HomeMy WebLinkAbout367 16TH PL - Building Permits. • �
i:
CITY OF COSTA MESA
t(,��pMFSq BUILD/NG D/VISION
>�� 77 FAIR DRIVE. COSTA MESA. CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
� FOR INSPECTIONS CALL: (714) 754-5626
�°'�°"° PERMIT NUMBER: B10-00388
PERMIT TYPE B ROOF2 STATUS: ISSUED
APN: 42519105 DATE ISSUED: 12/13/2010
ISSUED BY: RMD
JOB ADDRESS• f 367 16TH PL CMZ,
Vicinity: HOUSE AND GP,RP,GE ROOF��
Squares: 2900
Suite/Unit:
Valuation: $4,500.00
SCOPE OF WORK: TEAR OFF EXISTING ROOF MATERIALS, INSTALL 1 LAYER OF 30# FELT ON A 4:12 PITCHED ROOF AND
REROOF WITH 30 YEAR COMP SHINGLES ON AN ATTACHED HOUSE AND GARAGE, APPROX 29 SQUARES. REPAIR
AND REPLACE SHEATHING AS NEEDED. COMPLIANCE FORMS ATTACHED TO JOB CARD AND CITY PERMIT.
OWNER: VALENZUELA, GEORGE
PHONE: 949-645-9368
APPLICANT: MUNOZ, JOSE
PHONE: 714-925-2346
CONTRACTOR: HIGH RIDGE ROOFING
Address: 12821 OERTLY DRIVEUnit:
City/State/Zip: GARDEN GROVE, CA 92840
ARCHITECT:
ENGINEER:
FEE SUMMARY
Reroof Plan Check:
Reroof Permit Fee:
Reinspection Fee:
Bldg Std Admin Fund
$o.00
$111.25
$0.00
$1.00
Address: 367 16TH PL
City/StatelLip: COSTA MESA, CA
Address:
City/State2ip:
License No.
License No.
PHONE:
License No. 931122
714-925-2346
CELL:
PHONE:
PHONE:
Unit
Unit: :
HOURS FOR GONSTRUGTION AGTIVITY; EFFEGTIVE 3/18/2070 - PER GMMC Sec. 13-279
Monday thru Friday - 7:00 am thru 7:00 pm. Saturtlays - 9:00 am thru 6:00 pm. Prohibitied all hours - Sundays and the following Federal
New Years Dav. Memorial Dav. Indeoendence Dav. Labor Dav. Thanksaivino Dav and Christmas Dav
NOTICE: The work authorizetl by this permit shall comply with all applicable handicap access requirements under California staNtes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPEC710NS: In order for the work authorized under lhis permit to be considered legal, such work must comply with all applicable wdes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and f nal approval vrill result in the expiration of Nis permit.
COOEt. INSVELTIONME ORTE INTIPRLS COOEt INSPEGTIONTYPE DRTE IN7171AL
1816 Firetl System Final Fire Preven�ion 206 Final Mechanical
7268 Pool Spa Final {, � 208 Final Plumbing
Z00 Final Re-Roof . %� 3'� �1' �) �p LU 270 Final Electncal
!
201 Final BIocWRelaining Wall 212 Final Fire Preveniion
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Sile
204 Final Demolition 250 Final BuildinglOccupancy
.-
WORKERS' COMPENSA710N DECLARATION:
I hereby aKrm untler penalry of perjury one of the following declarations:
❑ I have and will maintain a cenifcate ot consent to sel!-Insure tor workers'
compensalion, as provided for by section 3700 of the Labor Code, (or lhe
pertormance o( the work lor which this permit is issued.
❑ I have antl will maintain wurkers' compensation insurance, as required by
seclbn 3700 of the Labor Code, for the perfortnance ot the v.ork for which this
pertnit is issued. My workers' compensation Insurance carrier and policy
number are: 1
cartier. l�lLl9���� ��'U�� ��tl�l0
(Tnrss�wineedipt�emmpleteddtnepennRisvaluMatone untlretlWA�)
Poli� Number. � � �! �f 6 �� �
❑ I cehify that in [he performance of the work for which Ihis permit is
issued, I shall not employ any person in any manner so as to hecome subject
to the workers' compensation laws of Califomia, antl agree thal if I should
become subject [o the workers' compensation provisions o( Seclion 3700 of
the Labor Code/,/1 shall forthwith c m ly with these provisions.
