HomeMy WebLinkAbout211 16TH PL - Building PermitsI
.
4Lo ' MF 9 - CITY OF COSTA MESA
BUILDING DIVISION
F 1
o .
DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
JPKIIIL
PERMIT
+rte e. P00-00430
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us - 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 211 16TH PL Status: ISSUED
Suite No 2 Applied: 08/03/2000
Issued: 08/03/2000
Vicinity: UNIT 2
Parcel Nunmber: 42520105 ISSUED BY:
Applicant: FOWLER, MARK •
Address: 10372 STANDFORD#Q
Phone: (714)590-9964
GARDEN GROVE,CA Zip: 92840
Owner: RIDGEWAY, TOD W TR
Address SUITE 231
NEWPORT BEACH,CA Phone:
240 NEWPORT CENTER DR Zip: 92660 Y4
3741
Contractor: CALIFORNIA ROOTER & PLUMBING tir_�I
.rnR
y2J
Address: 10372 STANDFORD#Q D
Phone: (714)590-9964 A+" 7!!
GARDEN GROVE,CA Zip: 92840
License: 703820
Arch / Eng:
Address:
Phone:
Zip:
•
License:
SCOPE OF PERMIT
REPLACE GAS LINE FOR EXISTING APARTMENT(UNIT 2).
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 50.00 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 50.00 0
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 $9.80 1 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: $33.30
COMMENTS/SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord. No.92-28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(WOO)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers compensation,as provided for by section 3700 of the Labor Code,for the performance of the
rk for which this permit is issued.
_.6have 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 works mpe�nsa�y/ti,nn Insurance carrier and policy number are: ��/S-��
r Carder. /'��c7 YY, 5 ( Policy Number:
1— -(This"secllo need not be completed if the permit is • eo ar one hundred dollars($100)or less.)
❑ I certify that in the performancep the work • hich this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Cali • '.,and agree •.t if I ould become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these pry/S.'. :.
Applicant Signature:- ./ L Date: 43— 3 -C u
WARNING:FAILURE TO CU'" °AKERS'•• PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL-PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE f O .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.liceg,ed under ovisions of Chapter 9(commencing with Section 7000)of Division 3 of-the Business and rofessions Code,and my license is in full
force and effect.# _//0' /'7i / [lass tl-13
Contractor re:_ d� /!�'` r /��� [DDate:. e__ '3 —�v
CONSTRUCTION LENDIN /GENICY■: /` �,(lG(//
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec,7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not appty 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 appty 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 see-Li,'37 .}"l Business and Professions Code for this reason:
Signature: '--c--- _"_ Date:
Owner ID verif)ed by drivers license. ❑Yes 0 No Driver's License No. Expires:
Verificattiion 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:
I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 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 futuureebuilding occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health end 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.
W
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes 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).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that 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•ot to occupy or allow occupancy of any building authorized by this permit until final inspection.
Si to Of-L=eel • s) Date - ^-0
CODE I INSPECTION TYPE PAIS INTmALI SON I INSPECTION TYPE PAIL ItiI1MALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall _ 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
PER IT NO. TRACT NO. LOT NO. UNIT NO.
