HomeMy WebLinkAbout3125 TAFT WAY - Building Permits t ►
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5011 Fn CITY OF COSTA MESA
BUILDING DIVISION
:j DEVELOPMENT SERVICES DEPARTMENT P RMIT NUMBER
*40 'Ugh
PERMIT
it ehmatia ' B01-01847
(714)754-5273 • Fax(714)754-4856 • w' .ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 3125 TAFT WY Status: ISSUED
Suite: Applied: 11/20/2001
•
Vicinity: HOUSE&ATTACHED GARAGE Issued: 11/20/2001
Parcel Number: 14169306 Zoning: R1 R1
Applicant: YOUNG, MICHAEL ISSUED BY: •
Address: 1015 E CHESTNUT
Phone: (714)953-5444
SANTA ANA,CA Zip: 92701
Owner: WARD, JOHN
Address 3125 TAFT WAY
Phone:
COSTA MESA,CA Zip: 92626
Contractor: YOUNGS ROOFING CO, INC
Address: 1015 E CHESTNUT
Phone: (714)953-5444
SANTA ANA,CA
Zip: 92701 License: 568560
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF EXISTING SINGLE FAMILY RESIDENCE&ATTACHED GARAGE(22 SQ).TEAR OFF EXISTING&RESHEATH
WITH 7/16"OSB. INSTALL 30#FELT UNDERLAYMENT&REROOF WITH 40 YEAR COMPOSITION SHINGLES.
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $4,000.00
Permit: $97.25 Claim Valuation: $4,000.00
SMIP Res: $0.50
SMIP Corn: $0.00
Other: $0.00
Inspection: $0.00
Total: $97.75
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:
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NOTICE: The work authorized by this permit shall comply with ail 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
244646(6/00)
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 for which this permit Is Issued.
r p Ilhave 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:
Ceardei:–""–\ 5r C1/4Th F)M}y Policy Number: IS ta 1 4-87
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
❑ I certify that in the performance 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 d agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with the vi ions. )
rApplicant Signature: f' ate:
O —r (11 2.6/ o1
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 DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,MD 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 tie. l S c,g 5-40 Class A C— 3
Contractors Signature:— Date: tip
)
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,CMI 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 peri.t
subjects the applicant to a civil penally 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.),
O 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 en 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 driver's license. ❑Yes 0 No Driver's 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,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:
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 ❑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 end 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 agermit for such construction or modification
from the South Coast Air(Duality 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? 0 Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
... AirOualiy.....aee.t.....i.t. r other air pollution
7 application,a permit fromn the South Coast res presdy ed Management District or nd S tdcontrolion district3been agency is required for the work which is the subject of this
have all of the disclosures prescribed by California Health end Safety Code Section 42303 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 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.
Slgnatur Of Legal Owner(s) II Date
�! 2dJ0 )
And/Or A ' ad Applicant '-
CODE 9 INSPECTION TYPE PATE UIDBALS SODS( INSPECTIONTYPE PAIL Iffalala
1618 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 1/1 ( 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
OWNER who). JOHN DATE 5-13-80
JOB ADDRESS 3125 Taft Way BUILDING PERMIT NO. 50095
GENERAL CONTRACTOR owner—Builder DESCRIPTION of WORK Roan Addition
AP No. 141-693-06 LOT 14 TRACT 4502 FIRE ZONE VALUES 14,177.00
,b„7.CTIONS Signature Dote TYPE V—N GROUP R-3 ZONE R-1
S!,r, -- - - -- SUBCONTRACTOR PERMITS ISSUED
GAS Date I Number I Signature
WATER Plumbing
ROUGH PLUMBING^
PROP. SWR. LINE I l HOUSE CON. 0
SPRINKLING SYSTEM '` I�
MISCELLANEOUS Im<, c1 1v� .DS ,-at.-1,..,
ROUGH HEATING AND AIR CONDITIONING
TEMPORARY SERVICE OR POLE
UNDERGROUND fl POWER Ei
ROUGH WIRING C� �.(9 '7. 1 Heating and Vent.
