; CITY OF COSTA MESA
• P O. BOX 1200 • 77 FAIR DRIVE • CALIFORNIA 926281200
1 :
VFir DEVELOPMENT SERVICES DEPARTMENT
......„_ee
BUILDING DIVISION •
COURTESY NOTICE OF PERMIT EXPIRATION
August 22, 2008
Rachel M Davis Living Trust
1103 Victoria St
Costa Mesa CA 92627-3931
PERMIT NUMBERS: M07-00565
FOR: Change-out Furnace
PROJECT ADDRESS: 1103 Victoria St., Costa Mesa
Our records indicate the above listed permits were obtained for property improvements or
alterations at the above address. Per the 1997 Uniform Building Code, Section 106.4.4
Expiration, permits are valid for 180 days from the date of such permit, or the date of the last
inspection for the project.
Our records do not show an inspection for these permits within the last 180 days nor have
they had an approved final inspection. If you have a signed inspection card showing that an
inspection was made within 180 days, or that the final inspection was approved, please
contact this office so we may correct our records. If you do not have an approved final
inspection, your permits will expire on September 8, 2008. Additional fees will be required to
finalize expired permits.
Requesting an inspection—If you need to request an inspection, please call our Inspection
Request Line at 714-754-5626.
Requesting an extension—If you wish to request an extension, requests must be made in
writing addressed to Ed Petros, Chief of Inspection, at the above address, detailing
circumstances and listing an estimated date of completion.
If you have any questions, please contact the Building Division at 714-754-5273, between
8:00 a.m. and 4:30 p.m., and a staff member will assist you. The accuracy of records
affecting your property is our goal and we appreciate your working with us to resolve this
matter.
Sincerely,
i di ;/ /. //• .
Mary Jane Weidenkeller
Office Specialist II
cc: Empire Plbg., Heating & A/C
7050 Lampson Av
Garden Grove CA 92841
Badding Division(714)754-5273 - Code Entorcemenl(7141754-5623 • Planning Division(714)754-5245
PAN(7141754-1356 • TDD(7141754-5244 - vnn:0 costa-mesa ca us
� CITY OF COSTA MESA
BUILDING DIVISION
> ,.,,, , DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER
1. 1 sr ea I
O In PERMIT B06-01598
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.cSUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 1103 VICTORIA ST Status: ISSUED
Suite: Applied: 09/25/2006
Vicinity: RESIDENCE AND ATTACHED GARAGE Issued: 09/25/2006
Primary Occ: R-3 Dwellings/Cong Res<10 Type of Construction: V-N
Parcel Number: 42203166 Zoning:
Applicant: DAVIS, RACHEL
Address: 1103 VICTORIA ST
Phone: 949-631-4330 ISSUED BY:
COSTA MESA,CA Zip: 92627
Owner: DAVIS, RACHEL M
Address 1103 VICTORIA ST
Phone:
COSTA MESA,CA • Zip: 92627
Contractor:, OWNER-BUILDER
Address:
Phone:
Zip: License: 000000
Arch : Eng:
Address: • Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF RESIDENCE AND ATTACHED GARAGE:T/O EXISTING COMPOSITE SHINGLES,REPAIR/REPLACE SHTG AS NEEDED,FELT PER
MFGR'S SPECS,APPLY 30-YEAR TIMBERLINE COMP SHINGLES. 17 SQUARES;PITCH UNKNOWN BY PROP OWNER(WILL CHECK WITH
INSTALLER)
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $4,200.00
Permit: $111.25 Claim Valuation: $4,200.00
SMIP Res: $0.50
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $111.75
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
A pi
p
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomla 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
2446-16(6/00)
. ,
DECLARATIONS '
i
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 Ccde,for the performance of the work for which this permit Is issued.
My workers'compensation Insurance carrier and policy number are:
Cartier: Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
!!�Y0:3 I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Califomia,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,1 shall forthwith
comply with these pnisions. � ^ \\ /
A(iprt�'$fgnetur"a �i.� (^VI �l Date' p/a 51/ 0 4
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EM OVER TO CRIMINAL PENALTIES AND CML FINES UP TOONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDMON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3705 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.Lie.p 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(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
cts the applicant to a civil penalty cf not more than five hundred dollars($500).):
e
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 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 properly who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
Q .4arrox pt oder s c Business and Professions Code for this reason:
�'tore�At�f.A �
tips-709/—709r'0 9
Verification of Ownership by(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 authodzed 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 Cade).
❑ 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 WIII 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 ❑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
Depanment 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? ❑Yes ❑No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication rm
a eil for such construction or modi/icatlon
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes ii 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 pernil be within 1000 feet from the outer boundaries of a school? ❑Yes ❑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 dlstdct 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? ❑Yes ❑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: Dale:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION 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 state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-d ribed property fgr' Notion purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
r 51.4 C✓J Q I r2 6/0 6
ggIanatdre'.O1'Legal'Ow`nerer(s) !iyDala
4v
And/Or Authorized Applicant Date
ODE t, INSPECTION TYPE all INTMALE CODE/ INSPECTION TYPE PATE INTMALS
1616 Fixed System Final Fire Prevention _ 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof can 210 Final Electrical
201 Final Block/Retaining Well 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
VnmcR MENDFZ. E. _ UAIt 6-P8-73
JOB ADDRESS 1103 Victoria Street BUILDING PERMIT N0. 36$74
GENERAL CONTRACTOR D. W. McFerran_ DESCRIPTION of WORK Alum. Patio Cover
AP No. 115-661-01 LOT 02 TRACT 643 FIRE ZONE VALUE $ 750.00
N CTIONSSignature Date GROUP .T TYPE TV ZONE M1
soles SUBCONTRACTOR PERMITS ISSUED
GAS
Date Number l Signature
WATER Plumbing
ROUGH PLUMBING
PROP. SWR. LINE ❑ HOUSE CON. ❑
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING
TEMPORARY SERVICE OR POLE
UNDERGROUND p POWER n
ROUGH WIRING Heating and Vent.
TRENCHES 0 FORMS 0 STEEL REINF. 0
FLOOR SYSTEM
BOND BEAM D STEEL REINFORCE n
SHEATHING
FRAME AND FLASHING
`
LATHING — IN OUT
PLASTER, BROWN COAT
ST' 'TURAL, FINAL Electric
Ht G, VENT., REFRIG. AND A.C., FINAL
PLUMBING, FINAL AND GAS TEST n
ELECTRIC, FINAL
PAID t, 8.50
36874 Am 28-73x-au3517* *****
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Completely e
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U 1 hereby acknowledge that I have read this application and slate Stkit
✓ that the above information is correct and agree to comply with
CCall laws regulating building construction, and I shall not employ r t5G2
r any person In violation of the workman's compensation laws of
y the State of California. TAX co
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ZI hereby certify that I am properly Iicensed as a contractor under SO. FT. o
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR j
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: e
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am exempt from the provisions of the State of California Business
VALUATIONm
and Professions Code, vision 3,Cha ter 9.
PERMIT FEE $ Ple tv
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Signature of at
nominee c�J� r $ �/`�/� 0� PLAN CHECK $ E
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... TOTAL FEE $