CIT OSTA MESA Co STR UCTION PERMIT I �9Y�5� A•P•dk Zone
^ ►y z✓' e. i A� J
Address ?'Q/ r�,�y�� O�(. S Main Building: Accessory Building:
pncaot's Mailing Address !Iq i a 00 TYPE OF CONSTRUCTION U NEWII�lU��ADD U ALTERATION U REPAIR
•
-T� y, ❑ CONVERSION ❑ DEMOLISH IdOTHER XP row* 1 T Front 0
Owner's Name -a-an Phone p q/ DESC'IPTION OF WOR /USE OF 8 0 • it • - v �jy• �• � B Rear N
Address/+7 TIYt✓.'1/'irs�q/ �sa�9/ t".72/6./^l s� t ra lnSYi/gr+.SC. cf'..i, . .1:L _. - .P Oh S/ �' ? A I
Arch/Eng. License No. TYPE OF P'RMIT I♦ GRADING • FOUNDAel ON • TRUCTURAL yM I C Right G
• Left
Address ys� �y /y��s� ❑I-1 TENANT` ❑ ELECTRICA1 ❑ PLUMBING ❑ MECHANICAL .v'.Y_a/•„ S R
Contractor's Name r,(f°SQ .Pe14%i•`�ht -. p one )(116: .v9i— tTJ^OTHER %P(J�O Ping. Ref.�k Parking Req./Provided E
�Q L 2 PROJECT DESCRIPTION SQ. FT. . Y�&2tk OCCUPANC O
Address(mailing) �(a7 1C-2 pr St (��a P14 9a6.'lG r Planning Notes:
�r q �
CONSTRUCTION TYPE VALUATIONS J/1)'/1�i90 M
City License No. CLQ/� / ZONE GRADING CU.YDS._ ACRES
LICENSED CONTRACTOR DECLARATION S'
I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: ,
with section 7000) of Division 3 of the Business and Professions Code, and
my license is in fu for e;qd effect. ELECTRICAL FEES
QLicense Class — 7 Lic ,.e No
Date T • . Signature uu/' a.. .ir/ PLUMBING FEES Automatic Washer Transformer 0 15-50 KW
WOR RS' COMPENSATION D-CLAR ION pole Sub. •
0 50+KW
I hereby affirm that I have a certificate of consent to self-insure ora certificate Bar Sink Showers
f 'orkers' Compensation Insurance, or a certified copy thereof (SectionCooking Unit Meter ❑up to 100 amps
1 , Lab. C.) �/ �`, Backflow Preventer Service Sink
Policy No. AC2?797-tf9 Companyefb*P Fa.,c.f] Backflow Irrigation Sewer Cap Dishwasher Meter Dover 100 amps
�Cpprtified copy is hereby furnished. Dryers ❑Gas ❑Electric Sub Panel
Date " tlsgt]y,js filed with the city if g ivis{ ,- .�// n Bathtubs Sewer Connection _
Date Q"vs, Applicant �R(Aa_—U-vr�� Fan
Motors ❑0-1HP ❑1W-8
EXEM 10 FROM WORKERS'CO PENSA4 ON DECLA TION Clarifiers Solar Collectors
(This section need not be completed if the permit is for one hundred ($100) or Dishwasher Solar Piping F.A.U.
less). Inc.Solar 09.15 HP ❑16-15+
I certify that in the performance of the work for which this permit is issued, I Fixtures
Shall not employ any person in any manner so as to become subject to the Drinking Fountains Solar Tank Microwave -
Workers' Compensation Laws of California.
DateB
Date Signature Floor Drains Swimming Pool vv/Spa/Spa Pole Light
NOTICE:If,after making this declaration, you should become subject to the
Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks Urinal Outlets Range
comply with such provisions or this permit shall be deemed revoked. -
CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet Switches Sign
I hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is issued (Section 3097 Civ. C.) nterceptors Water Heater Garbage Disposal Standing Sections
• Lender's Name
Lender's Address Kitchen Sink Water Service Generator 00-5 KW 05.15 KW Trash Compactor
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash
following reason (Section 7031.5 Business and Professional Code: Any city or .
county which requires a permit to construct,alter,improve,demolish or repair P—Trap Laundry Trays
any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he/she is licensed pursuant to the provisions of Roof Drains
the Contractor's License taw(Chapter 9 (commencing with Section 7000)of
Division 3 of the Business and Professions Code) or that he/she is exempt Reinspection Fee $15 Issue Fee $ 3
-refrom and the basis for the alleged exemption. Any violation of Section
.1,5 by any applicant for a permit subjects the applicant to a civil
., .ialty of not more than five hundred dollars($500). DEVELOPMENT SERVICES REQUIREMENTS:
Li $ 3 I, as owner of the property or my employees with wages as their sole Reinspection Fee l $15 Issue Fee Zoning Approved By Date
compensation, will do the work, and the structure is not intended or offered -
for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES Building Approved By Date
License Law does not apply to an owner of a property who builds or improves O� /S/�a
thereon, and who does such work hirnself/herself or through his or her own Application Issued By a Date O !!!
