HomeMy WebLinkAbout573 19TH ST - Building Permits^ 2%R%f3
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�COSfA MESA BUILDINCrSAFETY DEPARTMEM'
� P.O. 60X 1200 COSTA ME8A� CALIFORNIA V2E2!
For App11mM fo Flll In ComplNoly
TYPE OR PRINT
ADDRBDY 3� , �Th. f,
COSTA MESA, CALIFORNIA
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DEC-1-67Cq5f,00 014 � 40.
ArPLICATION fOR PERMR
BUILDINfi
For Offlce Us� Only �\ _
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1�[C[II� HO. �[11MIT NO. \ I�
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OPLOT•K�O-:•. ( •.(' �. C• ...HOWONIAT • ' .••.�.•
/7 T YARD6MPROVED YARDBAPPROV6G
EXISI'INO BLDO. '/� P'� O f� , n�• J • MAIN BUILDINO ACCH880RY BUILOINO
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IIIDSYAR LEFT � . . .RIONT N.�81D P7.
. DESCRIPTION;OP �WORK� - : . �.e�o ' rr. -- �rr.
� ALTHRATION . � ADDITION. RHAR !R.
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- � '� ' � ' - DI@TANC! 06T. BET. MAIN Q
REPAIR '� MOVINO � �� �'' DQMOLI p MAIN BLDOY. ACCE69. BLDO/B.
euaoiNc �: .. .�•Nc6'c� - -�-^ . . vue.tF�. � •� ��J :cwrs��: �/�C.,o 6
IIIZH - �O . ROOMH � - BfOHI � T C. . . C �� � / APPROVGD � �
BXTCRIORWA - ..ROOP - n'�P��^ iA�R /
COVERINO - D COVERINO `�li � T[ I —�l0
UY[�O�oul IN � W011K.MBtP[ r0 GD ( .. '� � � p,
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1 H[P60Y ACKNOWL�DO[ iXAT.I NI1V6 qfAD YXI� AI►LIGTON TMl A YNT �NOWry UHD[R VALUATIOH 1! �OP TXf �
AND BTAT6 TXI�T T11[ ApOV{,IG CORP6CY AND AOM[t TO CAY. 'URPOs[ O! CdTAOLIGNINO A P[FMIT P8[ ONLY.
VLY WITX ALL CITY ORDINANCO A(�G tTA7i {AW� 11[OYMTNO yALUATION �
CYILOINOeOHHiRIlCT10 /�� !i%7 /�-� �
PHRMITTB Q Or ^li/��.�/1 j}y�� �/ V PHRMIT FEH �% �(/v �
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AUTMORIZ[DAOQNL L�� / /,�p.50
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Conditions: : . . . . -- - - � "— � - -- - - _ �
� . � . -
. , . . .
1.'�Tree pla.nting'compatible with the area. ,
- 2. Construct car�ercial sidewalks and� concrete 'drive approach on -' ;
. W. 19th Street.at.spplicant!s expense�_per_standard , '
spe.cifications o£,;ttie City of Costa Mesa. " .
3. -Provide a 16' mini.mum driveuay. - .- .
4. Applicant tb tak�e out Building Permits and'bring existing
building up to code. . -' "- - i
5• Hlacktop drivexay and parking area as_shown, to include'." '
striping. . , I
6. That the fronb 10' be landscaped.under the.direction of the"
Planning Director in place of parking ,S�ace �/$.
7. ,That a'rear entrance beeprovided to the co�ercial area for '
easy access-from the�parking lot:� - - ,
I 8. That a sigri "parking in the reer" be instaLled under the_ i
direction�of.t&e Di'rector of Planning:•, � '
� ,'
9.:,;Clear all weeds and organic matter that would present a fire
'hazard�on:the property.
10. Must meet all�conditions of Uniform_Fire Code arid Title 19. J
e-•M . . - . _._ - - -- - - -- � — - - - - -. .- — _ � . - - ` _ ._ - - _ - - �.
- - -�-_..------ --- ------------ . - —_ ,-- —,- -- - � �-. .-- ',
- . -- . .- -- -- � ;- -- - - -- -,-- - � . - - -' - --- -- ' -- --- - - - i .
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ApD�icant to till in all spaees except thosa within heavy �oraer Iines antl sign all approv��ate aeclarations.
CITV OF COSTA�MESA7 �CO�N�S�TRUCT/yIO,,�N�,P/ERMIT
Project Addreis ��L, �L �• %%/lY" 5%-
Applicant's Mailing AQ(Jress
Owner's Name - ' Phone
Address
Arch/Eng. License No.
Address ��y� /
Contracto 's Na ���D� � ryi[ �- Pho e b l i
Addresslm'�� „� 3� '!�� �
City License No �6
LICENSED CONTRACTOR DECLARATION
1 h¢reby af(irm Mat I am licensetl untle� ptovisions of Charter 9(commencing
with section 7000) of Division 3 of the Business antl Professions Cotle, antl
my license is in full fo e ect. /.``
� License�la � ' License No �(O f i0 �
Date F<_ 5'g t
� WORKERS' COMPENSATION �ECLARATION
� hereby affirm tnat I have a certificate of consent to self-insure or.a certi4icate
, "Workers' Compensation Insurance, or a certifie cop th?/$p f tion
]0. Lab. `�%�7/D� ��C1'(/ �•:
olicy No. Company ��
8 Certifietl opy' herebyfumishetl.
Cer ietl i5 � wrth the city BuiI�DiYision.
Date' APplicant
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(This section neetl no[ be com0�etetl if the permit i5 fo� One huntlretl ($300) o�
less).
I certify that in the performance of the work for which. chis perm�t is issuetl, I
shall not employ any person �in any mannet so as to become subject to the.
Workers' Compensation Laws of California.
Date Signature
NOTICE: It, after makin9 this aeclaration, you shoultl become subject to the
Workers' Compensdtion 0/ovi5ion5 ot the LabOr Cotl¢, you must forthwith
comply with such' p�ovisions or Ihis p¢rmlt shall be tleemetl revoketl.
GONSTRUCTION LENDING AGENCV �
I hereby a(9rm that tnere is a construction lentling agency for the per/ormance
ot the work'tor which this permit is issuetl (SeGtion 3097 Civ. C.)
Ltntler's Name
L.entler.s AUtlress
OWNER BUIL�ER DECLARATION
I hereby a(flrm that I am examp[ t�om'the Contracto�'S License Law tor the
followin9 reason (Section ]031.5 Business antl Profe55ional Cotla: Any ciry or
county which iequires a pe�mit to construct, alter, improve, tlemOlish o� repair
any structure, prior to Its issuance, also requires tne applicant tor such permit
to file a signetl statement that he/she is licensetl pur5udnt to the p�ovi5ion5�0f
the Gontractor's License Law (Chapter 9(commencin9 �+itn Section ]000) of
Division-3 ot-the-Business-antl�ProtessionsCotle)-or that°he/she irexempt
;�y`„herefrom and the Ibasis tor the alleqetl exemption. AnY violation ot Section
'�q�;031.5 by any applicant for a permit subjects the applicant to a civil
. tnalty of nof more than five huntl�etl tlollavs ($500�. � ,
�"L7 1, as owner ot the property or my employees with wages as their sole
compensation, wi11 tlo the work, antl the structure is not intenaetl or otferetl
for sale (Section 7044, Basiness,antl Professional Cotle: The Contractor'S
� License Law tloes not appty [o an owner ot a property who builtls or improves
tnereon, antl who tloes such work himseli/herselt or through his or her own
employees, provitletl tnat such improvements are nof intentletl or offeretl tor
Sale. It, howeve�, tne builtling or imp�ovement I5 soltl within one yea� of com-
pletion, the owner will have the bu�tlen Of p�oving he/She tlitl not builtl or im-
prove for the purpose oi sale).
