HomeMy WebLinkAbout1881 Tahiti Dr - Building Permits 4 a CITY OF COSTA MESA
► ' BUILDING DIVISION
r "'" ' ' DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
PERMIT
699-00726
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 1881 TAHITI DR - Status: ISSUED
Suite: Applied: 05/24/1999
Vicinity: Issued: 05/24/1999
Parcel Nunmber: 13941204 Zoning: R1 R1
Applicant: RICHARD MURPHY ISSUED BY:
Address:
Phone: 714-893-5852 '
Zip: - -
Owner: SCROGGS, JOSEPH A TR ,'
Address 1681'iTAHITI OR' ' - _
mo ;
/iii/ V - Phone: 714=545-1404 - - ' ' v
COSTA MESA,CA" - - Zip: 92626
Contractor: , R J-MURPHY_CONSTRUCTION
/Address: 6022 GLENWOOD DR '�
-
�
_ Phone. 714-893-6852 _ =
• � 'i, HUNTINGTON BEACH,CA
,v.. ,. Zip: 92649. License: 639661
Arch : - - Eng:
.Address: , - Address: ,
-
_ , _ '' "Phone: - - - Phone: N
Zip - -. License: Zip: License:
SCOPE OF PERMIT v
KITCHEN REMODEL,REPLACE CABINETS, PATCH WALLS,REPLACE PLUMBING&ELECTRICAL. `
FEE SUMMARY ' -
' Plan Check: $0.00 / , Calc Valuation: . .52,500.00
Permit: , $74.75 _ _ Claim Valuation: $2,500.00
SMIP Res: $0.50 - '
SMIP Corn: $0.00
Other: $0.00 =-
Inspection: $0.00 .
•
'-' Total: ' $75.25
PLANNINGB ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0;0 Left 0-0 • - Right 0-0
- . ,
' ACCESSORY Front 0-0 . Rear 0-0 Left 0-0 Right 0-0
PARKING Existing: 0 Required: 0 Proposed: 0 /
,
NOTES:
•
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
C
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 carrier and policy number are: Q / _
� Tt rUN 17
Carrier: - Policy Number: /. 0092-3 zC
c I 3 –
(This section need not be completed If the permit is valued at one hundred dollars($10 or less.) ' ' ' r`
O I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these pro visi ns. /may / _
Applicant Signature: "7-. ^..� - Date: °J – 2-S4 – 92
WARNING:FAILURE TO SECURE WORKERS'Cy
/^lPENSATION COVERAGE IS UN •• FUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,00Q,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 79900)of Division 3 of the Busines and Professions Code,and my license is in full
force and effect.Lic.# �09 ( Class# -//
Contractors Signature: _ _ _ IL /�� ,. Date: 5'– 24 – "'
v
CONSTRUCTION LENDING AGENCY:
O 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.F by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
O 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 and Professions Code for this reason:
Signature: Date: _.
Owner ID verified by drivers 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,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 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 ❑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 0 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
t 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? ❑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 a plication appermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? D Yes D No
(Section 65850.2 of the Califomia Govemment 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,end authorize representatives of the City of Costa Mesa to enter upon the
above-des i.ed property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
S –LSA - 5'9
Signature Of -.al Owner - / Date /
`1 And/Or Authorized Applicant ( Date /
CODE I INSPECTION TYPE • MATE INTITIAL$ -. ' ;ODES INSPECTION TYPE " PAN INTmALS
• 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 7--24–Rd,
2446-46
•
y �' CITY OF COSTA MESA c'
�t e..t. BUILDING DIVISION
1. trria" ' DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
#; PERMIT
49-00294
(714)754-5273 • Fax(714)754-4856 - 77 FAIR DRIVE,COSTA MESA,CA 92626
. PLUMBING PERMIT
Job Address: 1881 TAHITI DR Status: ISSUED
Suite No Applied: 05/24/1999
Issued: 05/24/1999
Vicinity:
Parcel Nunmber: 13941204 ISSUED BY:
Applicant RICHARD MURPHY
Address: . i -
Phone: 714-893-5852 ,
Zip:
Owner:/'SCROGGS, JOSEPH A TR ' -
Address'//1881 TAHITI DR' _ - '
Phone: - '
i • ,/ -COSTA MESA;CA Zip: 92626 / ,;
' ,J/ - . �: � v _
/ / � i_
,ri -
Contractor: R J MURPHY CONSTRUCTION .
.
