HomeMy WebLinkAbout132 21ST ST - Building Permits 4f�' CITY OF COSTA MESA %
BUILDING DIVISION
F r I DEVELOPMENT SERVICES DEPARTMENT P IT NUMBER
4 'PERMIT B06-01311
stotsomms 64.
(714)754-5273 • Fax(714)754-4856 • www.cl.costa-mesa.ceUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 132 21ST ST Status: ISSUED
Suite: A Applied: 08/02/2006
Vicinity: CARPORT ,r En frif Issued: 08/022006
Primary Oct: R3 Type of Construction: V-N _.
Parcel Number: 42612105 Zoning:
•
•
Applicant: CIRALLI, PAUL •
Address: 735 FARAD ST t
Phone: 949-548-9884 ISSUE
COSTA MESA,CA Zip: 92627 VVVV
Owner: ETHERINGTON, ROGER F TR
Address 2700 NEWPORT BLVD#222
Phone? 949-723-0625
NEWPORT BEACH,CA ' Zip: 92663 •
Contractor: z /OWNER-BUILDER ;
Address: -
" Phony:
•
Zip: License: 000000'
Arch : Eng: '
Address: Address:
Phone: -.• Phone:
Zip: License: License:
SCOPE OF PERMIT
FIRE DAMAGE REPIAR TO FRONT ENTRY AND CARPORT.WORK TO INCLUDE:REPAIR AND REPLACEMENT(LIKE FOR LIKE)OF FRAMING,DF
LATH,PLASTER,-FRONT DOOR AND EL WORK.
REF#:E006-021
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $9,500.00
' Permit: $181.25 • Claim Valuation: $9,500.00
SMIP Res: $0.95
SMIP Corn: $0.00 •
Other: $0.00
Inspection: $0.00 •
Total: $182.20
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 "
•
•
•
•
•
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requkements 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. •
U
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-S62e •
•
,
2446-48(8'c0)
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DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirin 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,far the performance of the
work for which this permit is Issued.
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued.
My workers compensation Insurance carrier and policy number are:
Cartier: Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
I certlfy.that in the performance of the work for w itis Issued,I shall not employ any person in any manner so as to become subject to the workers'
-compensation laws of California,and agree that if I s • • •_ •• e subject to the workers'compensation provisions o Selion 700 of�e Labor Code,I shall forthwith
comptywith th• . .
Applicant Signature: �• �_��� •rDete:- 2
WARNING:FAILURE TO r D. -L'CCI(;WEMGE IS WFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARS(5100,000),IN ADDITION TO OF COMPENSATI• DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEYS 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.Lie.a Class a
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: 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 hear she is licensed pursuant to the provisions of the Contractors License law(Chapter 9(commencing with Section 7000)of DMslon 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 penally of not more than five hundred dollars($500).): •
❑ I,as owner of the property,army 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 Ucense Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). '
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors Ucense 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 Ucense No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bit 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(38)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 Safely,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 or wit the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑ eo ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully compiled 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 egpplication aper it for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes U No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
_..._..r. __ _ .......r..._..._. __.
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 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? ❑Yes 0 No
8 (II Nes",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 dry 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.
•aura 0 eget Owner(s) la-)OLODate
T_-Ar.Autho ..•Applicant Date_ ,
•
CODE 1 INSPECTION TYPE PAIL Nal CODEt INSPECTION TYPE 2811 191MALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1268 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
Z
204 Final Demolition _ 250 Final Bullding/Occupancy • &I O -
CITY OF COSTA MESA
BUILDING DIVISION
trn ; ; 8 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
!sem PERMIT /06-01312
oss
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(714)754-5273w�• Fax(714)754-4856 • www.cl.costa-mesa.ca$UILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
•
Job Address: 132 21ST ST Status: ISSUED
Suite: A Applied: 08/02/2006
Vicinity: CARPORT ROOF Issued: 08/02/2006
Primary Occ: U1 Type of Construction: V-N .