� A li�/ (�p Wn,'SSlgnalure �'� Oa(�C` �
��-
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNL4WFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($700,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affrm that I am licensed under provisions o( Chapter 9(commencing
with Seclion 7000) of Division 3 0l the Business and Prolessions Code, and
my license is in full force and eRect.
LI���'� ? L CCI359;#.
-� ��(�a�—� a
�CaNrzdol,sSiBnaWre rDate�_ _-�
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirtn that [here is a conslruction lending agency for Ihe
per(ormance o( the work (a which Ihis permit is issuetl. (Sea 3097, Civil Code).
Lender's Name:
Lentler's Adtlress:
SignaWre Da�e
OWNER-BUILDER DECLARATIONS:
I hereby aHirm that under penalty of perjury that I am EXEMPT FROM 7HE
CONTRACTORS LICENSE LAW for the (ollowing reasOn (Sec. 7037.5,
eusiness and Pmfessions Code: Any ciry or counry which requires a permit to
consWct, alter, improve, tlemolish, or repair any structure, pnor to its
issuance, also requires Ihe applicant for such permit to f le a signetl statement
that �e or she is licensetl pursuaN to lhe provisions of the Coniractors
License Law (Chapter 9(commencing with Section 7000) o! Division 3 of the
Business and Professions Code) or that he or she is exempt Iherefrom antl
the basis !or the allegetl exemplion. Any violation o( Section 7031.5 by any
applicant for a permil subjecls lhe applicant to a civil penalty of noI more Ihan
five hundred dollars (3500).):
❑ I, as owner of the property, or my employees with wages as their sole
compensation, WILL DO THE WORK, and the stmcWre is not inlended or
oRered (or sale (Sec. 7044, Business and Professions Code: 7he CoNracrors
License Law does not apply [o an owner of property who builds or improves
thereon, and who does such woAc himself or. herself or through his or her own
employees, provided that such impwvements are not intended or offeretl for
sale. I!, however, the building or improvement is sold within one year of
completion, the owner-builder vnll have the burden ot pmving thal he or she
did not build or improve for purpose of sale.).
❑ I, as owner o( the property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to construct the prqect (Sec. 7044, Business and
Pmfessbns Code: The cont2ctws License Law dces not apply to an owner of
pmpeny who Duilds or improves thereon, and who contracts for such project with
a cont2ctor(s) license pursuant to the Conl2ctors License Laws.).
❑ I am ezempt under sec.
Business and Professions Code tor this reason:
Signawre Oa�e
005]-Ofi (3/W )
Ovmer ID verifetl by tlriver's license. ❑ Yes ❑ No �
Driver's License No. Expires:
Verification of Ownership by (type of tlocumenl, i.e. - propeny lax bill or tleetl):
DIVISION OF INDUSTRIAL SAFEN PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five (5) or more feet in depth into wfiich a
person is required to tlescend, will be made in connection with work authorized
by Ihis permit, antl that no building sWCWre, scaHdtling, false�wrk, or demoli�bn
or dismantling thereo(, will be more than thiny-sa (36) (eet high. (Chap. 3.2, Grp
2. M 2, Sec. 341. Title B, Cali(omia Atlministrative Cotle).
❑ As ovmer-builder, I will not employ anyone to do work which would
require a permit from ihe Division o( Industrial Safety, as noted above, unless
such person has a permit to do such work (rom lhe division.
Appl¢anfs SlgnaWre Date
Division of Industrial Safety Permit Number.
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicaN or preseN or fuWre building occupant need to file and
cehify a Business Plan for emergenty response to release or threatened
release of a hazardous material? � Yes ❑ No
(Section 25505 of the Califomia Health and Safety Code requires, with some
exceplions. Ihat a Business Plan be fled 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 cu6ic (eet of compressed gas
a� standard temperaNre and pressure�.
2. Does or will the applicant or present or future building occupant neetl to file
a regis(ration form tor acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the Califomia Health and Safety Code, vrith some
exceptions, requires regislration with lhe Costa Mesa Fire Depariment by
each business which at any one time has on hand a quantiry of acutely
hazardous matenals equal to or greater Nan a weight of 500 pounds, or a
volume of 55 gallons. or 200 cubic feet of compressetl gas at sfandartl
temperaWre antl pressure).
