HomeMy WebLinkAbout189 LEXINGTON LN - Building Permits I t _
44.0
,5" CITY OF COSTA MESA
BUILDING DIVISION
> 1.,. ..fir DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
4. �,,., PERMIT P07-00151
e
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesaRLUMBING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 189 LEXINGTON LN Status: ISSUED
Suite No Applied: 03/13/2007
Issued: 03/13/2007
Vicinity:
Parcel Nunmber: 41916448
Applicant SCOTT LITTLEFIELD / /1,(5/----
Address: 24707 SAN FERNANDO RD ISSUED BY:
Phone: 661-259-7131 ' Y`
SANTA CLARITA,CA Zip: 91321
' Owner GALVIN, PATRICK M
Address 189 LEXINGTON LN
Phone:
COSTA MESA,CA Zip: 92626
Contractor AFFORDABLE WATER HEATERS AND PLUMBING
Address: 24707 SAN FERNANDO RD
Phone: 661-259-7131
SANTA CLARITA,CA Zip: 91321
License: 627368
SCOPE OF PERMIT
WATER HEATER CHANGE OUT
FEE SUMMARY
AMT QTY . AMT Q1Y AMT QTY
ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 Sump Pump $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 $0.00 0 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 $0.00 0
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) $0.00 0
Drain,Roof $0.00 0 Shower $0.00 0 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 $0.00 0
Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0
Gas(1-4 outlets) $0.00 0 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: $35.80
•
• COMMENTS I SPECIAL CONDITIONS
• NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia 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
L\) 2448-46(8/00)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
0 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
/Jwork for which this permit Is issued.
_07 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.
4 My wo ers'compensatio Insurance carrier and policy number are:
� Carrier: I 7-e-✓t t" yNumber: ZObi CFCt)Q,—
/ (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 provision
Applicant Signature: C; I- ' �� .Date: �' 13
'� )
WARNING:FAILURE TO SECU ORXERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES 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:
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 effecCLic. f Wali 1•+r Class 4 r 3C-
Contractor's Signature: _y1C Qtt Date: 3-13-C
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: Lenders 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 end 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 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 to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. 0 Yes 0 No Drivers License No. Expires:
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,wit 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:
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 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 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 aggermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LI Yes LJ 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'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 ryes",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 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,wlth all state laws and city ordinances relating to building construction,and authorize representatives of 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 Le I Owner( Date
Catt- 3-13 v�
And/Or A rized Applicant • -'Date
CODEC INSPECTIOuxeg ZEE 9=Tm41 CQPF( INSPECTION TYPE PAM IIB=DAL6
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing 1-3�'O'J 17J 3.
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
ADORES W MLDIM 189 LEXINGTON LN UNIT: CITY OF COSTA MESA — BUILDING PERMIT 9/S -006 d0
ariEntumCmmxGALVIN, PATRICK M PERM NO: M 086477
.cones: ESCAMILLA MYRNA F
189 LEXINGTON LN PERMIT NO: M 086477 PLAN CHECK NO: N GOVT: N SUPP: N
COSTA MESA, CA 92626
AP PL.MAILINGADORE34 CONSTRUCTION TYPE: V—N PERMIT TYPE: MEC PURPOSE: OTH
ARCHITECT ORENm1EER: ucNo: JOB DESCRIPTION : FAU CHANGE—OUT SQ FT:
ARCH.OR EWL'S ADORERS: UMT:
CLAIM VALUE: CALC—VALUE: GROUP OCC: R-3 /U-1
caumAttat'5Nu&CRYSTAL AIR (714 ) 534-2593
coparmion uwm 11801 MAC STREET COMMENTS: CHANGE OUT FAU
ADDREStGARDEN GROVE CA moo: 655036 *+E*+E*+E*R ***+ERE*+r*EE*E1Et EE****** EE**RrRERE**Er******************EE*EE***+t******M******+P+t+EEE
92641 UMT: ZONING REQUIREMENTS
LICENSED CONTRACTORS DECLARATION:I hereby eirm under penalty of perjury that I em licensed under provisions of Chapter 9 SETBACKS
(commencing with Section 7000)of Ditisim 3 01 the Business and Professions Code,end my learns is in full force and ales.