❑ I, ai owner of the property, am exUusively contracting with licensed con-
tractorsto con5truct the pro7ect (Section 7044, Busine55 antl Protessions Cotle:
The Contractor's License Law tloes not apply to an owner oi property wno
builtls or improves tbereon, antl who mnVacts fo� su<h D�ojects with a con-
tractor(s) li[en5e pursuant to tFle ContractOr'S License Ldv/). � am dware that
proot �of lheit Wo�ker'S Compenzation insu�ance shoultl be provitletl to me.
❑' I am exempt untler Section B. & P. C. for this reason
Date - Owner
I hereby certify that I have reatl this application and state that the above
iniormation is correct. I agree to comply with all city antl county ortlinances
antl state laws relating to buildin9 consVucti , antl hereby authorize repre-
sentatives of this city to enter upon t bove-mentionetl� propert or
inspectlon purposes. � /� L ��
Si9nature Daie h
Drivers' License or 55 �
TYPE OF�CONSTRUCTION �NEW LJ ADD LJ ALTERATION LI REPAIR
❑ �CONVERSION ❑ DEMOLISH ❑ OTHER q p # •
DESCRIPTION OF WORK/USE OF BLDG. �
�- S Main Buildi
TVPE OF PERMIT � GRAOING ❑ FOUrvDATiO ❑ STRUCTURAL T Front
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING �MECHANICAL B Rear -
❑ OTHER %�
PROJEC7 DESCRIPTION SQ. FT. OCCUPANCV C Right
K Left
CON�STRUCTIONTVPE VALUATION$ $
ZONE GRADING CU. VDS. ACRES p�ng. Ref. #
Remarks: R� l GJ �',,,j , . Planning Notes:
Preventer
Dishwasher
Drinking.Fountains .
FloorDrains -
Floor Sinks
GasService � Outlets
Interceptors �
Kitchen Sink �
Lavatories �
P-Trap
Roof Drains
Reinspec[ion' Fee
$15
Duct - Under Ground
Duct - Structural
Duct - Ventilating
�aQ¢t System ❑ Multiple
irepl/Fact Blt. ICBO #
Heating System & Ducting
�0.100,000 BTU �100,000
Rainspectian Fee � $75
CMF OBfiS-46, rev. 10/84 White - Builtling; Canary - Applicant; Pink - Accounting: Goltlenrotl - Assassor
PLUMBING
$hOW¢f5
Service Sink �
Sewer Cap
Sewer Connection
Solar Collectors
Solar Piping -
Solar Tank
Swimming Pool w/Spa
Urinal
Water Closet . •
� Water Heater �
Water Service
Auto-Wash '
Laundrv Trevs
Issue Fee
Hood or� Type I ❑
CanOPY� TYPeII ❑
Refrigeration System
❑0-t00,0006TU ❑100,000
System Repair/Alteration
Fire Dampers -
Registers
laue Fee
FEES
$ 3
ES
$ 3
E
Automatic Washer
ConstructionPoleSub. �
Cooking Unit ' �,
Dishwasher
Dryers �Gas �Electric
Fan
F.A,U.
Fixtures
Device Boxes �
Outlets
Switches
Garbage Disposal
Generator �0�5 KW �5-15 KW
,0271 E/^c4/^o7
Zone
Accessory Building:
Parking Req./Provided
Transtormer ❑ 15�50 KW
❑50+KW '
Meter ❑up to 100amps '
Meter �over 100 amps
Sub Panel
Motors OO-1 HP O1'/: - 8
Inc.Solar �9-75 HP �16-15+
Pole Light
Range
Standing Sections
Trash Compactor
I�LoS. , TL
FEES
Z
O
N
I
N
G
R
E
Q
M
T
S
� Reinspection Fee � �$15 � � luue Fee � $ 3'
DEVELOPMENTSERVICESRE�UIREMENTS: � -
Zoning Approved By Date
Building Approved By Date
Appliwtion Issued By Date �o Zy�'/�
SUMMARV OF FEES
BUILDING PEfiMIT $ SMIP $
PLAN CHECK $ - PERMIT '
PLUMBING ' $ ISSUANCE $
PIAN CHECK 25% $ _ ENERGV P.C. $
� ELECTRICAL- $ � GRADING $
. PLAN CHECK 50% $ �1�— MICROFILM $
MECHANICAL $ ����� TOTALFEE $ �OO_Sl�
PLAN CHECK 25% $ ��%. Lv � ,
/Q � J1
CONSTRUCTION AND PLANNING � POOL & SPA� •
APPROVALS Permit# Date Inspector qppROVALS Permit# Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. S[eel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical tJFER Grnd. , 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit�Undrgrnd. .
8. Foundation 59. Gas Pipe, O Undrgrnd., Test ,
"9. N/ater Pipe-Undrgrnd�. 60. Backwash Lines, P-Trap, O Undrgmd.
10. Structural Floor System 61. APPROVAL TO DECK '
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final , .
1�3. Roof Drains 64. Plumbing SYstem - Final
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Finaf , -
16. Rough Electric Wiring . 67. Fencing & Access Approval
17. Rough Wiring Sign - � 68. APPROVED FOR PLASTERING
18. Rough Electricgl-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL '.
19. Rough Heati�& Air Conditioning FIRE DEPT. REQUIREMENT ..
20. Rough Factory Fireplace APPROVALS Permit # _ �
21. Ducts, in Structure ' ' . 70. Underground Hydro ' "
22. Ducts, Ventilating 71. Product Piping � Gas ❑ Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.StorageTank OGas ❑Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structuraq & Monocoat - 75. Dry Chemical ,
27. Frame and Flashing 76. Dry Standpipe �� �
28. Lathing & Siding 77. FIXED SYSTEM FINAL � �
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION '
32. Electrical Power Meter�Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric = Notes:�'�.Z2•88 ��Qml� �LKPI�Q�.0 Q6 �ft+e_
34. Final Heating�& Air Conditioning �Q3 /� V KG (,.6�
35. Final Gas Pipe-Test
36.�Hood or Canopy ' �
I
37,�cFinal Factory Fireplace - , - � / �I
38: Final Plumbing � ' � �
39. Water Service-Final . ' , , .
'40. Gas Service-Final '
`
�41. Solar pomesticFinal '. - %, �
t
• •42. Backflow Preventer � - � ' ' _
.
43:�Backflow Irrigation ' ' ` � � '
44. landscape Irrigation System � �- �
45. Sound Attenuation � ' �
. �, . �
46. Handicap Regulations � � „
i i
47. FINALSTRUCTURE&BUILDING ^ � �'� • �'-'
� a✓
48. Special Requirements Completed � �. ,
49. Electric Release to Edison ' '�
50. Gas Release to Southem California Gas Co � , /
51. CERTIFICATE OF OCCUPqNCY
No. Date
\
�
�`�
' Applicant to fill in all soacez except those witnin heavy Dortler lines and si9n aIl approvriate tleclarations.
Cirv oP COSTa MESA CONSTRUCTION P RMIT PER IT NO TRACT NO. LOT NO. UNIT,NG.
_f--73 �. i ��ss�- � � g9 as�
Project Adtlress '
Applicant's Mailing Address TVPE OF.CONSTRUCTION EW ADD ALTERATION REPAI R
❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P. #
Owner's Name ��A/�6 � �/LQ��phone DESCRIPTION OP WORK/USE OF BLDG. � �
Address
, Arch/Eng: License No.
I Address
�� Convacror's Nam S yl�- Phone• l
Addreu (mailing) �.
City License No 6 •%��
LICENSED CONTRACTOR DECLARATION '
1 hereby affirm tbat I am licensetl untler provislons of Charter 9(commencing
with sec[ion �000) of Dlvision 3 01 the Business antl Pro/ession5 Cotle, antl
my license is in fup fy�F e@ct. /
Licens I s. � t% ��cense No.�6 �p �
Date ���� �
WORKERS' COMPENSATION DECLA0.ATION
�ereby aflirm Ihat I have a cCrtificate of consent to sel6lnsure or a certiil�te
Workers' Compensation Insurance, or a certifletllof��pj �$e,;t�pn
.00, lab. - K /�G! G
PoliGy No. �c 9�71Q,� COmpany
8 Certitietl copy hereby fumishetl. �
Cert' i�jj,ca 5' with tha city Buil ivision.
