HomeMy WebLinkAbout874 WILSON ST - Building Permitseoon�sswem�axc: 874 W WILSOt�' ST
a"'"_��+"�E"'�'�`"' ORTIZ, SOSE LUIS
"ODfl� ORTIZ, IRMA
874 W WILSON ST
:OSTA MESA,CA 92627642-8965
ARCXIfECT ON FNfJNEFA:
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OWNER BUILDEP DECIANATION: I haeby elfimi uMer panaly d perPrv �� � em wsmq Imm iM Conireaon Lianss lew la iM
tdbWeq �aeaon (�� ]�1.5 Bueiwes enJ Prdauions CaEs: AMW n muniy Mfiich npuim e pemin io mroWCY. Nv. "unprow.
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WONKEP'8 COMPd9�TON DECL�PATON: I Mr�Ey elfum under p�nMy d parjury aro d Ihs Idbwirq deduelioro:
� I haw uM wil meintein e anAcaa ol mnnnl to veHanaun br xakan' compsneetbn, n prwldad for by Beqbn Jro0 M ths tebar
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becana wbjaa to tM wken' mmpamelion kw� d Cdilamle. end epna Net d I tlwuk beoorn� ab�aC lo IM xvM1a�'
cpnpeiumbn qwi�um d SeCion 3)00 d iM lebor COC�. I tluA lonhvmh mmpy xiN tMm p�v.iNom.
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CONSTRUC110N LENUINO �OENCY: I hxeW afA�m urder prWry d parjury ilw Ihan b e conpivabn IsMinp apeMry M IM
peApmariw W Ih� v.ork M whkh Ihe pom�Y b's�uM (�� �. GH. GI.
LENDEP'8 NNAE:
LENOEP'S �DOflE94:
I cMily IMI I Mw nad Ihb applketion eM YeN Ihel �he above Intormmbn le comtl. I epros Io wmpy wil� NI tlry erd counry aMiwKee
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la iropenion purpons.
JOSE ORTIZ
om.: �—/D-5.�
(5151<l.WP) Whns-Buildiq 6 Selery; �rwMFla: Caneiy-Appifan�; Pink-Rwanue; pokanivd-Aswwor
CITY OF COSTA MESA — BUILDING PERMIT
PERM NO: H 073731
PERMIT NO: B 073731 PLAN CHECK NO: 03187-95 L GOVT: N SUPP: N
CONSTROCTION TYPE: PERMIT TYPE: STR FURPOSE: CON
JOB DESCRIPTION : CONST. BLK WALL W/WROUGHT IRON FENCE SQ FT: 59
CLAIM VALUE: 1,000.00 CALC—VALUE: 1,180.00 GROUP OCC: R-3 /
COMMENTS: 30" HIGH BLOCK WALL W/30" WROUGT IRON FENCE ON TOP
iF 1E iE iE iE iE aE iE 7E iE 1F iE iE iE iE iF iE iE 3F iE if �f 1E iE iE If if iE 1E iE 1E IE 9f If iF iE iE 1E iE iF iF ib if iFlf if 3E If 3E 1E ik iE iF jF M 1f �E �f 16 iF iE iE iE iE 1E fE IE iE 3F iE iF iF iF 1E 1E IE iE IE iE
Z O N I N G R E Q 0 I R E M E N T S
S E T B A C K S
------------ 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
PARKING REQ: PROV: PARCEL: 42236325 ZNE: Ri REF NO:
PLANNING NOTES> CONSTRUCT 59 LINEAL FT OF 30" HLOCK WALL WITH 30"WROUGHT IRO
> N ALONG FRONT AND LEFT PL. WROUGHT IRON GATE ACROSS DRIVE.