clryuc.No.:042006 uc.cc: C-20 uc.N9.: 5036 EXP: 03/98 MAIN BUILDING ACCESSORY BUILDING
FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
� � LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
OWNER BUILDER DECLARATION:I hereby ohm under penalty of perjury that I an exempt horn the Contractors License Law for the
goring reason(Sdion 70313 Busiest and Professions Code:Anyriyor county whtdu requires a permit toinstruct.akar.improve. PARKING REQ: PROV: PARCEL: 41901112 ZNE: REF NO:
mash•or recti airy ehudue,prior to is nroeal"Manivaan II"appivar wa
Ir pwmt 1°84 a signed stain"'hal he a she PLANNING NOTES>
licensed pursuant to the provisions Connectors ions of the Co ors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Busmen and Professions Code)or that he or she is exempt therefrom and the hasis for the alleged exemption.Any violation of Section >
7031.5 by any applicant for a permit dyads the aprems to a chi penalty of net mat than five hundred dolas(5500)). *******************************************************************************
❑ I.asowmr of the property amYrmtryemwih wages mlhei sole compensation,will do to wort and the structure is nor intended DEVELOPMENT SERVICES REQUIREMENTS
or aired for sale(Section 7044.Business and ProfessionsCode:The Contractors License Law does not appy to en owner of properly
who bolds or improves thereon.and wfio dose such work lmse,or herself or through his Of her own employees.provided the such
lmprowmaea an nit intended co arced for eVe,U.however.the heading or improvement a sad wihn ane Yew a mmpamn.me ZONING APPROVED BYDATE:
owner-builder will have the laden of proving he or she did not build or improve for the purpose of sale).
❑ Profession Code:The Cwirmaa License taw doeewith awed menctens not apps to t pro�whobust or improves thereon and whos and BUILDING APPROVED BY DATE:
contracts fon such projeds with a mgdoRs)licensed pursuant a the Cormactom License Law). a
❑ Iamexempt ud * *
under B.AP.C..forthisreason: APPLICATION ISSUED BY: DATE: t ' 8 8
************************************ ****************************************
°tlO1 0111111/:
wne LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:N
I do hereby certify that I ant aware of end understand the regriremeda of Catania Neagh and Safety Code Sedions 25505.25533.and
25534,and that I or any Mus building occupant will I wD not(uncle tune)need to comply will mid gate codes end the requirements for
areI construion applications BLDG PMT PLUMBING ELECTRIC - MECHANIC FIRE SMIP/RES GRADING
Provisions, PERMIT 13 . 25
Data: Applicant: • 25% SMIP/NON—RES
PLAN
WORKER'S COMPENSATION DECLARATION:!hardy affirm order penalty of perjury one of the following declarations: ISSUE FEE 22 . 00
❑ fhave and wilmaintain acertificate aCOMM toees4maefpwakers'compensation.mpd
aidfobYSedion3700daleLabr BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
Code, dama
h.pmced»wokfawihNtp«mwbbued. TOTALS----> 13 . 25 22 . 00 0 . 00 35 . 25 35 . 25 . 00
❑ !have and wi1 maintain warrent'compensation nsuranpe,as required by Sadist 3700 of the Labor Code.for the performance of the
wank fp which this punt is issued My wales'Cannpensatien insurance carder and pole/ember are:
Carrier: REVENUE DIVISION TOTALS--> COLLECTED:::: 35 . 25 OVER/SHORT: . 00
Policy Number: BLDG PMT PLUMBING ELECTRIC MECHANIC. • FIRE SNIP/TOT GRADING PLAN—CHECK
y(.• T�his neaion need nor be completed i the permit is for one s hundred dpYn/51001 or lest) 35 . 25
L.I
' I certify that in the prlamance or the work for which this panni Is issued,I Mall not employ any person in any manner eq m to
become subject to the workers'compensation laws of CVEortnia.and agree that D I should become skied to the workers' *******************************************************************************
compensation provisions of Section 3700 of the Labor Coda.I 1 comply orph wwithtm oprovisions. INDIVIDUAL F E E BREAKDOWN
//Dat�ee: i`i7) �{ We
FMYn/ng:Faun to neon wonuwiaompnnanon coverer e unlawful,end shall*tape en employer toannhra penalties and TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST
•
ell/fines cc to one hundred thousand dollen(S1040.3OA In addition to the coal or compensation,damages am provided con In
Section 37Oaerthe Labor Code,In«.a.and eflom ...e .r. MEC 1 INST FORC—AIR/GRAV FURN <= 100 K BTU 13 . 25 13. 25
n CONSTRUCTION LENDING AGENCY:I hereby affirm under penally of perjury that Ova b a construction lending agency for gel END OF FEES
performance of the mak for which this peril is issued(Section 3097.Civ.C).