Date� ` AOPi�tant i
EXEMNION FROM WORKERS' COMPENSATION DECLARATION
(Thissection neetl not be Comple[¢tl if the pe�mit is for one huntlretl ($300) or
Iess).
1 cer�i(y that in the perto�mance of the wo�k for which thls pe�m�t is ISSuetl, I
shall not employ any peRon in any manner so as to become subject to the
Workers' Compensation Laws of Califomia.
�ate� - Signature
NOTICE: If, after making this tl¢Claration,.you shoultl become subject tD the
Workers' Comp¢n5ation provi5ion5 Ot lhe Labor Cotle, you must forthwith
comply wi[h such proNsions or this permit shall b¢ tleemetl revoked.
CONSTRVCTION LENDING AGENCV �
I hereby at(I�m [hat there is a construction I¢ntling agency for Ihe pertoimance
ot ehe work for which this permit is issuetl (Section 3a97 Civ. C.)
Lentler's Name
LenOer's Atltlress � _
OWNER BUILOER �ECIARATION
I hereby a(firm that I am exempt trom the Cont�attor'S LicenSe Law for the
following reason (Seotion 7031.5 Business anC Protessional Cotle: Any ciry or
counry which requires a permit [o construct, alter, Improve, Eemolish or repair
any sVucture, prior to its issuance, also requires the applicant for such permit
to file a Signetl statement that he/she is licensetl pu�suant to the 0/ovisions of
the Con[ractor'z License Law (Chapter 9(commencing with Section ]000) of
Dlvision 3 of'the Bu5ine55 antl Prote55ions Cotle) or that he/she is ezempt
lheretrom antl tM1e basis for the allegetl exemption. Any vlolation of Section
J031.5 by any applicant fo� a pe�mit subjects tbC applicant to a civil
penalty o( not more than five huntlretl tlollars (y500).
LJ I, as owner o( the property or my employeez with wages as their zole
compensation, will tlo the work, antl tne structure is not intentletl or otferetl
tor sal¢ (Section ]044, Business,antl PrOf¢s5ional Cotle: The Contractor's
License Law tloes not apply to an owner o( a property who bWltls or improves
thefeon, antl who tloes such work himself/herself or through his or her own
employ ees, prOvitletl lhal suth imprOv¢men[5 are not intentled or offerea for
SdIB. Il, however, the builtling or ImO�ovement is Soltl wilhin one year of com-
pletlon, th¢ owner will hdve th¢ burtlen Of proving h¢/She tlitl not builtl or Im-
prove fot the purpose ot sale).
❑ I, as owner of lhe Droper[y, am exclusively contracting witn IlcenSetl con-
t�actors to consttuct lhe ptoject (Sec[lon ]044, Business antl P�ofassions Cotle:
The Contrattor's License Law tloes nol apply to an owner of proPerW who
builas or fmproves thereon, antl wM10 contracts for su<h projacts witn a con-
tractor(s) bcense pursuant to the ConVactor's License Law�. 1 am aware that
proof o( their Worker's Compensation insurance shoultl be provitletl to me.
❑ I am ex¢mpt untler 5ection B. & P. C. for th15 reason
Date pwner
I hereby certity that I have reaE
information is correcL I agree to �
antl 5tate laws relating to bulltlinc
sentativas of tnis city to enter
insvection purposes. `—
Signature
Drivers' Licensc or 55 �
a
t
' S Main Buildi
TYPEOFPERMIT GRADING FOUNDATIO STRUCTURAL � T F�ont
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING �MECHANICAL ' B Reaf
❑ OTHER A
PROJECT DESCRIPTION 5p. F7. OCCVanrvCv C Right
K Left
CONSTRUCTIONTVPE VALUATION$ $
ZONE GRADING CU. VDS. ACRES Ping. R2f. #
Remarks: � � � Gj � � � � Pianning Notes:
Backflow Preventer
Backflow Irrigation
Clari(iBrs
Drinking Fountains
Floor Drains '
Floor Sinks
Gas Service OuUets
Interceptors
Kitchen Sink . _
P—Trap
Roof Drains
Reinspec[ion Fee � $15
Boiler
Duct - Under Ground
Duct - Structural
Duct - Ventilating
�x�ust System ❑ Multiple
F irepl/Fact. Blt. I CBO #
Heating System & Ducting
❑ ai oo,000 sTu O i oo.000
Showers
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
Solar Piping
Solar Tank
Swimming Pool w/Spa'
Urinal
Water Closet
Water Heater
Water Service
Auto-Wash
� Issue Fee
Hood or Typel ❑
Canopy Typell ❑
Re(rigeration Sys[em
❑0.100,OOOBTU ❑100,000
System Repair/Alteration
Fire Dampers
Registers •
Reinspection Fee � $75 � � luue Fee
FEES
Automatic Washer
Construction Pole
Caoking Unit
Dishwasher -
Dryers ❑Gas ❑
F,A.U.
Fixtures
Device Bozes
Outlets
Switches
Gar6age Disposal
Generator �0.5 KW
�272 fi/24/97
�
—�Zone
Accessory Building:
Parking Req./Provided
ELECTRICAL
Transtormer � 15�50 KW
❑ 50+KW
Meter ❑up to 100 amps -
Meter �over 100amps
Sub Panel
Motors �61 HP 01 X- B
Inc.Solar �9-15 HP �16-15+
Microwave
Pole Li9ht
Range
' I Standing Sections
75 KW Trash Compactor
$ 3 I
�— Rainspectian Fee $15 luue Fee
FEES
DEVELOPMENT SERVICES REQUIREMENTS:
Zoning Approved By
' Building Approved By �
�Appliwtion Issued Bv
$ 3
BUILDING PERMIT $
PLAN CHECK $
PLUMBING $
PLAN CHECK 25% $
ELECTRICAL 5
PLAN CHECK 50% $
MECHANICAL $
P�AN CHECK 25% $
IC�o50 TL
Z
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1
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Q
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S
FEES
$ 3
SUMMARV,OF FEES , �
SMIP $
PERMIT
ISSUANCE $
ENERGY P.C. $
GRADING $
�� MICROFILM $ / �
�.l `"` TOTAL FEE $ �r a• �
CMF 0865-46, �ev. 30/84 Wnite - Bulltling; Canary - Applicant: Plnk - Accounting; Goltlanrotl - A5se55or ���(]ff _) D�r � j D!��
CONSTRUCTION AND PLANNING POOL & SPA
APPROVALS Permit # Date Inspector AppROVALS Permit # Date Inspector
1.�Temporary Electrical Service or Pole 52. Pool & Equipment Location.
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Elec[rical Condui[-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings � 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, � Undrgrnd.
10. Structural Floor System � 67. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final
13. Roof Drains 64. Plumbing System - Final
74. Rough Plumbing 65. Efectrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign � 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT �
20. Rough Factory Fireplace APPROVALS Permit # .�,
21. Ducts, in Structure 70. Underground Hydro `�
22. Ducts, Ventilating 71. Product Piping OGas OOiI �
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd. Storage Tank O Gas ❑ Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing � 76. Dry Standpipe
.
28. Lathing & Siding 77. FIXED SYSTEM FINAL '
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION '
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes:�2•ZZ•ee ,�RI+Gt• �.,I�PIR�iO � (pfi�,
34. Final Heating;& Air Conditioning 30b � UML. LrE�A
35. Final Gas Pipe-Test
36.,,Hood or Canopy �
37� Final Factory Fireplace . • . •`
38. Final Plumbing . . �
�
39. Water Service-Final � ' .
�
/40. Gas Service-Final , .
41. Solar pomestic-Final - - - . .
� 42. Backflow Preventer � ' . �
43. Backtlow Irrigation • � �
: 44. Landscape Irrigation System �
i
45. Sound Attenuation , . . � �
46. Handicap Regulations - • �� � � �_ . �
47. FINAL STRUCTURE & BUILDING . � , ' �
48. Special Requirements Completed .
49. Elearic Release to Edison •� �
50. Gas Release to Southern Califomia Gas Co �. -
51. CERTIFICATE OF OCCUPANCY
No. Date . .