!E iE 1!!f 1E ik iFlE iE IE 1E iE 1F 1E �E 1E 1E 1E 1E 1E 1E iE 3ElE iF IE 1! 1E ihlE iE iE 1f iE 1E iE iE 1E ih iE iE iE 1E iE iE IE 1E 1E 7E �E iE if iE iE 1E if if ik fE 1E iE 1E iE 1E �E iF if 3E iF ik ik it 1ElE �F �k IF iF iF
D E V E L O P M E N T S E R V I C E 5 R E Q U I R E M E N T S
ZONLNG APPROVED BY �A� DATE:
HUILDING APPROVED BY : /�Y1_ DATE: R I� ��
APPLICATI
LEGALIZATION:N F E E S U M M A R Y
BLDG PMT PLUMBING ELECTRIC MECHANIC
PERMIT 29.00 �
PLAN 18.85
ISSUE FEE
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK
TOTALS----> 29.50 0.00 18.85
FIRE
TOTAL
48.35
STRUCTURAL SEGMENT:Y
SMIP/RES GRADING
50
SMIP/NON—RES
PAID DUE
48.35 .00
REVENUE DIVISION TOTALS--> COLLECTED: 48.35 OVER/SHORT: .00
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
29.00 .50 18.85
iEfEfEifiEiEiEiEiEiEifikifiklFlFiElElElE�ElE�EfElElflfiElEfEiEfElEiEiE3EfElF�Fff1EfE1E1Eif1EfElEiEkfEfElElEifiEiFiElE1E1E�EifiElEiFiE�E3EfE�EiEiEiE1E1EiE1EiE
I N D I V I D U A L F E E B R E A K D O W N
TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST
SFA
59 RES—CONCRETE HLOCK WALL / FT
END OF FEES
EXPIT�ED,
DATE � � 9` •
20.00 1,180.00
ci on:s�c�: ,-,iapo72 : c o� Y^.,;
DA�Ev 0'.' 0,. Ti� E: F::i,1
�
.�
CONSTRUCTION AND PI.ANNING • POOL & SPA
�� AppROVALS Permit # Date Inspecto� qppROVALS Permit # Oate Inspector
1. Temporary Electrical Service or Pole � 52. Pool & Equipment Location
2. SOif Pipe•Undrgrnd. - 53. Steel Reinforcement �
3. Electrical Conduit Utitity-Undrgrad. 54. Forms -
4. EI¢ctrical Conduit-Undrgrnd. • 55. Electricat Bonding � .
5. Steel Relnforcement 8'../�_� 4 u�pr 56. Rough Piumbing & Pressure Test j''
4
-6. Ejectrical UFER Grnd. . 57. APPROVAL TO COVER�GUNITE
�7: Footings �u=qg ��,�,bi 58. Electrical Conduit-Undrgrnd.
9. Foundation � 59. Gas Pipe, � Undrgrnd., Test
' 9. Wzter Pipe-Undrgmd. 60. Backwash Lines, P�Trap, O Updrgrnd.
10. Structural Floor System 67. 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-Finai
15. Rough Electrical•Conduit " '� � 66. Solar System�Final
16. ftough Electric Wiring 67. Fencing & Access Approval '
77. Raugh Wiring Sign 66. APPROVED FOR P�ASTER�NG .
78. Rough Electrical-T Bar Ceiling 69. POOUSPA SYSTEMS FINAL
79. Rough Heating & Air Conditioniny . FIRE QEPT. REQUIREMENT
20. Rouqh Factory Fireplace ' . �� �- APPR'OVQL-S�. _ Permit #.^._� �-
21. Ducts, in Struciure -•� _ " - . 70. .Undergrounil Hpdro
s -
22. DUcts, Ventilating ' '� ' , 71. ProducE Piping O Gas C Oil
23. Gas Pipe�Rough & Test � ' � 72. Underground Ftush ;��_ �
24. Naof Framing' '- ��" . _ 73.' Under9rnd. Storage 7ank � Gas O Oil `;
::�.
25. Roof Sheathing • - � . 74, Overhead HYdro _. � r�' �
�
r�- .� _- ..._ .�,
26. T�9ar Ceiling (Stru�fural) & Monocoat ' �� r 75. Dry Chemical '� .;..p
27. Frame and Flashing -�� � ' 76. Dry Standpipe ' ' ��� • d1..
- 28. Lathing $F Siding : � - � . ,' - , � 77. FIXED SYSTEM{'fINA�, �, . �_'� .
29. Insulation _ � 78: FIRE PREV. FfNAL �
30. Drywall Nailing .HEALTH DEPT.AEQUIR��MENT
37. Plaster Brown Coat . 79. FINAL INSPECT7DN �
7 -_.