( LENDER'S NAME:
LENDER'S ADDRESS:
w I certify that I have read this appliiction and star that the above information is coned.I agree to comply with ss a in end county ord'vanms �_r{
and state lawn relaig to building construction ad hereby authorize represenretives of this city to enter upon the above-mentioned properly Bike.
e.
for inspection purposes. L+A_-
�H BELL "'
(/ ,'ice:---3i:G.:ij f..1::icy
( y ( Pail Name / b _ — - - �--
pmadyyCmegpLceatnConWacta ..
•
(515116 WP) White-Ooidng A Safety,Green-Re:Caney-Appian:PinkJiwaee:Gddrud-Assessor
4,
CONSTRUCTION AND PLANNING PG. s SPA
APPROVALS Permit# Date Inspector APPROVALS Permit# Date Inspector
1. Temporary Electrical Service or Pdle 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 UF ER Grnd. 57. APPROVAL TO COVER•GUNITE
,7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, 0 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 - J • 70. Underground Hydro
-r
22. Ducts,Ventilating - - 71. Product PipingII.Gas ❑Oil
23. Gas Pipe-Roygh & Test - L - : 72. Underground Flush -
24. Roof Framing - : 71 Undergrnd.Stor'egeTank 0 Gas 0 Oil
25. Roof Sheathing ' 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat . i 7;1 75. Dry Chemical
27. Frame and Flashing •• 76. Dry Standpipe , 2 •
28. Lathing& Siding _ - 1 77. FIXED SYSTEM FINAL '
29. Insulation • - - - 18. 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: y • i.$�'; `
34. Final Heating& Air Conditioning t .51 0.
35. Final Gas Pipe-Testdie p n
36. Hood or Canopy - - . si �q
37. Final Factory Fireplace , , - ' '. �
38. Final Plumbing 0
39. Water Service-Final • - - _
40. Gas Service-Final - . .
41. Solar Domestic-Final I _
42. Backflow Preventer
43. Backflow Irrigation - '
44. Landscape Irrigation System z - . __ .
45. Sound Attenuation . _
46. Handicap Regulations .: . _
' 47. FINAL STRUCTURE& BUILDING ,
48. FINAL PLANNING -
49. Electric Release to Edison ' - ' .
. 50. Gas Release to Southern California Gas Co '
51. CERTIFICATE OF OCCUPANCY
No. Date
g R MF q CITY OF COSTA MESA
:fa`, BUILDING DIVISION
1. 1 .i.3-- -...Q r DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
°•4%ftemsDAPERMIT / P99-00682
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 869 LIARD PL Status: ISSUED
Suite No Applied: 12/6/1999
Issued: 12/6/1999
Vicinity:
Parcel Nunmber: 41806406
ISSUED BY:
Applicant NOCK, RON
Address: 11612 KNOTT ST
CA Phone: (714) 895-1246
GARDEN GROVE Zip: 92841
Owner HARRINGTON, J LANCE
Address 869 LIARD PL
Phone:
COSTA MESA,CA Zip: 92626
Contractor: NOCK PLUMBING
Address: 11612 KNOTT ST
CA Phone: (714) 895-1246
GARDEN GROVE Zip: 92841
License: 707775
Arch l Eng:
Address: .
Phone:
Zip:
License:
SCOPE OF PERMIT
WATER HEATER CHANGEOUT.