1
ACD�ieant to fill in all spaces except those within heavy oorae� lines ana sl9n all av�roo�iate tleciarations.
CITY oF COSTA MESA CONST/RUCTIO PERMIT
Projec[ Address � �� • / �� S%
Applicant's Mailing AQdress
Owner's Name L/ i,� o.� .2a Phone
Address
Arch/Eng: License No.
Address /��.�l
Contractor'sName �'6� A/��'�/y�/�. �Ptin,,,,�66 lf
Address (m �i� � �� �1f'�a�-�J_��
City �icense No. ' � /5 7�/
LILENSED CONTRAC70R DEGLARATION '
I hereby affirm [hat 1 am Iicens@tl untler provisions of C�arter 9 �commencing
with section �000) of Division 3 of the Business antl Profe55ion5 Cotle, antl
my licenso is in tull for ntl ¢�(. �� �/
Licens [la(s ✓ cen5e No.
Date L SlgnatLrp
WORKERS' COMPENSATION 4ECLARATION
hereby attirm that I have a cerqficate ot consent to self-Insure or a certJflcate
Workers' Compensa[ion In54ranGe, Or a certi�i coDYu���(��tion
d00, Lab. C �j ���'.�7
Policy IVo. �� /(� �,� Compan��_i�._.�/
BCer ifietl cop is hereby (umishetl. N�C ��
C tifr¢Af y' ' tl wl[� the city Buil i on.
Oate L' APPlican[
E%EMPTION FROM WORKER$' COMPENSATION DECLARATION
(TnisSectiOn neetl not b¢ comple(¢tl If the ptrmit is for One huntlr¢tl (§300) or
icsg.
I certily that in NC Per(ormanCq ot Ihe wo�k fo� wltich this pCrm�t is I55ueQ I
snall not employ any person in any manner so as to become subject to the
Work¢r5' Compensation Laws of Califomia.
Date Si9�atwe
NOTICE: I/, atter making tnis tleclarallon. You shoultl become subject to the
Workets' Compensation p�ovisiOns of the Labo� Cotle, you mus� forthwitM1
comply with such provislons or tnis permit shall be tleemeA revoketl.
CONSTRUCTION LENDING AGENCV '
I ne�eby afthm that there is a coqstruction lentling agency fo� the pertormance
of the work for wbich this permi[ is issuetl (Sec[ion 3097 Civ. C.)
Lentler's Name
Lantlet's Atltlre55
OWNER BUILpER pECLARAT�ON
I hereby afiirm that 1 am exempt irom the Contractor'S Li<ense �aw for the
follOwing rea5on (Settiori 7031.5 Bu5ine5s antl ProteSsional Cotle: Any city or
county which requires a permil to conztruct, alteq improve, tlemolish or repair
any 5t�ucWre, p�ior to It5 i55Uaqce, also requires [he applicant for Such pe�mit
to til¢ a signetl statement that 4e/she iSlicen5etl pur5udnt fOlhe provlsioq5 0(
the Contracror's License Law (Chapter 9,(commencing with Seclion �000) ot
Division 3 of the Buslness antl Professions Cotle) or tha[ he/she is exempt
Iheretrom antl the basis tor the alleqetl exempHon. Any violation of Section
]031.5 by any applican[ for a permit subjects the applicant [o a civil
[enalty o/ not more than five M1untlretl tlollars ($500).
L.J I, ds Owner of the O�operty Or my employees with waqes as their Sole
Compensation, will tlo Ihe work antl the structu�e is not in[antletl or offeretl
for Sale (SeCtion 7044, Businet5 antl Protessional Cotl¢: The �Contractor's
�icense L'uw tloes not apply [o an owner ot a property wbo bulltls or improves
the�eon, antl who tloes such wprk hlmself/M1e�self or through hi5 or he� own
employeei, provitletl Ihal Such Improvement5 are not int¢ntletl or offored (or
snle. If, M1oweveq the bui101nq or imp�ovement i5 soltl within one year of com-
pletioq the owner will have tne burtlen of provin9 ne/she tlitl not builtl or im-
prove tor tne purpose ot sale).
❑ 1, as owner of the property, am exclusively contracting wilh Ilcensetl con-
tfactOrS t0 Cons�fucl the project (Saclion ]044, Busin¢55 dntl Prof¢Silons Cotle:
The ConVactor's License Law tloCs not apply to an owner of p�operty who
builtl5 or Improves tp¢reon, antl who cOntract5 for Such proj¢Ct5 with a con-
tracmr(s) ucense pursuant m the Contractor's License Law). 1 am aware that
prOot of their Worker's Compensatlon insurance shoultl be P�ovitletl to me.
❑ I am exempt under Section— B. & P. C. 1or this redson
Date
I nereDy certi(y that I
information i5 Correct. I
antl slate laws relating t
Sentatives ot thi5 city
inspec[Ion pu�pases.
Signature
Drivers' Llcense or 55 �
Ownor
v¢ rBetl this application antl State [hat the above
ree �V comply wl[h all city antl county ortlinances
builtli�g C struCtion, antl he�eby aulhoriie repre-
nter n the above-menHonee propCrty }or
_ ,,,,a ��—ZS�-�
TVPE OFCONSTRUCTION �S.NEW U ADD LJ ALTERATION IJ REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHER q.p, #
DESCFiIPTIONOFWORK/USEOFBLDG. �
S Main Buildi
E
TVPEOF�PERMIT GRADING FOVNDATIOry, STRVCTURAL T Front
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING '$ ECHANICAI A Rear
❑ OTHER C Ri9ht
PROJECT DESCRIPTION Sq. F7. oCCUParvCv K
CONSTRUCTIONTVPE VALUATION$ g Left
ZONE� GRADINGCU.VDS. ACRES p Rf#
Remarks:
In9. e .
`� � Planniny Notes:
3eckflow Irrigation
9athtubs
Clarifiers .
Dishwdsher
Dririking Fountains
Floor Drains ' '
Floor Sinks
3as Service Outlets
Interceptors �
Kitchen Sink _
Lavatories
P—Trap
Root Drains
Reinspectio� Fee $15
Boiler
Duct- Under Ground
Dutt - Structural
Duct - Ventilating
�x�ust System ❑ Multiple
Firepl/Fact. Blt. IC60 #
Heating System & Ducting
❑0.100,000 BTU �100,000
Showers
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
Solar Pipin9
Solar Tank
Swimming Pool w/Spa
Urinal
Water Closet
Water Heater
Wa[er Service'
Auto-Wash
Laundrv Travs
Issue Fee
Hood or Typel ❑
Canopy Typell �
Refrigeration System
❑0-100,OOOBTU ❑100,000
System Repair/Alteration
Fire Dampers
Registers �
Reinspection Fee � $15 � � laue Fee
CMF 0865-46, rev. 10/84 White - Builtling; Canary - Applicant Plnk - Accountin9: Goltlenrotl - Assessor
FEES
$ 3
$ 3
Automatic Washer
Construction Pole Sub.
Cooking Unit
Dishwasher
Dryers �Gas ❑Electric
, Oz73 5/24/�7
Zone +
Accessory Builtling:
' Parking Fieq./Provided
ELECTRICAL �
Transformer ❑ 75-50 KW
❑ 50+KW
Meter ❑up to 100 amps
Meter ❑over 100amps
Fan
F.A.U. '
Fixtures
Device Boxes
Outlets
Switches
Garbage Dispoul
Generator �65 KW 05-15 KW
Sub Panel
Motors � 41 HP � i h- 8
InaSolar 09-15 HP �i6-15+
Microwave
Pole Light
Range
Sign
Standing Sections
Trash Compacror
I Reinspection Fee �$15 ' I luue Fee
DEVELOPMENT SERVICES REQUIREMENTS:
2onin9 APProved By
Buitding Approved By
._ n
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FEES
$ 3
Z
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SUMMARV OF FEES
BUILDING PEFMIT $ SMIP $
PLAN CHECK $ PERMIT
PLUMBING $ ISSUANCE � $
PLAN CHECK 25% $ ENERGV P.C. $
ELECTRICAL $ GRADING �5
PLAN CHECK 50% $ �;� � MICROFILM $
MECHANICAL $ _Sl_L_ TOTAL FEE $ .�O ��O
PLANCHECK 25% $ 7-I-CJO � •
/08�s
CONSTRUCTION AND PLANNING POOL & SPA �
APPROVALS Permit # Date Inspector AppROVALS Permit # Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe�Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility�Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plurribing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. �Footings 1 58�. Electrical Conduit-Undrgrnd.