32. Electrical Power Mecer�Final ' _' ` 80., POOD CERTIFICATE ISS,UED
33. Final Electric -� . . � Notes: - . � • - � �*
��
34. Final Heating & Air Conditionirig - • t�' �y pC � fj/�,�.�/� �
� !r� �
35. Final Gas Pipe-Test�� - . - � � .
36. Hood or Canopy `-' ' _ _ � - ' • ' � � ,
37. Final Factory Fireplace . �
�38. Final Plumbing - , , � '
39. Water Service-Final, :_ � ' � � , . � �� �
� 40. GasServiw-finai .. - • ' �u .
.. i
41. Solar pomestic�Final� , � - ,_� i. c =
42. BackflowPreventer � � -'_ '
�
43. Backflow trrigation . _ � -
44, landscape trrigation System � � . , ' _ . _ '
�.
45. Sound Attenuation " . -� . � - - .
46. Handicap Regu{ations + , �
47. FINAL STRUCTURE & BUILDING `
48. FlNAL PLANNING � - ' -- : .
49. Electrfa Retease to Edison , ` _ ._: _ - ,
50. Gas Release to Southern Calitornia Gas Co . � _
51. CERTIFICATE OF OCCUPANCY �
No Date
�
EillC" Jr 1t 1�S
QQ9q �? 2�93'i'A
FSL,�^.;i ::.L'K� f�
6�L�P CO Q1�^'a C
�
�D IVISION OF BUILDING SAFETY
�f J,JJ :. CI7Y OF COSTA tJ�ESA
,� , ; APPROVED
j � fl �� S•
�� ,
ThiS 5¢i G� 6�� s ana sD�C+cations MUST ba kept on lhis b6 at atl Wrtes
�„,1.�,n �i w make afry changes or aReration an same withoul w1fl�
„Am ��St6trn6y ��he Division of Building and Sa}ety. Gry al Costa Mesa. �
�ih'ping v1 ihts plan atM spCCific3tl0iK SHALL NOT be heW t0 pertf$
e� to be an apprpvai of the Violation ot any proN5i00s ot any Clly at COSb
r, 'T��ll2�se [_c. ::0 Dermit shaN expire funitation a� Dacome nuN atW wid B
Y� ��oui!abig or h•ork is no� commenc and mamtained aclive par UHC §303
� within 180 days of usuance. �
ADDIT10t�S, OELETiD:iS, �.. .;��-t v — —
BE APPROVED L�Y 7HE PL.tl�iil[dG Gc°AR�Pr1ENi
0
�b
�caocra
�7�
O
to0 �
�a�oe�ee
a7�
Permit .� 313 �
THIS.NUMBER MUST A�COMPANY
AlL INSPECTION REQUESTS
�n s-I-rue-I- 5�► l � neal -��e-4- o� btock
>all - no� +o exe�ed 30" in he�gM--
�i-i-�+ 30 +� � W ro��h-t' crn -to� o�
Wall .�o+a� 1'�eic�h+ o� t,�a11 g wro��h�
1ror� no�- -4�o e�cceed (o �� n he�gh-t' •
�un5'�"7'G��'�'. W rou �- ��ron c�a-�e aeross
�riv��a�r , � � �
►�
�csiocrcc
� �—
�'-�," 3�'-��,
I�f''->f Y�II.�Cif�STAEET d
11pIDEMCt
Cement Copi�g Optional —
ChennelBlock With 1�3/8¢r
Horizontal Top of all
Fences
For Fenees 5' or Less
Vert, Bars 3(B"yi at 4' -0" O.C.
For fences Higher Than 5'
Vert. Bars 3/8"� at 32" O.C. -'
Fill Cells Solid With Grout "
Where Steel Oceurs
Reinforci�g Steel Shall
Conform to See.A-15-39
A.S.T.M.
All Steei to be Lapped
24•• or ro Code
NATURAIGRADE
TWp 3/8"� BARS
CONTINUOUS TOP
& BOTTOM
HORIS.STEELMUSTBE?IEO�N ,
7LACE AT TIME OF tRENCH
INSPECTION.
TYPICAL
.T'.
� � ��
n p N
n
D
�W�DTN
� SEE Crtt
9 BELOW
D.I'n
FOOTING REQUIREMENTS CHART
=ENCE ___ _.