FEE SUMMARY
AMT QTY AMT QTY AMT QTY
ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 Sump Pump $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 $0.00 0 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 $0.00 0
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) $0.00 0
Drain,Roof $0.00 0 Shower $0.00 0 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 $0.00 0
Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0
Gas(1-4 outlets) $0.00 0 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: $35.80
COMMENTS/SPECIAL CONDITIONS 6
t} a _ i
Mkt' ., -
Mkt'
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
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:' .
O 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 hick this permit Is issued.
ave 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 Insuranc: :frier a •..I number ar pp �(...6C-14-
\\��--.. ,,rr r / �/'/`
Carrier: - ,r 4_ �" v — Policy Number: /V[.c.Y _ 4' ( ! 3 T cc
(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 Califor nd 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 provisi /Z 7 _5
Applicant Signature: Date: /
WARNING:FAILURE TO SECURE W ERS'COMPEN ERAGE IS UNUW FILL AND b`BIECT-AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FIN UP TO ONE HUNDRED
THOUSAND DOUARE(sic0,000).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 Cha1pier9(commencing with Section 7000)of Division 3 of the Business antlpy i Code,and my license is in full
force and effect.Lic.0 ger_ 7 7 'J Class 0
Contractor's Signature: Date: _7' — ' 9
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 Cade).
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).):
O 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 property who builds or improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner 113 verified by driver's license. 0 Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-properly 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,faisework,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:
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 Flre 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 Califomia 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 0 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
......_.._._ ..-_
4 If an RMPP is presently required,has Section 25534 of the Califomia Health and Safety Code been fully complied with? CI Yes ❑No
_—.--sub,..c.t_of t-__...—_at_
5 Does he will the applicant upresentlty a or future building itct o from at require for the work which is the subject this 0 estion appermii for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LI Yes LJ 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 ❑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
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 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-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
ature Of Legal Ow •r(s) Date
lz-2 s
..•r Authorised Applicant Date
CODE 4 WE DA. INTRIAL$ CODE. INSPECTION TYPE DALE ttfEIA69
1616 Fixed System Final Fire Prevention 206 Final Mechanical
T2001266 Pool Spa Final 208 Final Plumbing
/Ton Kr-
200
Final Re-Roof 210 Final Electrical
•
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Flre Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
2446.46
•
ADDRESS OF BMLDOC: 189 LEXINGTON LN DIT' CITY OF COSTA MESA — BUILDING PERMIT
aerERS NAME IF KNOWN: GALVT.N, PATRICK M PERM NO: R 072608
ADD" ESCAMILLA, MYRNA F
189 LEXINGTON LN PERMIT NO; 8 072608 PLAN CHECK NO: N GOVT; N SUPP : N
COSTA MESA,CA 92626
AFPL.SWUNG ADDRESS: CONSTRUCTION TYPE; VN PERMIT TYPE: STR PURPOSE: OTH
ARCHITECT OR ENGINEER: UCNO.: JOB DESCRIPTION ; T/OFF, SHEATH & REROOF W/COMP SHINGLES SQ FT: 2, 924
ARCH.OR ENG.'S ADDRESS: WIT:
CLAIM VALUE; 2., 924 . 00 CALC—VALUE: 2, 924 . 00 GROUP OCC: R-3 /
COITRACTOWSNAIE: STOUT ROOFING INC ( 310 ) 923-6775
CONTRACTORS MUM P 0 BOX 4309 COMMENTS: SMOKE DETECTORS REQUIRED PER 91 UBC
ADDRESS: DOWNEY CA UC.Pa: 402536 *****>t********** - ********sr************ ***********SEN**Nuc****k•x***aF*x*****>ESE***
90241 DIT: 7. ONING R EQUI R EMENTS
LICENSED CONTRACTORS DECLARATION:I hereby affirm under penally el ry theft am(keened under p• of Chapter 9 SETBACKS
(commando°with Section 7000)of Division 3 of the Business end Professions .,.and my license S in fug force. .1 effect.