employees, provided that such Improvements are not Intended or offered for Boiler Hood or Type I 0 _
sale. If, however, the building or improvement is sold within one year of com- Canopy Type II 0 $UfA ARV OF FEES
Mellon, the owner will have the burden of proving he/she did not build or inn- Duct-Under Ground )o� 6
prove for the purpose of sale). BUILDING PERMIT $ SMIP_ $
❑ I, as owner of the property,am exclusively contracting with licensed con- Duct-Structural Refrigeration System
tractors to construct the project(Section 7044,Business and Professions Code: PLAN CHECK $ PERMIT
The Contractor's License Law does not apply to an owner of property who Duct-Ventilating 00-100,000 BTU 0100,000 BTU PLUMBING $ ISSUANCE $
builds or improves thereon. and who contracts for such oroiects with a con- - ENERGY P.C. $
tractor(s) license pursuant to the Contractor's License Law). I am aware that Exhaust System 0 Multiple 0 System Repair/Alteration ' PLAN CHECK 25% $
proof o// their Worker's Compensation insurance should be provided to me. ELECTRICAL $ GRADING $
13I am exempt under Section - B. 8 P.C.for this reason u Firepl/Fact.Blt. ICBG# Fire Dampers MICROFILM $
PLAN CHECK 50% $
Date Owner Heating System& Ducting Registers MECHANICAL $ (o3..Sb
I hereby certify that I have read this application and state that the above ❑o-100,000 BTU 0100,000 BTL TOTAL FEE $
Information is correct. I agree to comply with all city and county ordinances PLAN CHECK 25% $
and state laws relating to building construction,and hereby authorize repre-
sentatives of this city to en • upon the above-mentioned propert for
Inspection pu _ps /I �—
Signature /..r.4. __ ;Ay Date aY
Drivers' License or S* _ _ Reinspection Fee $15 Issue Fee $ 3 • y, ^�.^,_i--- 7--1_'r C_ - _
l . ..i _.
0865-46,rev. 5/88 White - Building; Canary - Applicant; Pink -Accounting; Goldenrod - Assessor
lSTRUCT{ON AND PLANNING
'
AROVALS Permit POOL �A
. mporary Electrical Service or Pole Date Inspector APPROVALS Permit#
52. Pool & Equipment Location Date Inspector
iTe
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. 'Electr,icalUFERGrnd. 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
i¢. Rough Electric Wiring 67. Fencing & Access Approval
r
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
ie. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
-
79:•Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20: Rough Factory Fireplace APPROVALS Permit#
i
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing c16 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: , 8 , 1e , 6
•i e35 y
aket
34. Final Heating & Air Conditioning : ��/ ,
"'� rJ
35. Final Gas Pipe-Test 1
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 ,, ,,, .j
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING I
48. Special Requirements Completed /N/
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co LA)
51. CERTIFICATE OF OCCUPANCY �: '7
No. Date 'y
TRADITIONAL REALTY
August 25 , 1989 -
TO: The City of Costa Mesa
RE : Smoke Detectors
207-211 E . 16th Place , Costa Mesa
Please be advised that this office is the Managing Agent
for the subject property, which is 8 units . The Owner is
Donald Stockman.
Each of the eight apartment units have a smoke detector in
them. The units are rented with the smoke detectors in
working order and the Tenants sign an agreement that they
will keep the smoke detectors in working order during
their tenancy.
If you have any further questions , please give me a call .
TRADIITIIONAL REALTY,Q/ G�OGCe � INC.