Address: 6022 GLENWOOD DR
Phone: 714-893-5852 ,
HUNTINGTON BEACH,CA " - Zip: 92649 .
r- License: 639661- • "
Arch/Eng: - '
i
Address: , "
Phone: - '
- - Zip:
License:
` • - _ - SCOPEOF-PERMIT . /
KITCHEN REMODEL,REPLACE CABINETS, PATCH WALLS, REPLACE PLUMBING&ELECTRICAL.,
1DISHWASHER, 1KITCHEN SINK, 1WSH BASIN, RE:B99-00726.' ,
FEE SUMMARY • ,
AMT QTY AMT QTY AMT QTY
ISSUE FEE $22.00 • 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 ' $0:00 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 $8.75 1
Dishwasher '$8.75 1 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 `.\-:W.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 I vent $0.00 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 $8.75 1 ' Water Softener $0.00 0
Gas(Over 4 outlets) $0.00 0 Sink,service/mop, _$0.00- '0 OTHER $0.00
Gas Repipe $0.00 0 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: $48.25
• 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
DECLARATIONS
, I
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
Erwork for which this permit is issued.
XN 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 CLIC(I.- Cu N Policy Number: / 3 d 0 az_3 - 99
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.) •
--
O I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these pr. ':'•ns. yJ�
Applicant Signature: —'moi? -e Date: ^Lei —4,
WARNING:FAILURE TO SECURE WORK�,. •• PENSATION C6QERAOE IYuNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND COLLARS($100800),IN AD.• ON 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 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.Lic.# (0 3 9eO(o Class x /3
Contractors Signature: Date: S - 234 • 9 7
CONSTRUCTION LENDING AGENCY:
O 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 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.).
O 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,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).
O 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 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 R (R
MPP(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 apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes ❑No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
ermit b 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).
._.- . __fere-.-.__.air polluti__ agency._._..--_-_.r..—......wsubef this
7 a a cation from tae South isclos Air Quality Management is Healthat hr other air p Odti eon controln42303 district been agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California and Safety Code Section made? ❑Ves 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,end authorize representatives of the City of Costa Mesa to enter upon the
above-described roperty for inspection pu •oses.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
947
Sture Of Leg. •wner(s) Date
And/Or Authorized Applicant Date
CODE I INSPECTInN TYPE " PAlE - jNTRIALS - .LODE! INSPECTIONTYPE' -• - . - PATE MAO
1616 Fixed System Final Fire Prevention 206 Final Mechanical �Y
1266 Pool Spa Final 208 Final Plumbing 7'a6-7 /pct JR1
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
2446-46
' CITY OF COSTA MESA
�``, � BUILDING DIVISION PERMIT NUMBER
H i '-r i DEVELOPMENT SERVICES DEPARTMENT
PERMIT
99-00451
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 1881 TAHITI DR Status: ISSUED
Suite No Applied: 05/24/1999
Vicinity: Issued: 05/24/1999
•
Parcel Nunmber: 13941204
ISSUED BY:
Applicant: RICHARD MURPHY
Address: ' - ' - - -
f ' . .Phone: 714-893-5852 - -
Zip:
Owner SCROGGS, JOSEPH A'TR -
Address�,"t881 TAHITI DR - - -
/, _ - Phone: ,
' i COSTA MESA;CA- .- Zip: 92626 - `� ;
•////2
,,�Contracroc- RJ/MU_RPHYCONSTRUCTION .,,
'`:Address:" 6022GLENWOOD DR
Phone: 714-893-5852
'HUNTINGTON BEACH,CA ' - - Zip: 92649
. ' -• License: 639661
- , . . / -
SCOPE OF PERMIT
' KITCHEN REMODEL,REPLACE CABINETS,PATCH WALLS,REPLACE PLUMBING&ELECTRICAL -
' 7FIXTURES,4OUTLETS, RE:B99-00726. `
' FEE SUMMARY •
Quantity - , -/ - Quantity ,
'ISSUE FEE ,
$22.00 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 Fixts $7.00 7 up to 50 kva/kw $0.00 0
Recept Outlets ', $4.00 4 • up to 100 kva/kw $0.00 0
Switches` • • - $0.00 0• • '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 I Ckt '. . $0.00 0 " . . ,
Service to 200a $0.00 Os - Misc.Conduit $0.00 0 - "
.
Service to 1000a. -, - $0.00v , 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 ' '- _1- $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 '
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 $33.00
Intermed Pole $0.00 0
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
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:, -. , ;) .• r : • .. •
❑ 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.
AI 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'com0ensation Insurance carrier a d policy number are: pp
Carrier: -T�TF—�'�N Policy Number: �3 00 C77 3 — qy
(This section need not be completed if the permit/s valued at one hundred dollars($100)or less.) ' ' '
O I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these prows p
Applicant Signature: L� Date: - — /9
WARNING:FAILURE TO SECURE WORKERS'COMP ATION COVERAGE IS UNLAWF AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),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 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.Lic.# f 3 nT a/ / Class# Q
Contractor's Signature: 7� J Date: 7 ^ .t—'" — 99
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: 4r-alJ'sLender's Address:
Signature: Date: _
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I em 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 end 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 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,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).