CITY LW.NO.: 93'j7 sac.CLASS: C 39 Lie.NO.: .� 253 EX•� 4 y' 5 — MAIN BUILDING ACCESSORY BUILDING3j 9 a1C ' k� = RNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
Date: Ll/ Cohmf� LEFT: FT IN RGHT: FT IN LEFT; FT IN RGHT: FT IN
OWNER BUILDER DEC RATION:I hereby affirm under of perjury that I ern exempt horn the Contrtlors a Law for the
tdlowng reason(Sedion 7O31s Business and Pr essipn Code:Any city or county with requ'irese permit to•. ... .,cher,improve, PARKING REQ: PROV: PARCEL: 41916448 ZNE: REF NO;
repro'demolish.or repany structure,poor to is issuance.also requires the applicant fa such permit to hit a signed statement that he or she
is licensed pursuant to the praysans of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the PLANNING NOTES>
Business and Professions Code]or that he or she is exempt therefrom and the basis for the alleged exemption.My violation of Soffit >
7031-5 by any apptnan rot sPermit subjects the eWicsra moa civil penalty dnot more them free hundred dollars(S.i0Ol. ***************************IE****************************IF*k********************
❑ I,as owner ofthe popery or my employees with wages as their sole compensation,sol do the work,and the structure is not intended 1) E V E L O P M ENT S ERVIC ES REQUIREMENTS
or offered for sale(Section 704A.Business and Professions Code:The Contractors License Law does not aorta)an owner of propesy
who builds or improves thereon,and who does such work himself or herself or through he or her own employees,provided that such
improvements are not imendedoroffered for sale lt,however.tM building or an
4nprovement is sold within one yedtemplet,
tthe ZONING APPROVED BY DATE; ;
owner-builder will have the burden of proving he or she did not build or improve for the purpose of sale).
❑. sexclusively
and
Professssionn Cthe
ode:The t�ndos,Lianseealractiffi ww does not lapppplyytto an oovmer ofp property wo construct ho bbuiproject ids or improv thereon tion ereeon aannd who BUILDING APPROVED BY ; DATE:
•4ontracts for such projects with a mntrador(s)licensed pursuant to the Contractors license law).
❑-'amexempt under Section: B.AP.C.,for this mason: APPLICATION ISSUED BY: DATE:
*******************************************************************************
Dotal LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMFNT: Y
I do herebycertify that I am aware d and understand the requirements d Cattomia Hsieh and Safety Code Sections 25505,25533.and
25534,end that I or any Muss building oxmWm wig/will not(circle one)need to corn*with said state cedes and the requirements for
apermit for cpwmmdhpmodde:atfromtheAiOutstay ManagementDistrict.Residential construction applpadeare exempt from these BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
prwifione. PERMIT 54 . 00 . 50
Dale: Applicant: SMIP/NON—RES
WORKER'S COMPENSATION DECLARATION:I hereby affinn under penalty of perjury one of the following decimations: PLAN
❑ I hand wmaintan a certificate 000ment toseginsure lem
r workers'wmpatln.a
ioSeatided for by Sed37Wd1M Lobar ISSUE FEE
at l
112(ede.f«Ihe pedommerha.dthe workforwlhich this pemhnleixeaed. BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE.
IA Ihaveandwiimaintanworkers'campensattinsuran .es required by Section 3700oftheLaborCedekethperformanudthe TOTALS----> 54 . 50 0 . 00 0 . 00 54 . 50 54 . 50 . 00
work for with this permit is issued.My waken'compensation insurance carrier and policy number are:
Cartier: I'ATF EXPIRES REVENUE DIVISION TOTALS--> COLLECTED: 54 . 50 OVER/SHORT; 00
Poky Number: 04494/100 46117 10/19/95 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
(This section need not be completed i the panne is for one hundred dollars ••j• /a,.) 54 . 00 . 50
❑ 1 catty Nat in the penlamnance of the work for which this permit e . ...I .I no .•ploy any Person',IA,"manor o as to
became !o the woM1ns'campemdon laws d California . . ag..- that''A shdddbecone, . to t *******************************************************)E********w*************
rompers prints d van 3700 of the labor Code.I- .II, those• • -•
1 sr/q//fed �/ I N D I V I D U A L F E E B R E A K D O W N
Dale: .3/ '/ r Aped / •
Warning:Failure to secure workers'compensation co . - la unlawful,and shell subject en employer n M Ipenalties end TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST
civil tree up to one hundred thousand dollen($lO*000).M sddWon to the cost of compensation,Mr provided ler In
s«don37UdoftaLaborco*Int.netaneatomay'a/ws. SFR 7.924 REROOF BY VALUE RESIDENTIAL NO7ONF 1 . 00 7, 924 . 00
CONSTRUCTION LENDING AGENCY: I hereby affirm under penally of perjury that there ie a construction lending agency for the END OF FEES
performance of the work for which this permit is issued(Section 3097.Civ.C).