Parcel Number: 42612105 Zoning:
Applicant: CIRALLI, PAUL
Address: 735 FARAD ST
Phone 949-548-9884 ISSUED BY:
COSTA MESA,CA Zip:•• 92627
Owner: ETHERINGTON, ROGER F TR
Address 2700 NEWPORT BLVD#222
Phone: 949-723-0625
NEWPORT BEACH,CA Zip: . 92663
Contractor: OWNER-BUILDER -, - -
Address:
Phone:
Zip: License: 000000 .
Arch : Eng:
Address: Address:
Phone: _. Phone:
Zip: License: • License:
SCOPE OF PERMIT
FIRE DAMAGE REPIAR TO FRONT ENTRY AND CARPORT.WORK TO INCLUDE:TEAR OFF(E)DAMAGED ROOF MATERIALS,INSTALL SHEATH!
LAYER OF 15#FELT AND REROOF W/30 YEAR COMP SHINGLES ON CARPORT ONLY,APPROX 9 SQUARES.
REF#:E0006-021 AND 506-01311
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: " $2,700.00
• Permit: $83.25 Claim Valuation: $2,700.00
SMIP Res: $0.50 - '
SMIP Corn: $0.00
Other $0.00
Inspection: $0.00 •
Total: $83.75
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.
•
/
•
•
•
•
•
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 , .
•
2446-48(8/00) ,
•
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penally 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
work for which this permit is issued.
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed If the permit is valued at one hundred dollars($100)or less.)
I certify that in the performan : • •e 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 Calif o .,and tree that if I should become subject to the workers'compensation provisions of
Secttiipn 3700 of the Labor Code,I shall forthwith
comply with •' ' :4. (J/te G?
Applicant rDete:
+WARNING:FAILURE-TO SECURE W.'.. • 'COMP TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOI ARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS 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.Uc.# Class if
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that)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 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 wail have the burden of proving that he or she did not build or improve for purpose of sale.). '
❑ 1,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: _ Date:
Owner ID verified by driver's license. 0 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,faisework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3,2,Grp 2,An 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date: - __
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes 0 No
(Section 25533 of the California Health and Safety Cale.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 or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yeo
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or a the applicant or present or future building occupant require for the work which Is the subject of this,a,,ppplication aPPermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes L.I No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
.........._..._._any partfacility .__._ _____ . ._...
6 Will of the to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑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 Safely Code Section 42303 been made? 0 Yes ❑No
8 (if yes-,attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above Is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
gn ra 'r t[s :..,t!) iate'\
-And/• .ut .,nt I Date- \J
900E90054 PE ' DATE NEM& 9005( INSPECTIONTYPE RALE MBA
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 Well 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final D 222 Final Be
204 Final Demolition 250 Final Building/Occupancy
DECLARATION OF AUTHORITY Bldg. Permit#
FOR AGENTS OF PROPERTY OWNER
TO APPLY FOR PERMITS This Permit#
Street Address:1� 1232 2A
Si- S-tncf x S u&ke CA 12141 AP Number:
1. I (we), t` -G1 v Ie'A1 rtiOn , declare that I am the Owner of Title of the above
referenced real property, and that I (we)hereby authorize:
Name: DOUg G 1 rAi t -f C1 ri,LUU. COAS'fl }IJR'elephone Number: (Ciq�}€-q$FSt"f
Street Address:// 1 '35 Fa rad Since
City: Cos-it .A&%& State: l_ A Zip: 4.2-(0z1
to obtain permits in my behalf,as owner/builder,for Ca ptX4 Art cituYIcy-—au rad ,e
at the above referenced property. O
2. Should any person become an employee engaged in the improvement of the property, I (we) shall immediately provide Worker's
Compensation Insurance coverage and cause a certificate of that coverage to be filed with the Building Division of the City of Costa
Mesa,as required by State of California laws.
3. As owner/builder in fact, I understand and accept that my responsibilities do not transfer to any other person, company or
corporation.