,
::�:... ::� ,
�� GENERAL- NOTES
MOR7AR:.�p�e_Par;t Plastic Cement, and
Thret� Parts Sand
GROUT; One Part Cement Three and
One Holt Ports S'ond
COP�NG: One Part Cement, Three
' ' Parts Sand
CONCRETE: Well Mized f.2-1/2:3-I/2
Max. ot'7-I/2 Gol�ens of
Water Rer SocM of Cement
GHOUT MA V BE POURED FROM TNE TOP
OF TNE FENCE IN CELIS WHEHE STEEL
OCCURS. � "'
CELLS AND AREAS OF HOR120N7AL RE�N�
FORCEMENT SHALL BE CIEAR, CLEAN &
FREE OF ALl MORTAR OEBRIS, ETC.
H OF E4RTNTCOTH
V? iHE ME�GTH Oi' FENCE
S�l6W BOTTOM OF FOGTiNG
� WIDTH 14�� . . . . . . . . . . .14� . . . 12 ...
THICKNESS 10��. . . . .
t0" ........... 8"
DEPTH OF EARTHTOOTH . . . 24" . . . . 20� . . . . . . . . . . . 16'�. . . .
I SPACING OF EQRTHTOOTH. . 12� . . . . . . . . . . .14� . . . . . 16'.
Ciiy of Costa Mesa, California
Bui ding Department
sca�E: ii2"= �'
OW NER BRISTOL ESTATES DATE
JOB ADDRESS 8%� W11SOn Street BUILDING PERMIT NO. �jS9%
GENERAL CONTRACTOR $. V, Hunsaker VALUE $ 8�856.00
i- 21 BLOCK rRncr 2873 Sin�le Res. w/att. �ar.
INSPECTIONS
DATE � SUBCONTRACTOR
FootingTrench ��ij%tf' %�Ti�i�
Foundation Forms and Grade to Garage �
Rough Framing � ,V �' —
Plumbing, Rough to Slab i"/1. � S �/ /3 3� �
Plumbing, Rough Complete � P S /p '�_ _
Temporary Pole 7— y
Wiring, Rough ,/f'/,�{ Q•/ � - r� �`
Heating, Rough G!J G 5 /D � �,1�n �
Ha�, Final e s ,'1 /i%S'
Sewer, House Sewer, St. ,5 � �s' ,�{
SepticTanko esspool D S� /�I
La'hina.In Out � /A-/d'��_
F sring
Plumbing, Final, Fix'�
Plumbing, Fin.al Gas
Wiring, Final
Occupancy � �
FOflM 210 3M 10�•vi
E 5 �2-ic-
— Y.
PERMITSISSUED
I NUMBI
' ' Costa Mesa Bnilding D�,.��,,ment
P. O. Bo: 3!7
•�rOSTA MESA, CALIFORNIA
% FOR APPLICANT TO FILI. IN
Building �"�
Addresa /iy �/ s�
Costa Mesa, California
Nearest /1L �. -
Cross St. U`� .a � i= it/ i d
No.
City
aeh Metesand Bounds)
ofLot �d..%'/��I NowonLot� �
of No.oi No.oi
[ing Bldg. — I Families I Rooma
ack Line Trom � Rear Vard ��'�
erofStroet �� SideVard i�y.�-
DESCRIPTION OF WORH
Iv I Aiteretion I� I Addition I
iir I I Movfng I I Demolish I
iin9 /O/ � Raoms �
� �Stories
� `erior Wall
� :�PPLICATION FOR PER1V �
BUILDING
�31
FOR OFFICE USE ONLY
Receipt No. Permit No.
3��
Receive by Date Redd. Date Issued
9- -�b � s =.i �
Building
Address
Costa Mesa, California
Nearest
Cross St.
Zone F, !, I Plans I TYP� 1/ G�P �
iC.� r Y ,L
��g G APPROVALS
�� VF Foundation Location Inspector
Forms, Materials,
Under-Plnning
�- Frame: Flre Stoos.