. 8. Foundation � 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trep, O Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap - 63. Heater & Vent-Final �
13. Roof Drains 64. Plumbing System - Final .
14. Rough Plumbing � 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final '
16. Rough Electric Wiring . - 67. Fencing & Access Approval �
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL '
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT ,
20. Rough FactorY Fireplace . APPROVALS Permit # _
21. Ducts, in Structure 70. Underground Hydro �
22. Ducts, Ventilating � 71. Product Piping OGas ❑Oil
23. Gas Pipe-Rough & Test 72. Underground Flush �
24. Roof Framing 73. Undergrnd.StorageTank �Gas OOiI �
25. Roof Sheathing , 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Stanclpipe '
28. Lathing & Siding 77. FIXED SYSTEM FINAL ��� �
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing , � HEALTH DEPT. REQUIREMENT
' 37. Plaster Brown Coat � , 79. FINAL INSPECTION .
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes: �L'ZL•8e �"R�/wR- �i�Rpi�� � P�i- "
34. Final Heating�& Air Conditioning aQb p (/•ML L•�ip
35. Final Gas Pip'e,'-Test
36. Hood or Canopy .
37.• Final Factory Fireplace . . .
38. Final Plumbing . .
.39.' Water Service-Final , ', '
40. Gas Service-Final .� ..
41. Solar pomestic-Final � , ' �
�42. BackflowPreventer , � ' ' �
�
�43. Backflow Irrigation � � � �' •
44. Landscape Irrigation System . • - iy �'� �
45. Sound Attenuation , � � ` � �
46. Handicap Regulations � ' ' ` ' �
�• .
47. FINALSTRUCTURE&BUILDING . -�
48. Special Requirements Completed �-� _ • .
49. Electric Release to Edison ,�_ � "
50. Gas Release to Southern California Gas Co �
U'
51. CERTIFICATE OF OCCUPANCY �
No. Date �
CITY OF COSTA MESA CONS7RU/CTI�ON, /PECRM7�I�T
Project Address �%� � • / �/ TI- J � •
Applican['s Ma{�{ng Address
Owner's Name �� hone �
Address
Arch/Eng. License No.
Address
Contraccor's Nam hon �
Address Imailingl
City License Np, _� CS ��/
LICENSED CONTRACTOR DECLARATION
I bereby atlirm tha� I am Iiconsed untler provisions of C�artar 9 �commencing
wifh sectlon ]000) of Dlvislon 3 of t�a Business antl Professions Cotle, antl
my Ilcense is In tu11 /or a il ct. �
Licens9� las Icense rvo��
. Oate 6 Sig t
WORKERS' OMPENSATION DEGLARATION
' hereby alfirm tha[ I havn a cerHBca[a Of conient to SeHansure or a cor�lica[e
(� Workers' CompanSaUon Insuranta, or a certi(i c DY lhp� oj j59ttlon
V 100. Lab. 1 � U YJGY `'
�ollcy No, ���7�� / Company
BCertiilea cop is nereby tumisnetl.
Cer fie i wlth the Uty Builtling IQn.
Dat¢ Applicant
EXEMPTION FROM WORKERS' COMPENSA710N DECLARATION
(Thissection negtl not be completetl if tha parmit is for one buntlred (E100) or
less).
I certity litat in the pe�formance of the wo�k to� which this Oermit iSlssuetl, I
snall not employ any person in any manner so as to become subject to the
Workers' Compqnsation Laws of Califomia.
Date 5igndtur¢
NOTICE: If, aiter making this tleclaration, you shoultl be<ome subject to lne
Workers' CompenzatiOn Provi5ion5 01 tne labor Cotlo, you must forthwilh
comply wlth Such provlsion5 or thi5 permlt Shall be tlaeTetl ravoketl.
CONSTRVCTION LENDING AGENCV
I M1ereby affirm that Inere Is a Construction lentling agency for (ha pertormanGe
of [he wark tor whiGh thiz p¢rTit iz ISSuetl (SectlOn 309] Civ. G.)
Lentler's Name
Lentler'S AOtlreSz
OWNER BUILbER OECLARATION
I hereby aHirm that 1 am exempt from the Contractor's License l.aw for the
tollowing r¢asOn (Section ]031.5 BuSiness antl Profe551onal Cotle� Any city or
county which /epuires d ptrTit [o const�ucl, alter, improve, tlemolish Or �epai�
any struclure, prior to its Issuance, also requires the applicant (or such permit
[o file a Si9netl statement that he/she is Ilcensetl pur5udnt t0 [he provi5ion5 of
the Con[ractor's License Law (Chapter 9(commencinq witn Section ]000) o(
Division 3 of the Busine55 antl Professions•Cotle) or [hat ne/she is exempt
`hereirom antl the basiz for the allegetl exemption. Any vlolalion of Sectlon
!031.5 by any applicant Por a permit subjects the appliGdnt [o a civil
�enalty o( not rnore [han liva huntlretl tlollari �5500).
I, ai own¢r ot the prOpG/ly or my ¢rt�ployees wlth wa9eS a5 thei� Sole
Comp¢nsa[iOn, Will tlo the wo�k, antl [hu st�uclure is not in[entletl o� oltEretl
tor sale (Settibn 7044, Bu57n¢ss antl Pr01lSSional Cotle: The Contractor'S
License 1., w tl4e5 not apply to an owner ot a O�operty who builtls or improves
lhe�eon, antl wh0 tloes such w0/k hiTself/ner521f o� through pis Or h2r own
employea5, provltletl that such Improvemenls are not Intentlotl or offeretl for
zale. M, howaver, Ihe bullding or improvement i55oltl wlthin one year of com-
plelion, Ihe Owne� wlll bav¢ the burtlep Of prOving h¢/s�e tlltl no[ builtl or Im-
prova for tho pUroose ol sale).
❑ 1, as owner of the prop¢rty, am exCluSively cont�acting with IlcenSetl COn-
vactorito cons�ruct tho project (Section 7044, Business antl Professions'Cotle:
The ConVactor�s License Law tloes not appty to an owner of property who
builtls or.lmoroves lh¢reon, ana who contracts lor such pro7ects with a con-
tractor(sl Imenge pu�suant to the ConlYac[o�'s LicenSe Ww). I am dwaro [hat
proof O( tbllr yyorker'S Compensalion InSuranc¢ shOultl be ProvltleC t0 mG.
❑ I am ezemo� untler Section B. 6 P. C. tor this roason
Date
I her¢by cerllly that ,
informatlon is Correct.
antl state laws relating
zentatives ol this city
InSpC<tlon pulpO5e5.
Slgnature
Drivers' Ucenso or 55 9
. Owner _
have reatl this
O owm�ng c9n
op��cant to fill in all spaces exceDt those witnin heavY Dortler Iines ane slgn all aporopriate tleclarations.