4. I agree to indemnify and hold the City of Costa Mesa and its employees or officers harmless from any claim resulting in damage or
personal injury to myself or any other parties as a result of work authorized by the permits from the City of Costa Mesa.
5. I declare under the penalty of perjury that the foregoing is true and correct.
Executed this r0 day of S(.4A1. 20 0(0 ,at ()Dela_ Ateaa_ , California.
UP_rintName: 1 Q3& r. Ober(nc+00
'Signature:
-Date: L LLL �"` 2
Note: This authorization does not grant authorization to perform the work as owner,
it solely provides for limited power of attorney to secure this permit in any behalf.
0779-46(rev.11/00)
11114v, CITY OF COSTA MESA
t/r BUILDING DIVISION
Y:{. „a DEVELOPMENT SERVICES DEPARTMENT PER IT NUMBER
F 4 I PERMIT
Ae so,sP • E06-00853
•
(714)75'4-05273 • Fax(714)754-4856 • www.cl.costa-mesa.ELECTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 132 21ST ST Status: ISSUED
Suite No A . Applied: 08/02/2006
Vicinity: FRONT ENTRY • Issued: 08/02/2006
•
Parcel Nunmber: 42612105
Applicant:ddressCI735 FARAD
I, PAUL
Address: 735 FARST ISSUETBY: cep
Phone: 949-548-9884
COSTA MESA,CA 'Zip - 92627
Owner: ETHERINGTON, ROGER F TR
Address 2700 NEWPORT BLVD#222 - •
Phone: 949-723-0625 N
, NEWPORT BEACH,CA., Zip: 92663 -
Contractor: OWNER-BUILDER ,
Address: _ '
Phone: • "
Zip:
License:000000
SCOPE OF PERMIT •
FIRE DAMAGE REPIAR TO FRONT ENTRY AND CARPORT.WORK TO INCLUDE:REPAIR AND
REPLACEMENT(LIKE FOR LIKE)OF FRAMING,DRYWALL,LATH,PLASTER,FRONT DOOR AND EL .
WORK. .
•
REF#:EO06-021 AND B06-01311 •
, WORK TO INCLUDE-1 LIGHT FIXT AND(,SWITCH:_. • ,.' • • - ,
FEE SUMMARY -
Quantity - Quantity
.,ISSUE FEE • $23.50 _• ____ _ " _ , Temp Dist System/Lighting• " $0.00 0 "
Temp service test $0.00 _ Busway/100.ft $0.00 0 '
Res.a/c package $0.00 - Standing Section $0.00 0
New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 •
New Res(3+units) ' , $0.00 0 Transformers up to 1 kva/kw $0.00 0 ,
Pool/Spa $0.00 0 - up to 10 kva/kw $0.00 0 , ,
Lighting Fins $1.10 1 'up to 50 kva/kw $0.00 . 0
Recept Outlets $0.00 0 - • Up to-100 kva/kw $0.00 0 "
Switches • $1.10 1 over 100 kva/kw '$0.00 0
Non Res Appl , $0.00 0 Low Voltage Equipment $0.00 -0 -
Res Appl $0.00 0 - • Low Volt Wiring System/Ckt. _ $0.00 0 ' '
Service to 200a $0.00 - 0 ' Misc.Conduit $0.00 0
Service to 1000a ' $0.00. 0 Misc.Conductor : . - $0.00-, - 0
Service over 1000a. , . $0.00 " 0 ' Circus(gen or ride) $0.00 ' . 0
Motors to 1 hp $0.00 0 Circus(mech ride or lights) $0.00 0 '
Motors to 10hp $0.00 0 - Christmas Tree Stand $0.00 , 0
Motors to 50hp $0.00 . . 0 - Fireworks Stand $0.00' 0 ,,-'
Motors to 100hp •. $0.00 � 0�- . - Other Electrical Fee , - - $0.00 i! j
Motors over 100hp . -$0.00 - , . 0 , , - ,--'
Communication drops $0.00 0 Investigation Fee $0.00
Sub panel to 200a $0.00 0 Plan Check Fee $0.00
Pole Light Pkg $0.00 • 0 .Reinspection Fee $0.00
Sign Circuits $0.00 0 ..
Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES. $25.70
Intermed Pole $0.00 0
••r
•
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) V
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+43(6D0)
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
work for which this permit is issued.
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued.
My workers'compensation Insurance canier and policy number are:
Carrier: Policy Number:
,,,(..Thais section need not be completed if the permit is valued at one hundred dollars($100)or less.)
•y� I certify that in the performance of the •• or which this permit Is issued,I shall not employ any person in any manner so as to become subject to the workers'
/\ compensation laws ofCalifornia,and a. ee the 11 should become subject to the workers'compensation provisions of Sectio4 3700 of the Labor Code,I shall forthwith
----damply with these pro s //
CApplicant Signature: 1 I Date: --- -- .3-/1tr:),
_WARNING:FAILURE TO SECURE WORNE-• COMPEN • ON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TOONE HUNDRED
THOUSAND DOL ARE($1OO,000),IN ADDM• •THE•• 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.Lk.a Class N
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued.(Sec.3097,Civil Code).
Lenders Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commenting with Section 7000)of DNLsion 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 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.). '
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business.end Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. 0 Yes 0 No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,faisework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safely Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the Califomia Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health.and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 1J Yes lJ No
(Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If 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 prope . - •=•'an purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
tura Of Lege • ner(s) Dat
"'Mir A / e -- -
uthor =•Applicant /Date__.__
D`Ie_-__._-
;ODE I INSPECTION TYPE PATE 9LE CODE( INSPECTIONTYPE ' '
II� DEE R'T M.S
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing 1p /��
200 Final Re-Roof 210 Final Electrical CJ/L7 -
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
• COUNTYOFORANGE . Application for Building :.:iit
BUILDING DEPT. Permit No 4/,, , W d r
•
636 No.Broadway AND FOR A
Santa ,California Certificate of Use and Occupancy
Phhone:one:KI 2-6211 P Y
Dat? X. 49 ✓
�..� �, �/ 7777
I. OWNER'S NAME ��! �}i'�' L 4 . ' �11 PHONE:.-- 6
MAILING ADDRESS-1/2Z - / /ac TYJ r � �'�r^�
Name.... ... Name
(Architect or Engineer) (Contractor)
Address Address
City City
•
State State • .
Lic. No... Phone Lic. No Phone
PROPOSED USE - .----
..............
•
2. JOB LOCATION..... .. Jict
(House No.) (Name of Street) (T n or chis�` ) 6
NAME OF AND DIRECTION FROM NEAREST CROSS STREETS4 ^�� "V
3. LEGAL DESCRIPTION: Lot.W.Aj 4 7T [J Block /...a . .'/l..- Tract../Y 3
. (Metes and Bounds Description—Use reverse a of form)
-4. CORNER LOT ( ) INTERIOR LOT/( ) ,f,,T�H,�ROUGH LOT ( ) SLOPE OF LOT ( )�(
5. SIZE OF BLDG.:.A 0 )(Q.Z.. --1-.AREA:,�t i 4 47/.SIZE OF LOT• d 0 $ //t AREA::t ` 6u -
r IP
(yI• /
6. HEIGHT OF BLDG • /7.�j�' CEILING HEIGHT:..!) NO. OF STORIESf(/
7. NO. FAMILIES / Size offSmallest
Bedroom- Size of Kitchen
S. EXTERIOR WALL CONSTRUCTION V �/j��INTERIOR WALL COVERING
(Frame, Stucco, Etc.), C��' / 3 (Plaster-Drywall,Etc.)
ROOFING COVERING ��rr"!�'*l* a1L-
9. STATE HOW MANY BUILDINGS NOW ON LOT AND GIVE USE OF EACH enc i ��
10. SETBACKS: Front Yard From Center Line of Street 7 -5-'4
r 9 ,
Nearest Side Yard � Rear Yard � Distance in Feet Between Bldgs. on Same Lot
(Property Line) (Property Line)
ll. A COMPLETE PLOT PLAN IS REQUIRED, SHOWING ALL STRUCTURES AND USE OF EACH.