�C //
William R. Reinhardt
Managing Agent
WRR:
CITIZENS IZENS HANK BUILDING • 30I EAST 17TH STREET • SUITE 204 • COSTA MESA.CALIFORNIA 92627 • 714/631-7370
wit
ADDRESS of WILDING: 211 16TH PL DMT' CITY OF COSTA MESA - BUILDING PERMIT
MINERS NAME IF KNOWN: TOD W RIDGEWAY PERM NO: B 080565
NDREss: 1400 W BAY AVE
PERMIT NO: B 080565 PLAN CHECK NO: 04888-96 L GOVT; N SUPP : N
NEWPORT BEACH, CA 92661
WRUNGAPPL. D ADDRESS: CONSTRUCTION TYPE: I PERMIT TYPE: STR PURPOSE: ADD
ARCHITECT OR ENGINEER: UC.NO.: JOB DESCRIPTION ; DECORATIVE BLOCK 6 WROUGHT IRON FENCE SQ FT : 1 , 200
NCH OR ENG'S ADDRESS: WIT:
CLAIM VALUE: 1 , 200 . 00 CALC-VALUE: 1 , 200 . 00 GROUP OCC : R-1 /
CONTRACTOR'S NAME:
CONRIACTORSMMUNG COMMENTS : 29 LIN FT OF 30" HIGH BLOCK W/ WI
ADORES& UC.NO.: *******************************************************************************
LINT: ZONING REQUIREMENTS
LICENSED CONTRACTORS DECLARATION:I hereby stunt under penalty of perjury that I am licensed under provisions of Chapter 9 SETBACK S
(commandng with Secgan 7000)of Division 3 of the Business and Pr fessi«u Code,and my license is in lull force end effect.
CRT UC.NO.: LIC.CLASS: UC.NO.: EXP : MAIN BUILDING ACCESSORY BUILDING
Contractor. FRNT: 20 FT IN REAR: 20 FT IN FRNT: FT IN REAR: FT IN
Dale: LEFT: 5 FT IN RGHT: 5 FT IN LEFT: FT IN RGHT: FT IN
.9WNER BUILDER DECLARATION:I hereby affirm under pendy of perjury that I am exempt from the Contractors License Law for the
;41owxg reason(season7031.5 Dueness and Professions Cede:Anydy or county which requires a permit to construct,alter,improve, PARKING REQ: PROV; PARCEL: 42520105 ZNE: R2 REF NO:
`amSiish,or repair any structure,prior to is issuance,also requires the applicant for such permit to fib a signed statement that he or she
Is licensed pursuant to the provisions of the Contraders License Law(Chapter 9(commencing with Section 7000)of Division 3 of the PLANNING NOTES> 30IN BLOCKWALL W/3 FT. OPAQUE IRON GRATING EXTENDING 29 LIN.
Business and Professions Code)orlhal he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section > FT. 7 ' 6 " FROM FRONT P/L . 2 BLIN FT, WALLS 4 FT. SEP , S P/L
7031.5 by any applicant for a permit subjects the spoken.to a mall penalty of not re mothan foe hundred dollars 155W0. *.*.*.*.N.*..****.***.******iEl(***********3****************lESE#*1E******************iE*1E****
0 I.as owner of the property or my employees with wages as their sole compensation,will do the work,and the,erasure is not intended
or offered for sale(Section 7044,Business and Professions Code:The Contractors Licence Law does not appy DEVELOPMENT E L O P M E N T S E R V I C E S R E U I R E M E N T S to an Owner property Q
who fomite or improves thereon,and who does such work lemseff«henef or through his or her own employees,pocked that such T /+ , ^� / ' —
owner:emeds are not intended rdcc enedfor sale.If,however,the bulkingprifor the se within one year d completion,the ZONING APPROVED BY I �1 N 'L, DATE: _/I_
{�., ownerbuilder will have the burden of proving he or she did not busk or improve lathe purpose of sale).