PE TJ�O�^�� TRACTNO. LOTNO. UNIiL,�
oc 'r ti-,
TYP^E OF CONSTRUCTION EW ADD ALTEFATION REPAI R
U CONVERSION ❑ DEMOLISH ❑ OTHER q,p, #
� DESCflIPTION OF WOqK/USE OF BLDG. - $ Main Buildi
E
TVPEOFPERMIT GRADING FOUNDA7lory STRUC7URa� T Front
� ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ya mECHANICAL 6 Rear
❑ OTHER A
PROJECT DESCRIPTION 5q. FT. oCCUPANCv C Right
K
CONSTRUCTION TVPE VALUATION $ g Left
ZONE' GRADING CU.YDS. ACRES Ping, fleL #
pemarks: Planning Notes:
P � PLUMBING FEES
aOPlication antl State that tho above
ly wltn all clty antl county ortlinancos
structlon antl hereby au[horizc ropro-
i tho above�mnnHoneA property far
� Daie '_{a L� ��
♦�
Preventer
Irrigation
Dishwasher
Drinking Founlains
Floor Drains
Floor Sinks
Gas Service Outlets
Kitchen Sink
L'avatories
P—Trap
Roof Drains
Reinspection Fae
UnAer Graund
Strucmral
$15
Eyhqist System ❑ Multiple ❑
� pl/Fact. Blt. �CBO #
Heating System & Ducting
❑ 0� 7 00,000 BTU � 100,000 BTi
Reinspection Fee � 575
— _ _�
CMF 0865-46, r¢v. 30/84 White - BUIltling; Canary - Appliwnt; Pink � HC<Ountin9; GOItlBnrOtl - ASSe550r
Shawers
Service Sink �
Sewer Cap
Sewer Connectian
$olar Collectors
Solar Piping
Solar Tank
Swimming Pool w/Spa
Urinal
Water Closet
Water Heater
Water Service
Auto-Wash
laue Fee
Hood or Typel ❑
Canopy Typell ❑
Refrigeration SVs[em
❑0-100,0008TU 0100,000
Syztem RepairlAlteration
Fire Dampers
Registers
laue Fee
$ 3
$ 3
/aUtomatic Washer
ConstruttiOn Pole Sub.
Cooking Unit
D ishwasher
Dryers ❑Gas ❑Eleci
Fan .
F.A.U.
Fixtures
Device Boxes
Outlets
Switches -
Garbage Dispoul
Generator O65 KW C
0274 E/24/?7
Zone
Acceuory Bui
ELECTRICAL �
Transformer ❑ 15-50 KW
❑ 50+KW
5KW
Meter LJup to 100 amps
Meter �over100amps ' �
Sub Panel
Motors�]0.7 HP01Y,-8
Inc. Solar �9�15 HP �i6-15+
Microwave
Pole Light
Fange
Sign
Standing $ections
Trash Compactor
4CFle�" TL
FEES
2
O
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I
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G
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�
M
T
S
I Rainspection Fee I$15 I I Issue Fee � $ 3'
DEVELOPMENT SERVICES RE�UIREMENTS:
2oning App�oved By Date
Building Approved By Data
Appl'raYon la ed By Dat�
SUMMARV OF FEES
BUI�DING PERMIT $ SMIP $
P44N CHECK $ PERMIT
PLUMBING 5 �SSUANCE $
PLAN CHECK 25% $ ENERG�' P.C. $
ELECTRICAL 5 GRADING $
PLAN CHECK 50% $ MICROFILM $
MECHANICAL 5 '�� TOTAL FEE 5 � ' a�
PLAN CHECK Z57b $ �j u �
/O d.oJ
CONSTRUCTION AND PLANNING POOI & SPA
APPROVALS Permit# Date Inspector qppROVALS Permit# Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit�Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe�Undrgrnd. - 60. Backwash Lines, P-Trap, O Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
17. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final -
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing 65. Electria�l-Final
15. Rough Electrical-Conduit 66. Solar System-Final '
16. Rough Electric Wiring 67. Fencing & Access Approval �
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAI
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT �
20. Rough Factory Fireplace APPROVALS Permit # _ '
21. Ducts, in Structure 70. Underground Hydro '
22. Ducts, Ventilating 77. Produtt Piping O Gas ❑ Oil
� 23: Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing � 73. Undergrnd.StorageTank OGas ❑Oil
25. Roof Sheathing 74. Ovenc�ad Hydro �
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
.F
28. Lathing & Siding 77. FIXED SYSTEM FINAL '
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing � HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION ��
32. Electriral Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes:(Z.j�-88 �,�YjMr �lL„(�i(�t0 �r6 ��
34. Final Heating & Air Conditioning aoa p V�. L�
35. Final Gas Pipe-Test
36. Hood or Canopy , '
37�•_Final Factory Fireplace •
38: Final Plumbing . r � ' �
39. Water Service-Final � '" , .
40. Gas Service-Final � ,
,41. Solar pomestic-Final ' '" ' ' � �
., �' �.
' 42. Backflow Preventer , % , �
:�
, 43. Backflow Irrigation -
94. Landscape Irrigation System +' �
45. Sound Attenua[ion � ' �- ' '
46. �Handicap Regulations � � " . �
47. FINALSTRUCTURE&BUILDING •; ' • . . ,
48. Special Requirements Completed � , � .
49. Electric Release to Edison , ' •
50. Gas Release to Southem California Gas Co „� C
51. CERTIFICATE OF OCCUPANCY
No. Date ,
��
a
AOP���ant to /ill in all sDaees except those within heavy Oortler lines ana sign all aporo0riate tleclarations.
CITv oF COSTn nnESA C/� /NSTRUC�T,c�IOfN PERMIT �
Project Address y�%� �'V • �91 ✓� i'%�
Applicant's Mailin Addre�s
Owner's Name 2Q ' Phone
Address
A�ch/Eng. � License No.
Address
Contractor's Nama D� � �_Phon
� Address (mailing) •
City License No. 3 � ���
LICENSED CONTRACTOR DECIARATION �
1 hereby atlirm inat 1 am Iicensatl unUer provisloqs oi Charter 9(commencing
witn saction 7000) ol Divlilon 3 ot the Bu51n ss antl Professlons Cotle, antl
my Iicense Is In lull jTce �tecL �,, ,,^ /
� LiC¢f159. CIdST �� ; i�ens0 NO.y 4a/��"�V
oate `�Z�_ aona���. : �
WORKERS' COMPENSATION DECLARA ION
I hereDy alli�m lha� 1 have a ttrti/icate ot consent (O SBlbinsu�o Or a certlflcate
il Workers' ComCpenutfon� suranco, or a CertHip.tl cypy tn�e��(cuon
800. Lab. � B F 1DU1� •
Poli<y No. � Company
8 C¢rtlfiGE cOpY is h¢reby furMShBtl. �_, �j �
Cer[ 'etl c is i with the city Builtling DI sion.
Date APPlicanl
E X E M P T I ON R OM W O R K E R S' C O M � E N S A T I q N D E C L A R A T I O N
(This soctiOn neetl not �e cOmpletetl ii Ihe Olrmit I5 for one huntlrOtl (5300) or
less):
I C¢rtify lhal In the p¢rfOrmdnGe o( the wo�k fo� �ynich t�ls DOrm�t IS ISSuetl, I
s�all not emo�oy any person in any manner so as to become su�ject [o the
Workers' ComOe�sation Laws of CalHornia.
Date Si9nature
NOT.ICE: If, atter making this tleclaration, you sryoultl become zub�ect to the
work¢rs' Compeniation provisions of the Labor Coae, you must forthwith
comply with such, provisions or tnis permil shall ba deamaC revoketl.
CONSTRUCTION LENDING AGENCV
I hereby atflrm that there is a constructlon Ientling agency ior the pertormance
ot the work for w�ich this permit I5 ISiuetl (SeCtion 309] Civ. C.)