12. (a) Footing: Width /4 n Depth in Ground /. Width ofofnWall .frim�•
(b) Size of Studs:...A.X_. Spacing /4 . "CC Material of Floor.L:, _ 2
(c) Size of Floor Joists• f. r Spacing r t "CC
y n
(d) Size of Rafters- 01- c Spacing 4 "CC
13. VALUATION OFPOSED ORK: Including all labor, plumbing, electrical wiring, heating, fire sprinklers, painting and
sewage disposal $ �''�G
14. I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE INFORMATION IN THIS
APPLICATION IS CORRECT AND THAT THE CONSTRUCTION WORK WILL CONFORM TO ALL LAWS OF
THE COUNTY OF ORANGE AND THE STATE OF CALIFO T A " I AB E THERETO.
Signed ---i_. re i
(Owner)
Plans Filed•
By.
(Authorized Agent)
FOR DEPARTMENTAL USE ONLY
FEES: � ING BY
Bldg. Permit $ 1 °,1),
U GROUP APPLICATION.... HEALTH
G TYPE —i�i FIRE
Plan Check • $ e / ZONING , MARSHAL
Total - • - $ ur DIST. 0. RL( PLANS AND �/
Receipt No. • �.� _ MSP I SPEC'S STATE
Paid to SHEET NO CORRECTIONS ENGINEER_
Date / — .^ c...J.. r e�."P_QCr>;��(aTi1�.Tia l • '
II 10 �I INS'EG
PERM IL EDiai
DATE Y __- L��Ll ii r;EPUiY'
5000-7-5D2 '
v '
OWNER SHEELEY, MAR' JANE DATE 10-2-59
JOB ADDRESS 132 E. 21st St. BUILDING PERMIT N010446
GENERAL CONTRACTOR Scotbh Const. Co. VALUE $ 9,539.00
AR No. 118-031-07 LOT TRACT FIRE ZONE DESCRIPTION OF' WORK Dwelling j
INSPECTIONS j,,1,41 DATE I GROUP I & J TYPE V ZONE R ji
Underground Soi1iOnIU.G. Water kw it,"47-tPERMITS ISSUED
Underground Gas .CPy it-3-gv SUBCONTRACTOR DATE NUMBER 70_A,"/
Overhead Water and Gas
Rough Heating '3.)9 i , tr
Rough Plumbing ..1 ,/-3.0)7k r f'&w..e f0 s. ft- IS-fl G /4,s--ar II_L
Miscellaneous .., /c ,i, _ �. .1�a-ti-,,.� :�1h-4-c. . •-4,-- 30 -4 ca 3n..2 '/ , 1 Li
Prop. Swr. Line, H Con. St/Swr. pity/.i +� ii 1-1() 9., /3 ✓ i
Sprinkling System
Heating, Final A 2 A 3GS;
Plumbing Fixtures GS// 9,r fCj 1J
Final Gas Test I/; /• ,i ' -w/_S4 _ / Y
Construction Pole f / I IA
Underground Power 1"
Rough Wiring a (72-----9-J-9 a! /41(.. -4ec . j7-19- /05-472/ a .
Trenches Forms Steel /O r�0 -` I/
Floor System 1 iV
Steel Reinforce Chimney Re-Rod ,tat
Bond Beam 1,B'' '
Sheathing /0 '�, Y� 9 ;
France and Flashing 'W. /4'
Lathing, In L-" Out ✓ /Jj , C //' 5"-- �
Plaster, brown coat - 73, e. jp/F 'Z -
Plumbing Fixtures, Final O '
Electric Fixtures, Final /_�
Building, Final a•�'gsL I\tv,1 6
OCCUPANCY -
1_
Form 210-3M-4-59 101 !16
1 ,446 c" [C,E RECEi J i
tp-
COSTA MESA BUILDING-SAFETY DEPARTMENT c/ - / - 5
P.O.BOX 317 COSTA MESA. CALIFORNIA FINANCE DEPT.O `' `'
FOR APPLICANT TO HU IN COMPLETELYLETELY APCITCA FORRPERMIT
qq 11yTYP/E�OR PRINT {//� BUILDING
ADDRESS /L/ V) /i, Q[ /oz` c'J T •
COSTA MESA, CALIFORNIA FOR OFF/CE USE ONLY
Mill � et/E £ //�6.Lsy I RECEIPT NO. I PERMIT NO.