LENDER'S NAME:
LENDER'S ADDRESS:
I codify that I have reed this application and state that the above information is correct.I agree to comply with ell city and county ordinances
and state laws relating to build' .ruction end hereby authorize representatives of this city to enter upon the adweomentioned propend
for inspection purposes.
D . ENE �URFORD /
/1 L !/ #Go✓�/� /. !/ • l ate: 573//9s�
DAT01 E: 05/31/95
TOT 5<.50
Signature of Owner"•entApreicanCCanl.-or
(5151-46.WP) WMe-Building A Safely Green-Re:Conry-Applcsnt:Pink-Annie:Goldenrod-Assessor
•
•
CONSTRUCTION AND PLANNING PG 9 SPA
Date IMnr Date Inspector
APPROVALS Permit # "�� APPROVALS Permit #
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 UF ER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd. •
• . 8. Foundation 59. Gas Pipe, 0 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:Firial
12. Sewer Cap •
63. Heater & Vent-Final - .
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final •
15. Rough Electrical-Conduit r 66. Solar System-Final
16. Rough Electric Wiring - 67. Fencing & Access Approval 1
17. Rough Wiring Sign 68. APPROVED FOR PLASTERJNG
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL •
19. Rough Heating & Air Conditl'oning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit #
21. Ducts.in Structure - - • 70. Undergrodnd Hydro -
22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil
23. Gas Pipe-Rough & Test •
72. Underground Flush
24. Roof Flaming - • , 73. Undergrnd.StorageTank OGas OOiS
25. Roof Sheathing asys
- 6,04._ 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat .' • 75. Dry Chemical
27. Frame and Flashing - 76. Dry Standpipe
28. Lathing& Siding• - 77. FIXED SYSTEM FINAL
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 r.
r -
45. Sound Attenuation ' . •
46. Handicap Regulations - -
47. FINAL STRUCTURE& BUILDING ((_Z-9( c2Wt
48. FINAL PLANNING l
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
OWNER SAN VISTA BUILDING COMPANY DATE 6-1-64
JOB ADDRESS 189 Lexington Lane BUILDING PERMIT NO. 22224
GENERAL CONTRACTOR Salve VALUE $ 114-L335.00
AP No. LOT 124 TRACT 160 FIRE ZONE DESCRIPTION OF WORK res watt gar
INSPECTIONS Signature D.T _ GROUP I&J TYPE V ZONE RS
Soil o i/ TERMITS ISSUED
Gas G J SUBCONTRACTOR DATE NUMBER
Waugh n/¢`� 7
Rough Corn. efrig. Air Cond. ❑
Rough Heating /4 7/04i - 77s,ay 335-
Rough Plumbing j Ii / ' �y ee /v -/-(� ,,t (i ,. tL d —
Miscellaneous
Prop. Swr. Line❑ House Con. p'St. Swr. 0 /-4' I//"/�tf ( ('yw„
encc 9 1963 4(3'7i1�
Sprinkling System �/ elf
_Construction Pole
Underground [1 Power C] - iC c�
Rough Wiring /jam li-,/c'•Cci / JUL 1 3 1$64 2 9 t;A
Trenches 0 Forms 0 Steel Reinf. es, t (,-70 4' ✓ ..+y= 0
Floor System _i., G /, S/c y / �6�
Bond Beam 0 Steel Reinforce 0 /, J
Sheathing I, / m t _ G
Frame and Flashing s m g-- /o fr e y.,
Lathing— In ®.Out 9� iii Q 2 — C. " _ ,y�U
Plaster, brown coat /` %r - g^— >� c 5` - (1 1V�',�1
Refrig. p Air Con. .p Final (._��/"' _ec
Heating, Final q/, i • ///yy .d 1
Plumbing Fixtures, Final la` , /7✓�/ � .