3. Does or will the applicant or present or fuNre building occupant need to
prepare an RMPP (Risk Managemenl and Prevention Program lor acutely
hazardous ma�enals)? ❑ Yes � No
(Section 25534 of lhe Califomia Health and Safety Code provides that lhe
Costa Mesa Fire Department may require the preparation, certification antl
fling with ihe Fire DepartmeM of an RMPP by businesses which are required
to register aculely hazardous materials with Ihe Fire Department.
4. If an RMPP is presently required, has Section 25534 of the California
Health and Safety Code been fully complietl with? ❑ Yes ❑ No
5. Does or will the applicant or present or IuWre building occupant require for
lhe work which is the subject of this application a permit (or such construction
or motlification from the South Coast Air Quality Management District or from
any other air pollution control district or agency? � Yes ❑ No
(Section 658502 of the Califomia Govemment Code requires that the requested
infortnation be (umished on applirations fv non-residential building pertnits�.
6. Will any part of the faciliry to be constmcted untler Ihis permil be within
1000 feet (rom the outer boundanes of a school? ❑ Yes ❑ No
(If'Yes", �he (acili�y must meet the requirement of Sec[ions 25534 and 42303
of the Calitornia Health and Safefy Code�.
7. If a permit (rom the South Coast Air �uality Management Dislrict or other
air polWtion control district or agency is required for the vrork which is the
subject ot this application, have all of the Oisclosures prescribed by California
Health and Safely Cotle Section 42303 been made? ❑ Yes ❑ No
8. (II yes". attach certificate of compliance from the appropriate air polWtion
control ot(cer).
CERTIFICATE OF COMPLIANCE: I certity that under penalty of perjury the
iniormation given above is correct I agree ro comply with all state laws and
city ortlinances regarding Hazardous Materials and Emissions.
Signature Dale
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
cenify under penalry of perjury that I have read this application and state that
the information given is correcL I agree to comply with all state lavrs and city
ordinances relating to building constmclion, and authonze representatives o!
the Ciry o( Cosla Mesa ro enrer upon the above-0escribetl property for
inspection purposes. I agree not to occupy or allow occupancy ot any building
authorized by lhis permit until final inspection.
� Siqnatur�eo,f(LegalOvmer�s) Date
c��� �Z� ('� ( 7_0 ��
(�a�AuthonzeOApplit�anl L�e�1
.
1'rescri tive Certificate ut' Com liance: Residential
Y� ke.cidentia/ Al[erations
Zone 7!
CF-IR-ALT •
(Paee ] of 51
Surface Details ror
Framing Thickness,
Assembly l�ame Material Spacing, U-
nr Tvne� and Siu' or Other' factor"
No1e: For lurred assembliea, accouming
�he idemi�caiion name
see
Values From JA4
Fcamed Continuou
]A4Table Caviry Insulation
Numbers R-value� R-Value'
Assembly
use �he Mass
?. /ndica�e �he Assembli� Nume or rype: Roaj/Ceiling, Wa(Is, Floors, Slobs, Crawl Space, Doors ond e�c...lndicaie (he Fr4me rype nnd Size: For
Wood, Meml, Me�al Buildings, Mass, en�er' 2x4, 2x6, w' e�c... see JA4 (a� o�her possible,frame rype assemblirs.
3, Eiver die tliiclmess (or mass in inches or Spacing Getween framing members emer; 1 G'a� 24 "OC; or O�her jor al/ oiher assembly drscripiion
such as Cnnm�ete Sandwich Ponel, Spandrel Panel, Logs, SereH� Bale Panel and e�c....
4. Bused on the CGmare Zone; enter �he Siandard U facror fi�om Table 7.5/-B, C ar D for eacir d J(erem assembl�� Name a� rype.
S. Emer �he TaGle number ihai claselr resemGle�� ihe yroposed ossemblr.
G. L•nter �he R-value ihai is being ins�a(led in the wall cavirn or Le�ween �he fi'm��ing,- oihe�wise, enier "0 ".
7. Enier ihc Coniinuous Insulaiiar R-valuefor �he proposed arsembl7': o�heiwisc, enter "0".
8. L•mer �he rnw mid column of �he U-Iactor valuc Lased a> Colvmn FTa61c Num6er ond en�er !he Assernbl�� U-fucior irr Colunvi J
9. TheYrOposed Asa�emLl�� UJacior, Column J, nwsr be equol �o or less (han !hc Standard U-fuclor in COlunm E ln complP.
Fwrin � Strips Constn�ction Table Sor Mass Walls Only
q It C ll C F G H 1 .1 K L M
)h�oposed Yruperties of Masnnry and Concrete Added ln[erior oi Cxterim' Insulnfion
�1'nlls Trum Iicfcrcnce in Turring Spncc 1'rom Refcrence +
Jnin� A i endia Tablc 43.5, 4.3.G. 43.7 Joim A iendia 9'nblr 4.3.13
a `c � � m C.