L' I,as owner of the property,am exdusively contracting with licensed contractors to coretrud the project(Section 7044.Business and �
ATE:cProfessions Coda:The Connadanot s License Law does apply to an owner d property who builds or improves thereon and who BUILDING APPROVED BY :_ ,AP DATE-
contracts
ontracts for such projects with a wwador(s)licensed pursuant to the Contractors License Law). �,,��jj��
X D1:1er /I�ZZe
Iamexempt under Seeclkln: B.SPC.fo Ns >. APPLICATION ISSUED BY: x!'(/0.7 DATE:
e:
�I Oen: 9A *******************************-**************************************#g **
I do hereby cartily that I am aware of and understand the requirements of Callomie 41 and Safety Sections 25505,25533,and LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:Y
25534.and Out I or any future building occupant will/wilt not(dere one)need to coat with said codes and the requirements for
°permit l«construction or modification from the Av uay arepemem District. mnslnutionappketiors ere exempt from Nate BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
provisions. PERMIT 40 . 25
Dale: Applicant: SMIP/NON-RES _,
WORKER'S COMPENSATION DECLARATION:I hereby affirm under penalty of perjury one d the following declarations: PLAN 26 . 16 . 50
❑ I have end will maintainu
erd
a certificate of consent to sell-inure for workers'compensation,as provided l«by Section 3700 the Labor ISSUE FEE
Code,for thepedormwe the work tor which this permit is issued. BUILDING-DIC > PERMIT ISSUE PLAN-CHECK TOTAL PAID DUE
El I have and will maintain workers'compensation insurance.a required by Sedim 3700 of to Labor Code.la the ped«m°nce d the TOTALS----> 40 , 75 0 , 00 26 . 16 66 . 91 66 , 91 . 0 0
work for with this pent is issued.My workers'compensation insurance rarer and policy number are:
Canter: REVENUE DIVISION TOTALS--> COLLECTED ; 66 . 91 OVER/SHORT: . 00
Poky Number - _ BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN-CHECK
(This section need not be completed y the perm*is for one hundred dollars($1001or less.) 40 . 25 . 50 26 . 16
.a I eery that in the performance of the work for which this penit is issued.I shall not employ any person in any manner 70 as to
bows eubled to the workan'canpmsaticn laws d Calif«ns,and agree that t odbecame subject shd becasubject to the wodmra' *******************************************************************************
/1 compensation provisions of Section 3700 of the Labor Code,I shall fpr n ply with those provisions. I N D I V I D U A L F E E B R E A K D 0 14 N
/ Dale: ii-1- Leg Applicant: (1TX M�P-.$
Warning:Failure to secure workers'compensation coverages unlawful,ant shall a an amp/o to criminal penalties and TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST
civil fines up to one hundred thousand dollars(5104000),In addition to the cost ompen stlom as provided for In
Section 3706 of the Labor Code,Interest,and attorney's feesSFC 1200 ALTER BY VALUE COMMERCIAL NOZONE 1 , 00 1 , 200 , 00
CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there s a construction ending 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: . 2 _ '
I randy that I have read this application and statinformations the above information correct.I agree to comply with all y ordinances end oouordinances �{s�'ltrunces x L jai y
end state Laws relating to building construction end hereby authorize representatives of the*to enter upon the above-mentioned properly
for inspection Wryoue. 01 00219730-00219732 TOT 66.91
—I`
TOD W RIDGEWAY DATE ` DATE: 11/22/95 TIME: 13:44
/ Print Date: //. Z Z --9 /b
Signature of Owma nv�AppLran m
(5151'45.WP) White-Building&Safety;Green-File;Canary-Applicant:Pink-Revenue:Goldenrod-Assessor
•
CONSTRUCTION AND PLANNING _ Pt & SPA
APPROVALS Permit # Date Inspector APPROVALS Permit # Date Inspector
1. Temporary Electrical Service or Pole ' 52. Pool & Equipment Location - _
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms •
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement z
// -0161 a- 56. Rough Plumbing & Pressure Test
6. Electrical UF ER Grnd. tJ 57. APPROVAL TO COVERGUNITE
7. Footings 0e-z7-.- O (����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 66. Solar System-Final •
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign _ 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating &Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit #
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil
23. Gas Pipe-Rough& Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing 74, Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL -
29. Insulation 78. FIRE PREY. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
_
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED s
33. Final Electric Notes:
34, Final Heating & Air Conditioning
35, Final Gas Pipe-Test •
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing
39. Water Service-Final .
40. Gas Service-Final
41. Solar Domestic-Final
42. Backflow Preventer
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations
47,. FINAL STRUCTURE & BUILDING
48. FINAL PLANNING .
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
,nn,JuMtrc na 6
�2o'Art I- /Re A)
Lc GO- sate-/C
C4P
" AjdRifjor, ,
K -1{11 r It Iffiffift
•
at
y /Q
Su+-.r4esrcNE
I
a0 ci/
L
\e-c)
_ - u tf
. S 4 oc I}
7,`„
rtoF eu /;nI�
APPROVED
CITY OF COSTA MESA
PLANNING DIV,
0.11 C Jt fk ht.
� ��° ECT TO BLDG. DEPT. RR�EG.