O 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 ❑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).
_ futuebung_..ccpant..need_--p-repaeRMPP
.tion"-rogran-_
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 ❑No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a2ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No
(Section 65850.2 of the California Govemment 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
B (If'yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-de I•ed property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
/Ignature Of Legal'- ner(s) Date
And/Or Authorized Applicant Date
COBE N INSPECTION TYPE PAIS INTRIAL$ COGEN INSPECTION TYPE"^' PATE INTQIALa
1216 FixedSystem Final Fire Prevention 206 Final Mechanical
1266 P000llSpa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical 711la2
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
2446-46
'
t
S � CITY OF COSTA MESA
e ►y _ i, BUILDING DIVISION
t' '•"7 ' DEVELOPMENT SERVICES DEPARTMENT 1114,
Jdf' PERMIT PERMIT NUMBER
B98-01325 1/
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 1881 TAHITI DR Status: ISSUED
Suite: Applied: 07/24/1998
Vicinity: Issued: 07/24/1998
Parcel Nunmber: 13941204 Zoning: R1 R1
Applicant: RODRIGUEZ, OTTO
Address: ��1
Phoria: " 714-227-7864 /1
,.; Zip: _ , I
Owner: SCROGGS JOSEPH A TR
.
Address 1881 TAHITI DR' ,///1/2/7 C''C - Phone:. _ - -
//COSTA MESA,CA . Zip: 92626 - - . ,
(4//(/ N // - - -
Contractor. j) Y
Address: N //////2/' j' \.
,v% .
j> -'' Phone: _ -
i
is/( ";/: Zip: ; ,
n'! ' /, /� License:.
'Arch/Eng i.. ,/ . -I- i
Address: ,..
-� Phone: -
/; /�•/I Sa
_
Zip: -
License: .
�.� SCOPE OF PERMIT
/ " i T/O EXIST AND REROOF"W/,1/2 OSB,AND MUNCIER CEDAR LITE TILE UNDER 6 PSI .ICBO#
ER2093 - - , '
.• , FEE-SUMMARY,',
Plan Check: , $0.00 __ . = Calc Valuation: - $19,350.00
'Permit: " $287.25 ' - /�/ Claim Valuation: $19,350.00
`SMIPRes: $1.94 - / - '
SMTP Cont-, ',4$1.94
$0.00 .
',;. Other.'y A'$0.00 -
Inspection: $0.00 ,
r
\Total: - .$289:19; - -
'
`v'- : \<�, PLANNING &ZONING - '
.
.
SETBACKS -
MAIN STRUCTURE Front 0-0:- ; Rear 0-0 Left 0-0 Right 0-0
ACCESSORY Front \' 0=0•'- Rear - "0-0 Left • 0-0 Right 0-0
\
PARKING Existing: 0 - Required: 0 Proposed: 0
NOTES:
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)7545626
DECLAWAICONS - Lr
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
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'corn satiorj.lnsurance carrier and policy number are:
Carrier: • rTh Policy Number:01M-- (4-117 (Co W
(This section need not be completed U the permit Is valued at one hundred dollars($100)or less.)
❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers'
compensation laws of California,and ree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
ly with these provisi ^� •---g �(_,j�
plicant S' ature: GIA�f felttNL OF L�DAEVT.J ate: / /
WARNING:FAILURE TO SE WORKERS' NSATION COVE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000).IN ADDITION TO THE COST OF COMPS SATION,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 licensed under pr visions 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.Lic.# " Class# e S
)CC. y:tura: , 11FgPrte'- of L&Lti FrA4.0 Date: 7;2
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 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 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 and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,I.e.-properly 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 AdminlstratNe 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 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 epermit 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 CJ 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 agencis 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
B (If"yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: . Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection.