U � j Y � U
S: v� ° � aL � �
Asccmblp � j � c° �' � c d;"u �° "_ _ Final
Mass Nmnc m- JA4 7nbic o_ i.,` _ F R o t A e•' � V—.= Assemb�
Tliichuess' T c' Numher' $�` _= ui =� u- �. � � c �'G m' U-fnCtot ° Commeni
I � I
Ifegia'b'aiinn Numbw': Regisiruiinn Uaie/Time: HERS Prnvider:
20bb' Residentiul Compliunce Fornxr Augue'i 2009
e Certificate of Cumpl e: Residential CF-IR-ALT � �
fi/[CI'RllOqS' . lPaoo'3 nf.Sl
TtOOr1NG P}20I)OCTS (COOL ROOFS)§15�(p12
When d�e nren ojecteriar rnojs�mjace m be�rep(aced eeceeds mnre than SO% ojOrc rxis�ing roojaren, or more ll�mr ],000 j�, �vhichever is
less, fhG ��eu'rnoftrtg oren nu�s! u�ce! fhe rnnfieg product "Cool Ronf'requircwents aj§I52(b)INi, 152(G)IHii, or I52(bJlHiii.
Cheek app(icab]e aLernntive or eicep(ia+ below if (he rooJaheration is ecempr j�om �he roofing produc! "Cool Roof f requirements. No�e: /jan��
one ojdie ol�erna�ives a rxcepriwr below is checked, �he Aged So(ar ReJlecmnce and Thermal Eminance requirements jnr roofing piroducis in
�118(iJ m'e na applicable. Do nor f(I iabfe below.
❑ Cool Roofs Not Required in Clima�e Zones 1-12, 14, and 16 wi[h a Low Sloped. Less or 2:12 pitch.
�ool )toofs Not Required in Climate Zones I through 9 and 16 with a Steep-Sloped Roofs (pitch greater than 2:12) and product unit weight less
AI[erna�lves tu §152(b)1Hi and §752(b)Hii, Steep-slope roo� (pim)� > 2:12)
=�—ln�'sulalion with a thertnal resistnnce of ai least 0.85 hr� °F/Btu or at least a 3/4 inch air-space is added to [he roof deck
over en eriic; Or
❑ Ex�sting ducts in the anic are insulated and sealed according to § 151(nl D; or
❑ In climate zones 10, 12 xnd 13, with 1 ft'. of free ventilation area of attic ventiletion for every 150 ft� of ettic iloor area, and
wbere et least 30 percent of the free ventilation area is wi�hin 2 feet venicel distance of the roof ridge; or
❑ Building has at least R-30 ailing insulation; or -
❑ Building has radiant barrier in the attic meeting the requirements of §I51(�2; or
❑ Building has no ducts in the attic; or
❑ ln climate zones 10, 11, t3 and 14, R3 or greeter mof deck insulation above vented attic.
Exception to §152(b)1Hiii, Low-slope rooT (pitdi 52:12)
❑ Building has no ducts in the attic.
❑ RooSng area covered by building integrated; photovoltaic panels and solarthermal panels are exa
❑ Roof constructions that have thermal mass over the roof inembrane wi[h at least 25 IWft is exemi
Note: If no CRRC-I label is available, this compliance method cannot be used, use the Performance
CRRC Product ID Number�
RoofSlope I Product Weight I Product
2:12 > 2:12 7< Slb/ft2 > 516/ft' Tvoe�
mpt from [he below Cool Roof criteria.
�t from the below Coo! Roof criteria.
Approach to sho�+� compliance, otherwise,
Aged Solar Thertnal
Reflectence�'4 Emittance SRIS
❑4
❑4
�4
Thc C1�C Producl lD NimiGer cmi Ge obmined fronr rhe Coo( RoofRaling Council's Haled Producl Direcmry ol wrv�r.coolroof.s.orePoraduus/searcl� nhn
ludicalc 16c lype ofprodi¢I is Lcing useA(nr Ihe rmf�ap, i.e. single-plp roaf, otplral! rnof, inelal roof, el[.