1 TRENCHES [ ORMS Q' STEEL REINF. EF $ t/G
. FLOOR SYSTEM
5 BOND BEAM [7 STEEL REINFORCE [l
SHEATHING 07C.9 c_"2-7/7
FRAME AND FLASHIN ttt-� .7..;1447
4( �iZ.�
LATHING — IN UT Ir."-. 1.-).5 7_t&stP
PLASTER. BROWN C AT ..sis -2-•3I4D
STRUCTURAL. FINAL3,c,
Electric
H 'G, VENT., REFRIG. AND A.C., FINAL /g 4-30.90 �f 7It
L. JING, FINAL AND GAS TEST 0 L•
ELECTRIC. FINAL C G ^/
BUILDING, FINAL C a` li aAQ .
21382 FEE RECEIVED
J JAN 17 1984
COSTA MESA BUILDING-SAFETY DEPARTMENT FINANCE DEPT.
P.O.BOX 317 COSTA MESA.CALIFORNIA
CITY OF COSTA MESA6'!1
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
For Office Use Only
BUILDING
ADDRESS 3125 Taft Way
R[C[IPT NO. 21E382.
COSTA MESA, CALIFORNIA J L
RECTtY DATE R�G8fY8pL/ JIAIT 1 e6U 1964
OWNER Northgate Homes / 6. IY
MAIL BUILDING
ADDRESS 15939 Las Flores ADDRESS
FIRE ��JJ
LECITY Fountain Valley TE 5316792 ZONE TYPE GROUP6Yef
LLyyTT.. APPROVED
ARCH
OR ENIGIN ER C. Hiller - NOPr•+52007 BY DATE
N NO.OF ZONING �..� ,
USE OP n[ v
ADDRESS Anaheim - p} /f /
/ r I PLANS / /I' BUIL. N' GY `I /,
CONTRACTOR BrITlRPr Cons+ ,Inc \ V
LEGAL
ADDRESS
15939 Las Flores DESCRIPTION
--772 /4.1,M7:
--� . ±�
CITY Fountain Valley A.P.NO. ��J //� / /uo�
( ) NOTE: NO EAVE OVERHANG SHALL BE LESS THAN
STATE TNO. 215049 NO. 531 ( 9'1 90.70 SIDE It REAR P.L.
EAVES
SIZE
65x102 NO.OF BLOTS. ALLOWED (U.B.C.REQUIREMENT)
MOT 0
NOW ON LOT
YARDS APPROVED YARDS APPROVED
USE OFG BLDG. 00 MAIN BUILDING ACCESSORY BUILDING
EXISTIN
(FROM C/LSTREET)
SETBACK LINE FROM 50 REAR YARD 29 FRONT ' S GFT. FT.
CENTER OF STREET �\
SIDE YARD I LEFT 5 I RIGHT 9 0 R.SIDE /OFT. FT.
DESCRIPTION OF WORK L.SIDE S FT. FT.
1 i
NEW X ALTERATION ADDITION RC" `J� .
DISTANCE BET. BET.MAIN ft
REPAIR MOVING DEMOLISH MAIN BLDGS. ACCESS.BLDGS.
BUILDING NO OF VAR.# DATE
SIZE 1434 ROOMS xi 6STORIES 1 C.U.P.# APPROVED
EXTERIOR Way ROOF APPROVE 1, ,I,1,� / l/ (//f
COVERING SLL�Ci CTO I COVERING shingle - BY �� DATE /� ] Q r
USE OF BUILDING AND WORK TO BE PERFORMED L Y //
single fam. res. watt. gar. a '
/+7/ BQ.FT.? - 4- z0 n' 7 i
I HEREBY ACKNO '-•- T. E READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE F
AND STATE TH: THE A=• E IS COR' -CT AND AGREE TO COM- PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. O
PLY WITH AL CITY OR•A ES AND STATE LAWS REGULATING
VALUATION
BUILDING C• BTRUCTI•� ` OO h
PERMIT FEE $I / O
SIGNATUR OF e e
PERMITTER , •- 4-A -•. S9 00 C r Jo ¢
AUTHORIZED AGENT $// / �� sta.
,n w
TOTAL FEE s/b
' JOB ADDRESS 3125 Tart way BUILDING PERMIT NO. 39949
GENERAL CONTRACTOR Owner-Bldr. DESCRIPTION of WORK Add Patio Cover to Res.
'� p ,. 141-693-06 LOT TRACT FIRE ZONE VALUE $520.00
INa.ECTIONS Signature Dare TYPE V GROUP J
SUBCONTRACTOR ZONE RI
SOIL GAS PERMITS ISSUED
JO Dote Number Signature
WATER Plumbing
ROUGH PLUMBING
PROP. SWR. LINE ❑ HOUSE CON, ❑
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING •
TEMPORARY SERVICE OR POLE
UNDERGROUND 7 POWER ❑
ROUGH WIRING Heating and Vent.