Lentler'i Name
Lentler's Atltlress
OWNER BUIL�EH DECLARATION
i here0y atlirm thal I am exampt from tne Contractor's LicenSe law for the
tollowing �ea50n (Settion 7031.5 Buslness antl Ptp/¢ssional Cotle: Any city or
county which requires a permit to construtt, alter, improve, tlemollsh or repair
any 5[ructure, p�io� lo its issuance, dlio rGquires tne applicanl (or such permit
to tile a Slgnetl Statem¢nt that he/ihe I5 Ilcensetl pursuanl f0 lh¢ provisions ot
the Cantractor's License Law (Chapter 9(tommehcing with SecHon 7000) of
Division 3 of Ihe BuSiness-antl Protes5ion5 Cotl¢)-pr thdt h¢/SM1e is exempt
therefrom antl t�e basis for the allegetl exemptibn. Any violation of Section
]031.5 by any applicant tOr a p¢rTit subjec(s the applicant to d Civil
�endlty of not more thdn live huntlretl t1011ars (SSpp),
I, as owne� ot th¢ prope�ly o� my em0loy¢¢5 with waqas as thei� sole
compen5ation, wi11 tlo the work, antl the structure Is not IntenAetl or oiferetl
(or sa10 ($ection ]044, Bu5ine55 antl Professional Cotle: The Conl�ac[o�'S
License Law tloes not aoPN to an owner of a pronerty who bulltls or improves
�hereon, ana wlta tloe5 SUCh wOrk hlTselt/he�5ell or throu9n his 0/ he� own
em0�oy ee5, prOvitletl tha[ such ImprOvemenl5 are nof Intonde0 or ofi0retl for
sale. If, however, the builtling or improvoment Is soltl within one year ot mm-
plation, tne owner will have the burtlnn ot proving he/she altl not builtl or Im-
prOVG iot thG pu�pose of sale).
❑ I, as own¢r o� tne pro0erty, am ¢xcluSlvely cpnt�acling with IlGtnsetl con-
tlactoR [O conSVuct the PrOjecl ($Bctlon 7044, BU5ine55 antl Profe55ion5 Cotle:
The ConlrattOr's License Law tloGs not apply to an ownar ol properly who
builtls or Improvos ttte�eon, antl wh0 conl�acts fo� such p�ojOCts wilh a con-
Irat[Or(51 I¢ense pursuant [o U@ �onVacto�'s Li�¢�s¢ ��y), I dm awa�e tttat
o�oor o( their Worke�'s CompensatiOn InSuranCB shoultl be Orovlaetl to me.
❑ I am exempt untler Sectlon B. & P. G �or this reason
Date
I hereby <crtily that I
informatlon is corract.
antl sta[e laws relating
sentativas ol thii city
InSpeCUon purposes.
$igpdtur!
Drivers' Licensa or 55 q
Owner _
have reatl lhis
TYPE OFCONSTRUCTION '�{.NEW U ADD U ALTERATION U REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.p..�
DESCRIPTION OF WORK/USE OF BLDG. -
� - S Main Building:
E
TVPE OF PERMIT GRADING FOUNDATI� STRUCTURAL T Front
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ECHANICAL B Rear
❑ OTHER %�
PROJECT DESCRIPTION 50. F7. OCCUPArvGv C Right
K Left
CONSTRUCTIONTVPE VALUATION$ S
ZONE GRADING CV. VDS. ACRES Ping. REf.'lF
Ramarks:' g . Planning Notes:
Bar Sink
Preventer
Irrigation
Drinking Fountains
Floor Drains
Floar Sinks
Gas Service Ouclets
1 nterceprors
Kitchen Sink
P—Trap
Roof Droins
Reinspection Fee � $15
Boiler
Duct - Under Ground
DUCI - $LfuCtuf21
Duct - Ventilating
�h�a s[ SyStem ❑ Mulliple ❑
Firepl/Fact. Blt. ICBO 51t
Heating System & Ducting
❑6100,000 BTU 0100,0008T
Reinspection Fee � 515
CMF 0865-46, rev. 30/04 White - Bulltling; Canary - qppllcant; Plnk � Accounting; Goltlenrotl - Assessor
Showers
Servite Sink
Sewer Cap
Sewer Connection
Solar Collectors �
Solar Piping
Solar Tank
Swimming Po01 wlSpa
Urindl
Water Closet �
Water Heater
Water Service
Auto-Wash
Laundry Trays
Isue Fee
Hood or Typel ❑
Canapy Typell ❑
Refrigeration System
❑aioo,000eTu Oioo,000
System Repair/Alteration
Fire Dempers �
Registers
laue Fee
$ 3
r:
$ 3
0275 E/2l/°7
Zone
Accessory Building:
Parking Req./Provided
ELECTRICAL
Automatic Washer 7rans(ormer ❑ 15�50 KW
Construction Pole Sub. ❑ 50 + KW
Cooking Unit Meter ❑up to 100 amps
Dishwasher Meter pover 100amps
Dryers ❑Gas ❑Electric Sub Panel
Fan Motors �0�1 HP �1 h- 8
F.A.U. Inc. Solar 09�15 HP �76�
Fixtures Microwave
Device Boxes Pole Light �
Outlets Ran9e
Switches
Gar6age Dispoul
Generetor �0.5 KW �5-15 KW
Standing Sections
Trash Compactor
5+
E:�oU TL
FEES
Z
O
N
1
N
G
R
E
�
M
T
S
I Reinspection Fee I$75 I � luue Fee � $ 3 �
DEVELOPMENT SERVICES RE�UIREMENTS:
Zoning Approved By Date �
BuildinB APP�oved By Date��j�'�j
AppliwtiDn IAued By nata_�O-F
SUMMARV OF FEES
BUILDING PERMIT $ SMIP S
PI.AN CHECK $ PERMIT
PLUMBING $ - ISSUANCE $
PLAN CHECK 25% $ ENERGV P.C. $
ELECTRICAL § GRADING S
PLAN CHECK 50% S �— MICROFILM $
MECHANICAL $ 5�• V9 TOTAL FEE s 63. �a�
PLAN CHECK 25% $ I Z..>>
6 3,7r e
CONSTRUCTION AND PLANNING POOL & SPA
APPROVALS Permit # Date Inspector qppROVALS Permit # Date Inspector
7. ;Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. � 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Ro�gh Plumbing & Pressure Test
6. Electrical UFER Grntl. 57. APPROVAL TO COVER•GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, O Undrgrnd., Test
� 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, O Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
� 12. Sewer Cap 63. Heater & Vent-Final
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final
75. Rough Electrical-Conduit 66. Solar SYstem-Final
16. Rough Electric Wiring - 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL �
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace �APPROVALS Permit # �
21. Ducts, in Structure 70. Underground Hydro � �
22. Ducts, Ventilating 71. Product Piping OGas ❑Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd. Storage Tank O Gas ❑ Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical .
27. Frame and Flashing 76. Ury Standpipe � �
28. Lathing & Siding 77. FIXED SYSTEM FINAL r
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION .
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric : Notes:12•2Z•�0 ��!'�/�T �jf,� Q6 �i,�-
34. Final Heating.& Air Conditioning �3 � v�.(� L.�,.p
35. Final Gas Pipe-Test ,
36. Hood or Canopy
37. Final Factory Fireplace '
38��Final Plum6ing ' ,i
39: Water Service-Final . �
r40. Gas Service-Final , �
41. Solar pomestic-Final . � , . .
�42. Backflow Preventer � •
43. Backflow Irrigation � • i
.
�44. Landscape Irrigation System . �
45.�Sound Attenuation � '
46. Handicap Regulations .' ' , � - '
47. FINAL STRUCTURE & BUILDING ' . ,
48. Special Requirements Completed � � . .
49. Electric Release to Edison � ' �
50. Gas Release to Southern California Gas Co ��'
51. CERTIFICATE OF OCCUPANCY
No. Date .
Aovlicant to fill in all svaces ezcept tliose within neavY bortler lines antl si9n all aporopriate tlaelaratlons.
CITYOFCOSTAMESA CO/�N�S�TRUCTIONPERMIT
Project Address �C 7� W. � 9T�.:.s%-
Applicant'S Mailing Address '
Owner's Name L��A/L� �/ZD� . Phone
Address T
A�ch/Eng: License No.
Address /
COntracto' N � Q�e%-i�w��i J"r/1/%� Pho e�,(�V�/ ��
Address �mailingl—=sx:6 �� • �'�' %���'� /�sl L-�C.I
City License No. ,3p 7 f/ �
�ICENSED CONTRACTOR DEGLARATION
� hereby affirm that 1 am licensetl untler provisions o1 Charter 9(commencin9
with section 7000) ot Oivision 3 oT the 9usiness antl Pro(essionz Cotle, antl
mY license is in full fp�ce a ef ct.
IJcens�.Clas ��/ license No.��
I Date {-, � 5'g t ' .