/(tlic dged /tepeciaice ix rm� avnilaLle irr.U�e Coo! RoofRaiing Co�a�ci/l+' Rarcd Produm Direcmp� iheri u.ve the /ni�in/ NeJlec�anm valuc fi'om ILe same
direclo�7• ����d nac Ihe egnolimr (0.7+OJ(()�r������— 0.2J io obiain n wlcuimed nged vulne. Wlrere p ia ihr. Lri�inl Solm' Reflecmnce.
Check bo.� i%Ihe �ged /ie/leclmme is n cokula�ed nalue uaing Ihe eqimliorr a6ove.
Calcu(a�c /dc SR/ valuc l�r u.ting �he S1U- Wa'ksl�eel al huP:/hv��vi• enernr cn env/iille24/ond emer ihc resulling valuc in �he SRI Column above and mmch ucopJ' o(
d�e Sltl- IVorksdee� m Ibe CF-lli.
� apply Liquid rield Applied Cuotings, [he coaling must be applied ecross the entire roof surfuce and meet the dry mil thickness or coverage
commendcd by the coa�ings menufacwrer and meet minimum performance requirements listed in §1 IS(i)4. Selec� the appliceble coating;
Almninwn-Pigmented Asphali Roof Coating �LJ Cemem-Based Roof Coating �� Uther
Regi�7rolion Niimbe�c Regislra�ion Da�e/fime:
2008 Residential Compliance Fornis �
HE/LS Provide+':
Augusl2009
__. 3iesidenti�l
-1R-ALT� �
Reside�zYLr+l Alterrztio�ts' (Pa�e 5 p1� i)
Pruject'N.imc r Clima[r"Lonck {"Ui:Stories
��s"ki j'��Sc. �0 II �f-i oi �—�-I ii I r Z
I-I�I:S 1'ERIF1 CATJ UI� SUMAIAI:Y The erila ccmem ngener shou(d pnr spec�ol ortcniiar m �hc HE2Sl�?easm�e.� specified m �his
checichsi belmr d comp(e�ed und sionec! CF-4R Fm�m fa- nil d�c meaa�iu�e.v syecified shnl! be subnnl�ed rn tiit: buildni� inxpec�or befmr 1u��d
vuC15CA�If1od:��B5t111p HL•I(.`,'i�erificnlionisrequiredfor�hismrnszu�c. �
❑ 1'ES ❑ NO 1'CS lu Climaie Zones ^_ and 9-I G, if more thaii 401ineai feei of ne�r ur replucemenl ducts :u�e ins�alled in uncondit�oned
space, the ducts urc to be senled per y;1S2f b)IUii and tlit newh� ins�alled ducts are to be insula�ed pei §151(ij] 0.
�$XC�PTIO�: Lzistine duct systems ti�n� are estended; which :ire cuustruc�ed, insWfned ur scaled �vitli nsbestos.
O 1'ES ❑ NO YES: ]n Climatc "Loues 2 and J-1 G, if tlie esistin� space-conditioning s��stem (HVAC equipmem and duciin�i is replaced, the
� ducu are to be sealed pei § I 52(bp Di. .
❑ YES ❑ NO 1'�S: In Climate Zones Z and 9-16, if [he ezisting HVHC equipmenl is repluced (mcluding the replacemeni o1 tht ai� handler:
omdnor condensing unii of n splii system, cooling m� heating coil, or the fumace J�eai exehanger) the ducts are to be
sealed pei §752(b)]E. �
❑�RCCPTION: Duct systems that are documented tu Lave been previnuslp sealed confirmed thruurL H�I25
- verification iu accordnnce with prucedures in the Reference Residential Appendix RA3.
❑ EXC�PT70�: Luct spstems with less than 4U lineer leet in uncouditianed spece _..
❑�XC�PT70�': L'.xisting duct s��stems conatructed, insulated m� sealed with as6estos.
Refrigerant Charee - Split Sl'stem KERS veriJicntion is reqaire�(a� rhi.r mearin�e. . �
❑ 1'ES ❑ NO YES: In Climate Zones 2 and S-li, when the existing HVAC equipmenl is replaced (including the replacement of the air
hai�dler, outdoor condensin� unit of a spJi� system A/C or lieat pump, cooling or heating coil, or [he Iurnace heat
measu�ement shall be
Central Fan Inteprated (CFI) Ventilation System and Fan �'att DraN�
The ve.n�ilation remiiremems of F150(o1 do not aoolv to ezistine residentiel homes.