J S�II �►���A TEItIfll
sTmss -
'! /1 I ,
30 `.,(&°t N Lai 3 C11e cLi aATeCrijt
; b � fL,
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
1 Y OF COSTA MESA CONSTRUCTIO PERMIT PEST NO..,� ��� TRACT NO. LOT NO. UNIT NO. A P # I Zone
ProjPdt Address _- T�I/f • _ S
' TYPE OF CONSTRUCTION U NEW U ADD U ALTT�RATION S Main Building: Accessory Building:
S� U REPAIR E 2
Applicant's Mailing Address�// � /W 7 (6A-wig* PS e• a• ��/ Front
JiMr Cai✓L Phone f3' ❑ CONVERSION ❑ DEMOLISH 19 OTHE- it; B' / ' T o
Owner's N me L AJaI 1yw . �1 8 N
�• D, CR PTIO/ OF WO'K/U 0 s LOG. ^ - - �•^ Rear
Address '7",'' .. - l• - - _, 'fig-,. • [ --,- .. - - 1 : Tice - a"L. C i A — I
Arch/Eng. License No. TYPE OF PERM T r GRADI rG II F: NDATI•N • STRUCTURAL/id C Right NG
Address ,��y y CI TENANT ❑ ELECTRI AL ❑ PLUMBING ❑ MECHANICAL � '' $ Left R
Contractor's Name '1 4`,CL 1ti iC�OOl-41v Phone &#S-7Z ®OTHER Resi/YXr - Ping. Ref.# Parking Req./Provided Q
a PROJECT DESCRIPTION SQ. FT. c37d-t ' OCCUPANCYJPlanning. Notes: MI
Address(mailing) • ' • ` v //'•"- ~�•" CONSTRUCTION TYPE VALUATION$ t'OOfl.00 T
City License No. . 07.� g' ZONE -. GRADI NG CU.YDS. ACRES S.
LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks:
with section 7000) of Division 3 of the Business and Professions Code,and ELECTRICAL FEES
7 my license is in full force aR�effect. ������y.,�sII••��
Licens CI ss (' 'Z� l s n LIce- NO.'x//45
Date Signature ;- Q. PLUMBING FEES Automatic Washer Transformer 00 50 5 KW
0 KW
WOR ERS�SATION DECLARATION Baf Sink Showers Construction Pole Sub.
I hereby affirm that I have a certificate of consent to self-Insure or a certificate
y, Workers' Compensation Insurance, or a certified copy thereof (Section Cooking Unit Meter Cup to 100 amps
I 9. Lab. C.) _ Backflow Preventer Service Sink
e..- �pt�, Dishwasher Meter Dover 100 amps
rolicy l•„ 6(1rT-Bg Company t -91*�«n Backflow Irrigation Sewer Cap
❑ Certified du.y is hereby furnished. — Dryers ❑Gas ❑Electric —
Sub Panel
ertofied o y ned with to-^t ttv ^re T L Bathtubs Sewer Connection
Date Q//✓�/ } 1 APP hcant y��• v�<a0 �T•Q•^"�✓� Fan Motors❑0-1 HP ❑1 '-8
EXEMP D ROM WORKERS'CO PENSA ION D L ATION Clarifiers Solar Collectors .—
(This section need not be completed if the permit is for one hundred ($100) or Dishwasher Solar Piping F.A.U. Inc.Solar 09.15 HP 016-15+
less).
I certify that in the performance 01 the work for which this permit is issued, I Fixtures Microwave
shall not employ any person In any manner so as to become subject to the Drinking Fountains Solar Tank
Workers' Compensation Laws of California.