MAILe OWNER /J//7-/� Y/ [� Jn
ADDRESS/p(pC,i//1.�L/-J/¢/^/5(,1(/�J,/y/J'/ RE-UCl/VEO p�3E9EC IV D DATE.ISSUED/
CITY A 0 S NA &- L ✓ '1(D TNO. ADDRESS /ry
ARCHITECT4a ol—C� NOG. COSTA MESA. CALIFORNIA
OR ENGINEER
4)a
FIRE / �
y'y/ ZONE TYPE GROUP
air
.,076'/ �CA STATE/r-i-KO By
I_ � DATE ///j
'//1 LJ 1/'� �TJY //LIC.QN OQ. /, 3
ADDR„,0 git vO /7���"l sail- t ZONING
LEGALion* i2 1/ ZONE I NO.OP USE OF NEW
�DESCRIPTION I N 5'I BLOCK I TIiA PLAN BUILDING
/ I J 0 �, I APPROVED
1,1 �/Z
A.P.NO. By �� JL DATE 9 ��/ 7
OF
/ J 1 row.
of BLDGe.2. YARDS EVES /// /
OF LOT ti---6 35o [�b I NOW ON Loi REQUIRED ALLOWED
ESE OF D 1q/4.4 X./4//1 (CENTER LINE ST.)
EXISTING BLDG. { V- FRONT j' IN.
SETBACK LINE FROM q?' / /
CENTER OF STREET .(J REAR YARD(J R. DE "7 FT. IN.
' 2I /
SIDE YARD I LEFT 7 RIGHT L.SIDE rFT. IN.
DESCRIPTION OF WORK 1
REARFT. thei-, IN.
NEW In II ALTERATION I II ADDITION I I ,/ S
REPAIR I II MOVING I NO.OF l/
SIZE I :3 ✓ II DEMOLISH I
'
SULDING'J �/� rj , STORIES /
7 ROOMS '/ /� [/
' EXTERIOR WALL ITy�,U.
LiICOVVF
ERING / /Q�C/'I
COVERING J�//LC
' USE OF BUILDING AND WORK TO BE PERFORMED '
/J /
d�-L�-a,/' /�-c.c
U ,•
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CON.
PLY WITH ALL CITY DIN NCES AND STATE LAWS REGULATING PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
BUILDING CONBTRU ON.
` O.