9çLoe9&owner( cliz Authorized-Apli Date
CODE 6 INSPECTION TYPE QSII MESS CODEf INSPFCTInn TYPF Deg 90IDAL5
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 711-791 210 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
2446-46
vVYIMO, UbLUV, M. D. Sin"' ; c.7-uv
JOB ADDRESS 1881 Tahiti Drive BUILDING PERMIT NO. 25476
GENERAL CONTRACTOR Owner-Builder DESCRIPTION OF WORK Residence w/att.garage
IAP No. 139-412-N+ LOT TRACT FIRE ZONE VALUE $300703.00
NSPECTIONS ignature Date GROUP I&J TYPE V ZONE R-1
oil S g-,(6-1.4. PERMITS ISSUED
Gas - SUBCONTRACTOR I Date I Number I Signature
Water I , PI ',bin_
Rough Plumbing 2 .�� /a _, - - lid
Prop. Swr. Line 'house Con. rn /j a -a2 : a f/f�J//f�i�J/ �jLll�t♦ 5
Sprinkling System I /
Miscellaneous
Rough Heating and Air Conditioning ✓/i f 4/15-'66
_Lr.1J
Temporary Service or Pole ,15" l
Underground 0 Power
Rough Wiring {'//!/m 712.)- c Heating d Vent. __ _
Trenches® Forms p Steel Reinf. 0 yj'/jfc y/,o/Fc
Floor System Ato.Z-. v,/,.,./G6 IlligIll
Bond Beam 0 Steel Reinforce ❑
Sheathing 0I# t-/.,y(l„u
Frame and Flas W_
Lathing— In a 6'ut d/$ G/8�4 o - 6/� �;
Plaster, Brown Coat
phi
////1J (// /
Structural, Final i� U/�P. Electric
Heating, Vent., Refrig. and A.C., 1 S 7--1,2- i'' y_ 4/44 .CjB' 5
Plumbing, Final and Gas Test i i -/(, r-/- /c/_(6ol g6 -
Electric, Final i t C
Building, Final /}. C cc
•
25476 /+ TA 1�/
COSTA MESA BUILDING-SAFETY DEPARTMENT CITY OF CS MESA
P.O. BOX 1209 COSTA MESA, CALIFORNIA 92626 -
For Applicant to FW In Completely APPLICtitrl RlrIFT
TYPE OR PRINT "�JI[p ��0000
BUILDING /88/ T 14/I r For Office Use Only
ADDRESS 17.194 Hi
![R T�E ,
COSTA /MEES�SA, /CALIFORNIA ---- 1{Jr ��GAI' TS _ �YJ E/ �o
�A CILi.. a. C. 6a . REC[I DOY &T. 3V-(OBI _ i9DCL
OWNER IYL-S..
MAIL H
T11IA-FYBUILDING
ADDRESS
ADDRESSFIRE
CITY � oaT61//2�'L ZONE
NO.
TYPE V OROUSJdi/
APPROVED ?trig DATE�-zq ‘ARCHITECT
EL BY
NT9.
ZONING
ADDRESS _ ZONE' 7 NEWS40
CONTRACTOR 6wu�L /'{�� I NO.O!PLANS C...--- BUILDING
USE Or BUILDING p
-
LEGAL LOT / / Y�L 3
ADDRESS DESCRIPTION
CITY A.P.NO. i37 - "1/a -p9
NOTE: NO EAVE OVERHANG SHALL BE LESS THAN
C.NO. ZO 8 4t— TEL
NO.EL BO'TO SIDE a REAR P.L.
EAVES
SIZE Sa4 I -6 1�� ( No.OF .O ALLOWED (U.B.C.REQUIREMENT)
OF LOT NOW ON IAT
USE OP YARDS APPROVED YARDS APPROVED
UOIN
F BLDG. �CAJe MAIN BUILDING ACCESSORY BUILDING
•
(FROM C/L STREIT
SETBACK LINE FROM 3D I IFRONT4
`J FT, RT.
CENTER OF arrant REAR YARD _
SIDE YARD I LETT K I I RIGHT `� , R.*IDE £_T. Fr.
DESCRIPTION( OF WORK L.BIDE �_!T. FT.
I /�- ALTERATION ADDITION REAR PT. FT.
DISTANCE BET. BET.MAIN&
BLDG*.
REPAIR MOVING DEMOLISH
MAIN BLDG*. ACCESS.
DATE
Dr"Dr" 'L 20
cfs ROOMS C.�` STORIES ' CAV•P.#
J ) APPROVED
ECOVERING RIOR WA La/b‘89 I ROOF COVERING WMA .. IPXlROV[DC///I/�� DATE3'3" W— Ce
USE OF BUILD HG AND WORK TO e[P[RfORM[D� 1)ULLL/ fL�U LK`ZJ//Y�L'L.�N�+ ttcllUllc�Mclv1S a
CcsstoGD.ree 4' APT- , N
7
c-2-2 O3� �•AC-
I HEREBY ACKNOWLEDGE THAT.1 HAVE READ THIS APPLICATION THE AMOUNT SHO UNDER VALUATION 18 FOR THE G
AND STATE THAT THE ABOVE.18 ECT AND AGREE TO COM• PURPOSE Or ESTABLISHING A PERMIT FEZ ONLY.
PLY WITH ALL CITY ORDINANCES AND ST WS REGULATING VALUATIONBUILDING 9
SIGNATURE O CONSTRUCTION.".../.......4`///J(C��`;�. PERMIT FEE 5
PERMITTEE
Sjv "l5 R N� i /`e) g
APLAN CHECK S (� -7 w
AUTHORIZED AGENT / V s/� r(�
TOTAL FEE /,J