TRENCHES 0 FORMS 0 STEEL REINF. ❑
FLOOR SYSTEM
BOND BEAM 7 STEEL REINFORCE n
SHEATHING
FRAME AND FLASHING
LATHING - IN 7 OUT n
PL' -`R, BROWN COAT
S', URAL, FINAL Electric
HEATING, VENT., REFRIG. AND A.C.. FINAL
PLUMBING, FINAL AND GAS TEST n
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PI PrTRIr GINCI
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PAIL .SO
_ 39949 "AY -9-?Stf:,,,OO 281 *****E
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
A
P LI9ATION FOR BUILDING PERMIT
For Applicant to Fill in Completely
[� !Amy /yj R E V DATE RECE VE DATE ISSUED
ADDRESS G 31 R..J JI-T/- city,.
t .5-6o
OWNER 091-1 I"( 1,314Ra A.P. NO./Q -te93-O6 PERMIT NO.
MAIL ivi BUILDING
•
Z ADDRESS 3�Z� T4rT \,J y e[v-1/'- ( t ADDRESS /25 7,croUo�
6. U CITY CO514 //_f/4- t NOTEI. a qa as, TRACT I LOT BLOCK
Z (-
CONSTRUCTION NEW ADD ALTE�IXEPAIR {MOVING DEMOLISH
O m LENDER
J O BRANCH 1//V 64 4s _
-t N OWNER �(_/"S/\J
m J ADDRESS -"�� T VALUE ///� •
-CO ARCHITECT p TEL. /I� VQyEi/( $i6
J N OR ENGINEER OMJNEC NO.
U Q ZONE TYPE i GROUP
a Ly APPROV r---
W Z CONTRACTOR VW 1 r3/\ BV OATS/1 d�
J O J
CCI Z
JCC ADDRESS
W w TEL. ZONE NO.OF .1 USE OF NEW ys4r/o
O= CITY NO. �/ PLANS ../.., BUILDING C-USE
Z I- _
LU O STATE CITY YARDS APPROVED YARDS APPROVED
to oc LIC.NO. LIC.NO. MAIN BUILDING ACCESSORY BUILDING
Z)O (FROM C/L STREET)
SIZE NO.OF BLOCS.'
OF LOT NOW ON LOT FRONT /641779e--i FT.
USE OF .
EXISTING BLDG. �/ R.SIDE /f FT. FT.
I- SIZE OF
Z NEW BLDG.//PC 2ZV. ROOMS STORIES L.SIDE 3QQ///EE T, FT.
ICE ROOF
O COVEERIING WALLRIOR COVERING _REAR fOFT. FT.
J USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
d MAIN BLOCS. ACCESS BLOCS.
0 A0 o 697/6 eciVE-R CU.P.# ^ 3
APPROVED
I- APPROVEDo Psi, • -9
N _BY 140 DAT'
Z W.
O .
UI hereby acknowledge that I have read this application and state . •.
✓ that the above information is correct and agree to comply with
all laws regulating building construction, and I shall not employ v
I- any person In violation of the workman's compensation laws-of - - .
fA the State of California. A ♦rs o
z I hereby certify that I am properly licensed as a contractor under //Vi(//�G? •
50. FT. .O
the State of California Business and Professions Code, Division 3, THE AMOUNT-SHOWN UNDER VALUATION IS FOR
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: •
CC
am axempt.from the provisions of the State of California Business VALUATION �f
and Professions Code, Division 3,Chapter 9. OW'S.. m
////// A / PERMIT FEE $ 6 el
Signature of 1_. 1r oLt.s/f �7 to
Permittee 'rtt "iiiuu`-ttt $ -20 PLAN CHECK $ E
a .....---
Cis o
Author] ed gent a
` TOTAL FEE $ 1
•
�O41"fts CI . 1 OF COSTA MESA
O �� CALIFORNIA 92626 eaP.O. BOX 1200
F
�• FROM THE OFFICE OF THE DIRECTOR OF BUILDING SAFETY •
c*PawnEo
Project Address 3/2 5` --711F- 7 414`/ e /1. Permit # 4'1187"
Project Name Type ' ii e `,
Owners Name flg..P MRs JB,/N AMR/5 C
owners Address 3 /25-- -7 9/C7 l'a9 y City Use (lily
Owners Telephone ���1 ,5 Lf a 6/ 5 /
I 6- Laia�ei/ as Caner, Contractor, Agent (strike out all
ex one) do hereby attest that employment of any person, or persons, is not
anti- ipated at the time of seeking the above-referenced permit. In the event that
any person, or persons, are employed under the provisions of this permit, I shall
immediately cause a valid Certificate of Workmen Compensation to be filed with the
Costa Mesa Building Division.