/) `4'- � VALUATION
SIGNAPERM TURE
E OF y,)^v/'/ C�-(�[� GI/'/'F PERMIT FEE $ 'y'�
1// $962 / 0 PLAN CHECK $ i1
, AUTHORIZED AGENT
, TOTAL FEE $ 34j------
OWNER S$EFLPYI Mary Jane DATE 2-25_63
JOB ADDRESS 132 E. 21st St. , Rear BUILDING PERMIT NO.18820
GENERAL CONTRACTOR Owner-Bldr. VALUE $ 83.00
AP No. 118-031-07 LOT TRACT FIRE ZONE DESCRIPTION OF WORK "Stall 9Verhd
Gnr.door
1I'T °ECTIONS Signature DATE GROUP J TYPE V ZONE R-2
PERMITS ISSUED
Gay SUBCONTRACTOR DATE NUMBER
Water
Rough Com. Refrig. 0 Air Cond. 0
Rough Heating
Rough Plumbing
Miscellaneous
Prop.Swr.Line 0 House Con. 0 St.Swr. ❑
Sprinkling System
Construction Pole
Underground 0 Power 11-
Rough
Rough Wiring
Trenches 0 Forms ❑ Steel Reinf. 0 _
Floor System
Bond Beam ❑ Steel Reinforce ❑
Sheathing
Frame and Flashing
Lathing — In 0 Out 0
Plaster, brown coat
Y'2. ❑ Air Cond. ❑ Final
Pt;; ."ing, Final
Plumbing Fixtures, Final
Final Gas Test
Electric Fixtures, Final an�p'y�� /_
Building, Final 7� �"c- 3 --- a — 6 3
OCCUPANCY
FORM BU4.BM - 7.61 1/4740Q
1 I '920
COSTA MESA BUILDING-SAFETY DEPARTMENT 4, E RECEIVED
P.O.BOX 917 COSTA MESA.CALIFORNIA
Feg ,, CC
For Applicant to Fill In Completely APPLICATION OR PERA�T' 1963
TYPE OR PRINT BUILD�NcINANCE DEPT:
ADDRESS C- ,`/ 'O For Ohtko YFP gl;>rCOSTA MESA
BUILDING / �1/j„ LA��_
o/AC RECEIPT NO. P[f MI
COSTA MESA. CALIFORNIA
�C/
RECErvI E DATE RECEIVED GAATTE ISSUED
OWNE 4000- 941-2414" ��`�J TJ'�o�..S�- 3
MAIL '/J'/�y�/J� _/ -o/ � BUILDING
ADDRESB��,C- J -�K�[/'P-�`Q.���- -t. ADDRESS
�j,/ TE �� o / FIRE ) ofCITY/ S�/ NO..� -J/ONZONETYPE °ROUPAPPROVBKit/
'(
ARCHITECT ! TEL BY i DATE
OR ENGINEER T - .ANO. 11 ZONING �� �,4,-, Ley/�/
ADDRESS ,ry�� //lI{6�Gd• zon6A ^ PLANS No.or ( I USE or BUILDINGBW W`i r ' !/' .
CONTRACTOR///'�/y9Cer- OJ,,, )� V// /
atec�` � DESCRIPTION / !/u-!
CITY A.P.NO. '( V� 03/ — o 7
NOTE: NO EAVE OVERHANG SHALL BE LESS THAN
STATE �-----Ie-. 90'TO SIDE&REAR P.L.
LIC.NO. NO.
EAVES
SIZE
(re? X l S I NO.NOW OF
ON BLDLOTOS. 1 ALLOWED (U.B.C.REQUIREMENT)
OF
USE OF � /� YARDS APPROVED YARDS APPROVED
EXISTING BLDG. , .. .4 MAIN BUILDING ACCESSORY BUILDING
nv (FROM C/L STREET)
SETBAC
NE
CENTERKOPI STREETM J //\(' REAR YARD F//EX FRONT FT. -1 /,/
C FT.
SIDE YARD LEFT I RIGHT ( R.SIDE FT. !/ FT•
DESCRIPTION OF WORK L.SIDE Fr. tib Fr.
NEW ALTERATION ADDITION I REAR FT. 4.-- FT.
DISTANCE BET. BET.MAIN&
REPAIR MOVING DEMOLISH MAIN BLDGS. ACCESS.BLDG9.
• VAR.# DATE
BUILDING NO.OF
SIZE ROOMS / STORIE / C.U.P.# /� APPROVED
EXTERIOR WAL4.) I CROOFOVV ERING L{J%`"��! BYPROV EqI, Y ,(/ DATE a 5=4.3
COVERING CC''II�I[[[��`�/`ALD��,TTT[[JJfff / GU O v
USE OFAt.". G AND Vfp"RTO en- -ORAD .I 'l
0-777
T/,-' GLS, U7.LQ_il✓ N
rip
SQ.FT. G
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE E
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT PEE ONLY. G
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING VALUATION
pBUILDING CONSTRUCTION. _� n
PERMIT FEE $ BSIGNATURE OF CC G
PERMITTEF ' DO IS CHECK
AUTHORIZED AGENT --ILL
TOTAL FEE $ /t