Ducted Sp1it 5)'stems - Air Conditioners and Heat Pumps: Airflo�� HERS i�eriiicarion is require� jor this measurc.
❑ Y�S ❑ N 0 YES: ln Climate Zones 1 U through 15, when the exisiing space-conditioning system (H VA C equipment and ducting) is
renlaced. the airf7oW� and ian watt draw shall be verified uer � 1;2(b) I Ci to meet the renuirements of 6li I(fl7B. (
v
Author's Ueclaration Statement
this Certificate of Comnliance documentation is accurate and
/v(
Companp
Signature:
Late
12 13 1-D la
]( Appl�cable G C H or i7 CEPE
�«.�,���. /
C�nYc�zn �i�DU� C� �/C� 2� 23 �(
unsiblc Buildine Designer's Declaratiur Statement
] am eligiblc underDivision i oft6c Culifarnia Business �nd Professions Cude to accepi responsibiliq• lor the building desi@n identified on
this CeniSca�e of Compliance.
1 certify thal Ibe energY feaiures and performancc speci5enlion:, 1or lhe building desiEn iden�ified on qtis CertiLcale of Cumpliance cmiforr
tn the rcquirumen�s ofTitlu 24, P.uts 1 amd G o9-the Culiibmi�� Code of Regulations. �
Thc bufldinp denign l�en�nre,� i�lentiGcd on Ihis Certiiicaic n1�Coinpliance:im cunsisteni with thc'mformatiun prnvided to docwneni tlii:�.
building ticsign on th: o0�ei applicoble coinpliancc Ibnn:,.. worlsl�ce�s; culculmions, plans and sPecificeuions subndltcd tu thc eniorcemeni
ueencr fo� apPrnval wi[h thiti 6uildin, permii xpnlicution.
Namc.
Comp:mY:
Hddres.
Gndtitaid'Lip:
Signaiure:
Lat=_:
License
r0l' G,1'.59,51(UiCC O) (�4L'.SII011:: i'C�lll'(IItl� 2hc Encrg.i' Sttuulm'rts, cnnuici Uic L'nergr Hotlinr at: I-RUO-; i2-:i31JU.
I�eg�svauon N'mnber� har�au�ui�on Gaie/Tuve HLIiS Fr�n�tiec
100�: Ice:ricieniiul Cump(iuncc Fnrms
/crgu.t7 �pOJ
' 235�34
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOZ 91] C09TA ME9A, GALIFORNIA
For Applicant to Fill In Completely
TYPE OR .PRINT _
COSTA MESA, CALIFORNIA
ISTATE � ' l TEL.
LIC. NO. NO.
61ZE ^i .,. _ /. � I rvo. o� eLnan.
USE OF
EXISTING BLDO.
BETBACK LIN[ FI10M
�
DESCRIPTION OF WORK
NO. OP
ROOMS
ROOP
1 HENEBY ACKNOWLEUGH TMAT 1 NAVH RHAO TN�B APPLICATION
•ND 9TAT8 THAT THE �BOVe IB CORRHCT AND AOqEB TO COM.
PLY WITH ALL CITY OqDINANCBB ANU 9TAT6 LAWG q[OULATING
BUILOINO CONBTpUCT10N.
61GNATUREOF � O�� �� v
PERMITT6F � (+ f'iJ.fA\ �/ L�/�
AUTHORIZHD AGHNT
FEE RECEIVED
FEB 19 1965
fINANCE OEPT.
APPLICA`fIONOFO�P�RAAR �
BUILDING
For Office Use Only
or
FIR6
L80AL
ZONINCi
��d �� — ���
OV ERHANO SHALL BE LEBS TMAN
YARDSAPPROVED
MAIN BUILDINO
(PROM C/LSTRHETI
VAR. $F
YARD9APPROVED
ACCESSORY BUILDINO
DATE
' �.
�t%Cj SG. Ff. �
0
TNE �MOUNT BNOWN UNDHp V�LUATION 16 POR TNH E
PVqP086 Or [BTABLIBHINO M1 PERMIT FEE ONLY. 0
VALUATION ((� n � m
PERMIT FEE § 7 �
T m
J `� f
s // � �J� PLAN CHECK $ � ¢
i �� `�'7J $
TOTAL FEE $ I