I agree to defend at my own cost, and to indemnify and hold harmless, the City,
its officers, agents and/or employees, from and against, any and all liability,
damage, costs, losses, claims and expenses, howsoever caused, resulting directly
or indirectly fran, or connected with the improvement under this permit.
I further state that I have read and fully understand the implications and re-
sponsibilities of the above statements, and will comply with all provisions of the
Contractors State License Law found under the Business and Professions Code,
Division 3, Chapter 9, of the State of California.
V // / les/44),)
Print Name
cy,
`- (/�OGr�•,-� /gyp/ °
Signature Date
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CMF 0777-46
6808 IFS/I3/80 108.99 TL
COSTA MESA BUILD! IAFETY DEPARTMENT APPLICA' I FOR STRUCTURAL PERMIT
P.O.BOX 1200 COSTA. _SA,CALIFORNIA 92626
RECEIVED PERMIT N° . 50095
For Applicant to Fill in Completely/ el —Use InkOnlyr / q I� ^
e BUILDINGnk O.9 2' ) T,cT AAy {i./- . A.P.NO. /Q.•/�`�O / J �[/�
BUILDING
R SS 3/23 TA�&J,A ,,,-xr,,
OWNER OR ,./� Of ///� y� /_/A�^ ADDRESS y
TENANT r�� ! .,.+ //(//J / ' /
UNIT ORN
MAILING Q ��jjrr /�f SPACE NO. .
ADDRESS ,3r.GJ T{9FT ,/,�/A TR.NG. __ LOT /dry ELK.
CITY /s'�ST/v MESA NOL D-6/5/
NEW ADD ALTER REPAIR MOVING DEMOLISH
CONSTRUCTION
LENDER
BRANCH OWNER foHI/ 4l4eo
ADDRESS VALUE
ARCHITECT TEL. USE RfyyL G(, $lib/77—
OR ENGINEER NO.•
t/,��
ADDRESS n ZONE •�.s �/� TYPEV,/� GROUP '`-r3
CONTRACTOR Q /a, BYPROVED co
DATE S----1?-8-0
ADDRESS P.2_ 44 3
TEL.
CITY NO.
FSTATE CITY APPROVED SETBACKS
LIC.NO. LIC. NO.
/ (FROM C/L STREET)
ILLI SIZE rY i NO.OF BLDCtS. A.�T/�.��,.JQ'�
p. OF LOT /Ql-!j X �� - fJ~ NOW ON LOT '� FRONT A ( Z'''r '5- •
.4�i USE OF s /i
EXISTING BLDG. 20.52.0,621./re R.SITIF /O FT.
/ /i
FSeparate permits are required for L.SIDE 3q FT. d
electric,plumbing and heating work. —j / t it
W REAR ( FT.{,f
(.. USE OF BUILDING AND WORK TO BE PERFORMED PLANNING ACTION
c <Aro
DATE
Q p_OQ/M"- a dl- APPROVED /��
.-) 22/ " /5 / �YROVED/,,y/�� DATE 61,4745
CL
/�(\ /—JV�I/
IQ
aa. I hereby acknowledge that I have read this application and state e.
cg that the above information is correct and agree to comply with
Cu( all laws regulating building construction, and I shall not employ i
Z any person in violation of the workman's compensation laws of "� v
V.1
the State of California. / �{y/ / /77 __ m
3 I hereby certify that I am properly licensed as a contractor under ( SO. FT, r-clj//yjj ry r`+
the State of California Business and Professions Code, Division 3, THE AMOUNT SHO N UNDER VALUATION IS FOR CO
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: n
am exempt from the provisions of the State of California Business e
VALUATION PERMIT FEE $ 72,
and Professions Code, Division 3,Chapter 9. v+
re
Signature of ) PLAN CHECK $ 36. �_ 2
y" o
Signal re / $ I /r / 71-- TAX $ Q,�9u
or
Authorized( ant Date 3-////64.42 Q F
... TOTAL PAID $/Q U ,79?
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