I hemby ecknowledge that I have read this ApplicaUon
and sta[e that the above is correct and agree to comply Lath. Int
with all City Ordinances and State Laws regulating
bWlding rnnstntctlon. Lath. Ext
Sfgnatureof
Permlttee �il-i�� ���C� Plaster, Int
Authorized Ag Plaster, Ext
ValuaUon Permit Fee $ ��j — Masonry Re
Plan Check S �� � Bond Beam
s �'��6—, To�i
Fee �� FINAL
HM R04 �o.ee o. a. e s. , '
I
Date
•W
W
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0
N
1�'
r
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�
A
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1 L V 1� Y[11\
� &how Iowtlon and distancea from
o1� properly Iine and between bulldings
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JOB ADDRES$74 W. Wilson St. BUILDING PEA
GAS
W RTER
PROP. SWR. LINE � J
SPRINKLING SVSTEM
ROUGH HEFTING AN� r11p �ONOITIONING
TEMPORnHY SERVICE OR POLE
UNOERGFOUNO I—I POWER I—I
F�OOP SYSTEM
BONO BEAM ❑ ST
SHEPTHING
FRAME RN� F�ASHING
LPTHING — IN _
PLASTER. BROWN CON
ST��iCTURAL, FINAL
1 JG, VENT., REFI
PL...aBING, FINFL ANC
ELECTRIC, FINAL
BllIL01NG. FINA�
RNO R.C., FINAL
TEST ❑
SUBCOHTRACTOR
- -� �
COSTA MESA BUILDING•SAFETY DEPARTMENT
P.O. 80X 1200 COSTA MESA, CALIFORNIA 92626
For Applicant to Fill in Completely
BUILDING �� r
ADDRE55 W
OWNER C�/�L /�j�/ V /(i(] /
•��: ��-���=�.p0i627•�- �.:;r�:11.23
TION FOR BUILDING PERMIT
A.P.NO. //�� �J ��—
BUILOING O y� ! f
ADDRE55 Q '/ //[ J
W W ^✓` TEL. >" TRA LOT BLOGK
d U CITV NO.
Z
Z Q CONSTRUCTION W AD P
O N LENDER
am
J � BRANCN
J N OWNER
m J AODRESS '� VALVE �
m ARCHITECT TEL. S 5
J a OR ENGINEER � IJ
U � ']' FIRE �{�
w � AODRESS �I ZONE 'IVPE GROUP !
a W APPROVE `�
W Z CONTRACTOR BY DATE /� '
J �
m Z
J � ADDRESS `
w W TEL. Z�N NO.OF USE OF NEW
�= CITV '�j NO.' PLANS BVILDING
ZF
wO STATE CITV VARDSAPPROVED VARDSAPPROVEO
j O 110. NO, � LIC. NO. '25 MAIN BUILDING ACCESSORV BUILDING
SIZE NO.OF BLDGS. (FROM GL S EET)
OF LOT � NOW ON LOT � qpNT FT.
USE OF
EXISTING BLDG. FT
I� SIZE OF NO.OF
z NEW BLDG. � ROOMS STORIES LSIPE FT.
a EXTERIOR WA ROOF
�% COVERING COVERING � REAR � T. FT.
J USE OF BU��DING AND WORK TO BE PERFORMED DI5TANCE BET. BET. MAIN &
n' MAIN BIOGS. ACGESS. BLOGS.
a
Q �( /� 7'� 'p VAR.91E DATE
O y C7 - C✓{I�/ C.U.P.qW APPROVED
yAPPROVED � �
z
�
UI hereby acknowletlpe Net I heve reatl this ap011cation antl state � g1AT
that the above informe[Ion is corract end a8rea to comply with
� all laws reg�letinp buildinp construction, end 1 shall not employ /� � / r�
F any parson in vlolation of Me workman'� compe�sation lews of L
y the State o( Celitomie. �
zI hereby certify that I em proparly licensatl as a contractor untler Sn• FT' T� e
the Stata of Californie Business end Profeczions Cotle, Divisicn 3, THE AMOUNT SHpWN UNDER VALUATION IS FOR �
Chapter 9, antl that such licenws ere in full force end effect, or 1 THE PURP�E OF ESTABLISHING A PERMR FEE ONLV: Q
am exampt from Me provlsions of the Sta[e of Celltornia Business
VAlUAT10N
m
antl Professions Cotle, Divisl , a0ter 9. � 1 � PERMIT FEE $ � j
SIB�et�ra oi / �— � m
Permlttee $/D�/%'J/ PLAN CMECK $ � E
( v " o
Authorizetl Apent � .�7� LL
T07AL FEE $
�OWNER ARNOLD� Jack D.