Date Signature Floor Drains Swimming Pool w/Spa Device Boxes Pole Light
NOTICE: If,after making this declaration, you should become subject to the - Outlets Range
Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks Urinal
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet Switches Sign -
1 hereby affirm that there Is a construction lending agency for the performance
of the work for which this permit is issued (Section 3097 Civ. C.) Interceptors Water Heater Garbage Disposal Standing Sections
Lender's Name -
Lender's Address Kitchen Sink Water Service _ Generator 00-5 KW 05-15 KW Trash Compactor
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash
following reason (Section 7031.5 Business and Professional Code: Any city or
county which requires a permit to construct,alter,improve,demolish or repair P-Trap Laundry Trays .
any structure, prior to its Issuance, also requires the applicant for such permit
to file a signed statement that he/she is licensed pursuant to the provisions of Roof Drains
the Contractor's License Law(Chapter 9(commencing with Section 7000)of
Division 3 of the Business and Professions Code) or that he/she is exempt Reinspection Fee $15 Issue Fee $ 3
•refrom and the basis for the alleged exemption. Any violation of Section
11.5 by any applicant for a permit subjects the applicant to a civil
laity of not more than five hundred dollars($500). $ 3 - DEVELOPMENT SERVICES REQUIREMENTS:
Reinspection Fee I $15 Issue Fee Zoning Approved By
co I, as owner of the property or my employees with wages as their sole Pe Date
compensation, will do the work,and the structure is not Theed or offered -
for sale (Section 7044, Business and Professional Code: Contractor's MECHANICAL FEES Building Approved ByDate
thereon Law does not apply to owner f a property who builds or improves
thereon, and who does such work himself/herself ror Intended
his or err own Boiler Hood or TypeApplication Issued By Dat
employees, provided that such improvements are not Inthin or ofofferedc for ❑
sale. If, however, the building or Improvement is sold within one year of Com- - Canopy Type II 0 SU RV OF FEES
pf, the owner will have the burden Of proving he/she did not build or im- Duct-Under Ground
prove for the purpose of sale). BUILDING PERMIT $ -e° SMTP $
o I, as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System PLAN CHECK $ PERMIT
tractors to construct the project (Section 7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who Duct-Ventilating 00-100,000 BTU 0100,000 BTU PLUMBING $ ISSUANCE S
builds or improves thereon.and who contracts for such oroiects with a con- —_
tractor(s) license pursuant to the Contractor's License Law). I am aware that Exhaust System 0 Multiple 0 System Repair/Alteration PLAN CHECK 25% $ ENERGY P.C. $
proof of their Worker's Compensation insurance should be provided to me. ELECTRICAL $ GRADING $
0 I am exempt under Section B.& P.C.for this reason Firepl/Fact.Blt. ICBG ilk Fire Dampers PLAN CHECK 50% $ MICROFILM $ _ ,l
Date Owner Heating System& Ducting Registers _ • MECHANICAL $ TOTAL FEE $ 623-S8
I hereby certify that I have read this application and state that the above 00-100,000 BTU 0100,000 BTL - PLAN CHECK 25% $
information is correct. I agree to comply with all city and county ordinances
and state laws rel. 'ng to building construction, and hereby authorize repre-
sentatives of t ' •ity to ente upon ,re above-mentioned pro.erty for
Inspection p "•i • , •S/ .. ' •
Signature Ira--: . d` Date• i a • . ,
Drivers' License or SS
i', 0865-46,rev. 5/88 White - Building: Canary - Applicant: Pink -Accounting: Goldenrod - Assessor
T
CONSTRUCTION AND PLANNING POOL PA
APPROVALS Permit# ; Date Inspector APPROVALS Permit #_ Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility•Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement56. Rough Plumbing & Pressure Test
6. -Electrical UFER Grnd. ` 57. APPROVAL TO COVER-GUNITE
7. Footing 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 Cap63. 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
174. Rough Wiring Sign 68. APPROVED FOR PLASTERING
181 Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20: Rough Factory Fireplace APPROVALS Permit#
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping O Gas OOil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing 7Q(bn 74. Overhead Hydro
26. T-BarCeiling (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 N tes: zit y
/c '-6 0.1A I I .rte
34. Final Heating & Air Conditioning ()O„t /I 3 • `1 '""
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
-
J1
43. Backflow Irrigation
r'
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations 4t '47. FINAL STRUCTURE & BUILDING / --
48. Special Requirements Completed (% -
49. Electric Release to Edison •".
50. Gas Release to Southern California Gas Co .j
51. CERTIFICATE OF OCCUPANCY -' )
No. Date
7073 =EE RECEIf .��r
COSTA MESA BUILDING DEPARTMENT to - 30 -3 S V
P.D. FINANCE DEPT.