Final Gas Test S# / . .
Electric Fixtures, Final Ce A_u• -1., V r
Building, Final /- , 7,), ? •
OCCUPANCY OLD FOR SPECIAL REQUIREMENTS
Form BU4-6M—a-63—S-13 P
22224 FEE RECEIVED
COSTA MESA BUILDING-SAFETY DEPARTMENT 44? l 9 19/4
P.O.BOX 317 COSTA MESA.CALIFORNIA FINANCE DEPT.�� MM�
For Applicant to Fill In Completely APPLIC4lTIOIQFFOQ`��TTPERMIrSA
TYPE OR PRINT BUILDING
BUILDING /29 ✓ •�, —fit For Office Use Only
ADDRESS ii 7 .,/r.0-n o• RECEIPT NO. /'V+EryRiT�+
COSTA MESA, CALIFORNIA nn e�-f{;4
/1„.4.612:-
'// �jl R[CI9[Y � [C¢19=� DATEISSUED
OWNER JCLBUILDING
MAIL ", ✓ ��• � .IUIV 1 I9
ADDRESS j/j (G /C: LJ C ADDRESS
CITY �i /9 .1/ NFIRE
Tos9D37/t7 ZONE TYPEit_ GROUP��J
APPROVED
AP 'TECT:NEE 6a ..Q No.-11,0 BY DATE
O
pp ZONING 4 t
ADDRESS 243,2 ✓..+. O+ 04e--4
.F ryL
Z , PLANS DBE OF
('�(�`^'^ /� PLANS BDILDWOI t. - i1
CONTRACTOR /.QA�� l I Cal a Stet-
ht.�} / L
/Jt! e. s &-P--
Cal
DESCRIPTION ,/J ac+S/b 0 dCI-1 . /.2 T
ADDRESS b //
CITY dI ,c . // A.P.NO. I ki / - `/1`l~ (f
STATE p/�/y /j TEL.Y� �j p/y NOT TO SIDE a REAR P.E: NO EAVE L.
OVERHANG
G SHALL BE L SS THAN
LIC.NO. //2/62— NO. bi 3) /8 /
EAVES
SIZEI NO.OF BLE305.NOW ON LOT O ALLOWED (U.B.C.REQUIREMENT)�
OF LOT P7O k'7o
USE OF //y YARDS APPROVED YARDS APPROVED
EXISTING BLDG. // O✓LC� MAIN BUILDING ACCESSORY BUILDING y�
(FROM C/j,.STREET) Yd
CSENTER STLINE FROM /�, REAR YARD _ FRONT CGI` FT. FT. cis
CENTER OP STREET �^^�
SIDE YARDI LEFT O I RIGHT D R.SIDE ` /FT. FT. ,.1‘1
DESCRIPTION OF WORK L.SIDE OFT. FT.
/ • CO
NE J� ALTERATION ADDITION REAR FT. FT. F.
DISTANCE BET. BET.-MAIN ft W
REPAIR MOVING DEMOLISH MAIN BLOCS. ACCESS.BLDGS. 2
BUILDING NO.OF ./ a VAR.# DATE W�
SIZE ;20 A. 3.Z ROOMS STORIES C.U.P.# APPROVED
EXTERIOR WA ROOF ROOF ((^^ Q, APPROV l(�L\�/ , , A 6" a
COVERING y1U.Ct,47 I COVERING (l' f-� BY lll "Z'�'1 DATE .� /`� `�
USE OFAND WORK Q BE ERFORME `` � tt
I-G/fQt ( Ft
U
4v�� �/ a� o D.
1 13 ea-SO.FT. 'I z0 4----
: in
I HEREBY ACK LEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE I ,A
AND STATE THAT E ABOVE IS CORRECT AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. O WO
PLY WITH ALL ITT RDINANCES AND STATE LAWS REGULATING VALUATION /mei m IL.
BUILDING CONS U ION. S N
SIGNATURE OF A _C_C I PERMIT FEE $ j Q
PERM ITTEFl ` 0 el m
$ /1/ $3S PLAN CHECK $ 21 ' Q
O E i
l e0 E
AUTHORIZE A6 T TOTAL FEE $ 72