„ 70B ADDRESS 7 West W
'[ r��ERnL CONTRACTOR Own
�"y`�t �ou5-573-25 �or
_` INSPECTIONS
� SOIL
� GAS
W ATER
ROUGH PLUMBING
PROP. $WR. LINE Q MOUSE CON. �
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGM MEATING AND AIR CONDITIONING
TEMPORARY SERVICE OR POLE
UNDEPGROUNO � POWER �
HOUGH WIRING
TRENCHES � FOflMS � STEEL R�I
FI.00R SVSTEM
BOND BEAM � STEEL REINFORCE �
SHEATHING
FRAME AND FLRSMING
LATHING — IN r] OUT �J
Sianoture
DATE
VALUE $ 200.00
SUBCONTRACTOR
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- - 34453
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. eOX 1200 COSTA MESA. CALIFORNIA 92626
�.� t�.��PAiDOO 72�J'�' �kit�ir5.��
�v;•
APPLICATION FOR BUILDING PERMIT
Po� Applicant to Fill in Completely
RECEIV O B DATE RECEIVED DATE IS/S�UED�J
ADIDRESS .�.� ,I� � / � / / ^ /
� ��_2S .PERMITNO.
OWNER � � A.P. NO.
BUILDING �(, �� \
MAIL ADORESS �� 1 U1�LSQN �Y—.
ADDPESS �
TEL. TRACT �� LOT �, BLOCK
CITV m.e NO.
CON5TRUCTION ' W �+ P
LEN�ER — l.J Y
/�
BRANCH �
OWNER ��K �AIU L�
ADDRESS p VALUE I"'
ARCHITECT TEL S I r N� — 5
OR ENGINEER
FIRE
AODRESS ZONE TVPE ROUP
�') BVPROVED DATEJ —
CONTRACTOfl L[/ �ER
ADDRESS
TEL. �ONE „ NO.OF �j USE OF NEW
CITY NO. K P�� L BUILDING ��OR�-H
STATE CITV �'ARDSAPPFOVED VARDSAPPROVED
LIC. NO. LI0. NO. MAIN BUILDING ACCESSORV BUILDING
SI2E NO.OF BLDGS. IFROM C/L 57REET) C
OF LOT �(7 X' O O NOW ON LOT RONT FT. .J FT. �
USE OF l
EXISTING BLDG. t I V� S FT. FT
512E OF NO. OF
NEWBLOG. ROOMS STOFIES L.SIDE FT. FT.
EXTERIOR WAL� ROOF C O1w O51 �O U
COVERING COVERING � REAR FT. \ FT.
USE F BUILD�NG AND WOFK TO BE PERFORMED DISTANCE BEf. BET. MAIN &
N () � MAIN BLDGS. ACCFSS.BLOCS.
VAR.3i'+ DATE
C.U.P.# APPqOVED
APPROV6D /
Gl/
I hereby acknOWletlBe thet I have reaA [his epplication antl state STqTE
that the above information is corract antl apre¢ to comply with
all laws regulaNng builtling consttuction, antl I shall not employ
any person in vjp�ation of thc workmen's compansation laws of
the State of Cal{tornia.
¢
I hereby certify ihat I am OroOarly licans¢tl es e connactor untler SQ. FT. 'T� c
tha Sxate of Cal{tornle Business antl Profezslons Cotle, Divisicn 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR �
Chapter 9, antl ihat such licanses are in full torce antl effect, or I THE PURPO6E OF ESTABLISHING A PERMIT FEE ONLY: e
am exempt trorq the prov(sions ot ffie Ste[e a/ Calitornia Business a
antl Protessions Cotle, Division 3, Chapter 9. �<.LUATION �''' ^� �p
PERMIT FEE $ J � � �
Signature of � m
Permittee /i /.%� i!E�� g \ PLAN CMECK $ E
� a
Auihoriz Agant w �� u
TOTAL PEE $' �