COSTA MESA,A. CALIFORNIA
PITY /IF CPV4 MCS8 Si
FOR APPLICANT1TO FILL IN// �// j/']'APPLICATION FOR PERMIT
BUILDINGADDRESS 3...1L•-`1ri/• %(O $ \ tGCfL'Ur^i.L' !/ 1 , ! BUILDING
COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY
/ C RECEIPT NO. 1 /')PERMIT ITJN�}[�
OWNER R.` I c_Q'E-•� / V� / /
MAIL _ `(( RE IVEO BY A REC/E��'�F G�"/� �.lPj//�/�I5J5/'(/BSY
ADDRESS -.1 t I+ P�.S.L RSL 4+4_11 ` C'e 0/ S 0' 1/ / / 3 `i
�'`� ^'\ `TEL. !J J BUILDING -j ! /``1/ /aX.r<
CITY W�nti� �y NO. "NJ V ADDRESS L//—I3 v
ARCHITECT1 LIC.
OR EA"'INEER KE CVO -Aw.;9 NO. COSTA MESA. CALIFORNIA
II 4.4•1C.
[� L .L orf 1 1 {� 1 FIRE �Si
ADDN__,S3l{3t V ld OpOL`O tte-1- bp_1 aJabW ZONE l
' _1 _ rr ,1` i ZONE NO.OF TYPE cyirAir i GROUP /
`�L tC RLRICtY NO. i� P .rte {��/
CONTRACT/ORR'` 1, f� p �//
ADDRESS `(� \L0.C�4Ytt NV- \•+If.a TNO.c 3"E LI BYPRO :� � - DATE 2 /J
LEGAL I7 LOT COfF[J`SFy9% 5
DESCRIPTION NO. BLOCK TRACT l 7i�j•77 '��F j� Q�
J / d 4 U YM f ge f,
A.P.NO, // 7 alb �-'6 Q} y r L
SIZE y i.y `�f NO.OF SLOGS. - COSTA Ml5/1
•
OF LOT Sb X. 13 (, y NOW ON LOT ti6`.-0 •
.? TN{� D[?'I'
SLt."'4 IU BLDG. DEPT. REG.
USE OF •
EXISTING BLDG. L•.O4.+--A.
SETBACK LINE FROMBy ./ %'f , /./J
CENTER OF STREET Ss REAR YARD to U I ri ,< v • T1(J/,� 1i i
SIDE YARD t I RIGHT LEFT — T /T�--,
DESCRIPTION OF WORK J - -� fie' - - .4:a .' . ..., p 91 T
NEW C ALTERATION ADDITION • •' '� •� � �� '
REPA,,. MOVING DEMOLISH {';; • J' to 1 ��1 Ja 1
GUILD L.. r (N0 OF :ill .. ..' L" 1lb 1.1 I
SIZE �, tt8 c1pLI/'t-�p1Q ROOMS ZO�•�+STORIES Z
F
COVEREXTERIOR ING WA
L 1'.c.c., COVERING LC,C‘2.
USE OF NEW �/� 1l ` // I ;
BUILDING \�\K\-\• IL./gly!Q�`VLwC,- q� AR. Nr•.. �F_— ,. FIROVED Z' sLlrl
HOLD FOR SPECIAL REQUIREMENT 7s o a Z3Lci_
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL
CITY ORDINANCES AND STATE LAWS REGULATING BUILDING CONSTRUC-
TION. ,•''�\� VALUATION
SIGNATURE O -}7 `^�-P
PERMIT FEE $ j D
PERMITTEE
�Lt
P
$ 5o < o
\ PLAN CHECK $
AUTHORIZED AGENT (((��� TOTAL FEE S 75
—
• /