'ORKERS' COMPENSATION DECLARATION
ereby a(Iirm that I have a certificate of mnsent to selt-insure or a certifiw[e
Workers' Compensetion Insurance, or a certifipSl c�U pJeof (�ection
'800. `�° `�G`2d 7/6.� ComPany K �LG �
PolicY No.
❑ Certifietl co is hereby furNshetl. _
p Cer (leq P�g1�Qtl with the city BuilGing,B on.
pa[e ' f�� qpplican[
�XEMFTION FROM WORKERS' COMPENSH ION DECLARATION
(This section neetl not be tampleted It fhe permit is tor one huntlred ($100) or
IB55).
� certify [hat in the perfOrmanG< of th¢ woYk for whlch this p¢�m�t is i55uetl, I
snall not employ any person in any manner so as to become subject to tne
Workers' ComPensatlon LawS'of Cali/ornia.
Oate Signature
NOTICE: It,after making this Geclarafiun, you ehnultl becoma zu�iect to tha
Wotkers' Compen5ali0� P�ovisio05 of th¢ ldbor Co�e. You mu5t forthwith
cOmply witn svth plovi5ion5 Or this pe/mit Shall be tleem¢tl revoketl.
CONSTRUCTION LENOING AGENCV
I he�eby afiirm that [here is a construction lentling agency for the Oer�ormance
O� Ihe work tor which thi5 Permit' Is i55ueE (Section 3091 Civ. CJ
Lentler's Name
Lentler's AtldreSs
QWNER BVILpER UECLARATION
� hereby a/lirm that I am exempt from the Cantractor's License Law tor tne
ipllowing reason (Section ]031.5 Business antl Professlonal Cotle: Any tl[y or
county which requires a permit to construci, alter, Improve, tlemolish or repav
any siructure, prior to �ts issuance, also requlres the appilcant tor sucn perm�t
to ��le a signetl statement that ne/she is lic¢nsetl purivant to the provisions of
�pe Contractor's License Law (Chaptet 9(commencM9 �+'�th $action ]000) of
pivision 3 of the Business and Professions Cotla) or that ne/sne is axemp[
;perefrom antl the ba5i5 fov [he dll¢getl exemption. A�Y violatio0 of Section
703L5 by any appliGant fo� a Permit subjects tha appliGant to a clvil
penafty of no4 more than tHe huntlretl tlollars ($5�U).
[7 I, as owner ot the property or my emPioyees with wa9es as their sole
cPmpensation, will tlo the work, antl the sVucture is not intentled or offeretl
for sale (Section 7044, Business ana Pro(essional Cotle: The Contractor's
�icense Law tloes n0l aPPly [o an Owne� o( a praperty who bulltl5 or improves
�pereon, antl wno tloes such wo�k himselt/herseli or Ihrou9h his or her own
emp�oyees, providetl lhac su<h improvements are not Mtentletl o� otteretl tor
�le. If, however, the builtling or Improvemant is soltl wiihin one year oi com-
pletlon, the owner wlll have the burtlen oi provin9 he/she tlitl not builtl or im-
�rova for Ine Purpose o� sale).
I, as owner of [he pro0erry, am exclusively con[ractin9 wi[h licensetl con-
tractors td construct the project (Section ]044, euslnezs antl Professions Cotle:
7hn GOntracto�'S l_iConie C.aw dOeS not apply to an owner ut property who
builtls or Improve5 llte/eon, dntl who mntracts to� such projects with a cOn-
Vactor(sl ncense-pursuant to the Contractor's License Law). I am aware tnat
pfoot oi [heir Worker's Compenia[ion insurance shoultl bo provitlatl to me.
❑ I am exempt untler Section B. & P. C. for this reason
OA�e
� hereby certi/y that
intormatiOn 15 corract.
antl state laws relating
sentatives of this tlty
irt6Pection purposes,
Si9nature
D/ivers' License or 55 q
CMF 0865-46, rev. 10/84
Owner
have read thi5 application antl state that the aDove.
agree to comply wlth all tlty antl cOunty ordlnanCeS
o buildi�j9 const�uGtlon, antl h¢reby autho�iz¢ repre-
tQ�piq/ upon Ihe above-mentioned property (or
/` �-� �-��� �ta Z ��
N► agya� � �-. ���ys c
TYPE OF,CONSTRUCTION NEW ADD ALTERATION REPAIR
❑ CONVERSION ❑ �EMOLISH ❑ OTHER
DESCRIPTI�N OF WORK(USE OF BI.DG.
TVPE OF PERMIT GRAOING FOUNDATIO 57RVCTURAL
❑ TENANT ❑ ELECTRICAL' ❑ PLUMBING �MECHANICAL
❑ OTHER
PROJECT DESCRIPTION � 5�. FT. OccUPANCv ,
CONSTRUCTION TYPE VALUATION $
ZONE GRADINGCV.VDS. ACRES
ReTarks: ,
Sink
Preventer
Irrigation
rinking Fountains
loor Drains
loor $ink5
as Service Outlets
Kitchen Sink
Lavatories
P—Trap
Roof Dreins
Showers
Service Sink �
Sewef Cap
Sewer Connection
Solar Collectors
Solar Pipin9 � �
Solar Tank
Swimming Pool w/Spa
Urinal
Water Closet
Water Heater
Water Service .
Auto-Wash
Reinspection Fae � $75 � � laue Fee � a 3
Duct - Under Ground
Duct - Structural
Duct - Ventilating
f�icb�ust System ❑ Multiple ❑
�Firepl/Fact Blt. ICBO #
Heating Syitem & Ducting
❑0.100,000 BTU O100,0008T
Reinspection Fee � $15
White - BWltling; Canary - Applicanh Pink - Accountlpg; Goltlenrotl - ASS¢SSor
Hood or Typel ❑
Canopy Typell ❑
Refrigeration System
❑aioo,00asru ❑iao,oaoaT
System Repair/Alteration
Fire Dampers
Registers
Issue Fee
A.P. �`-
S Main Building:
E
T Front
A Rear
C Right
g Left
Ping. Ref. �(k
Plannin9 Notes:
Auromatic Washer
Construction Pole Sub.
CoOking Unit
Dishwasher �
Dryers �Gas ❑Elecfric
Fan
F.A.U. '
Fixtures
Device Boxes
Outlets
� �]276 6/2l/c7 . j�^am 7�
ZOne
AccessoryBuilding' '
Z
O
N
I
- N
G
R
. Parking Req./Provided E
Q
M
T
S
ELECTRICAL .
Transformer. � 75�50 KW
- . ❑50+KW'.
Merer �up t0 100 amps
Merer ❑over100amps
Sub Panel
Motors�0-1 HP 01'f.-8
� � Inc.Solar 09-15 HP �16-75+
Microwave
Pole light
Range
Garbage Dispoul I I Standing Sections
Generator �0-5 KW �5-15 KW Trash Gompactor
Reinspection fee $15 luue Fee
FEES
�DEVELOPMENT SERVICES REQUIREMENTS:
2oning Approved By
Buildin8 APf+roved By
Aooliwtion Issued BY n
$ 3
FEES
$ 3
SUMMARV OF FEES '
BUILDING PERMIT $ SMIP _ $
PLAN CHECK $ PERMIT
PLUMBING $ ISSUANCE $ �
PLAN CHECK �25% $ ENERGV P.C. $
ELECTRICAL $ GRADING -�$
PLAN CHECK 50% $ MICFOFILM $
MECHANICAL $ • v `� TOTAL FEE $ �! ' ��
PLAN CHECK 25% $ ��-� . C1J
��a.'l7
CONSTRUCTION AND PLANNING POOL & SPA '
APPROVALS Permit # Date � Inspector ppPROVALS Permit # Date Inspector
1._Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms � .
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test � �
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings � 58. Electrical Conduit-Undrgrnd.
�8.�Foundation � 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgrnd. .' , 60. Backwash Lines, P�Trap, O Undrgrnd.
10. Structural Floor SYstem 67. APPROVAL TO DECK '
11. PropertY Sewer Line & House Connection 62. Backwash & Receptor-Final �
12. Sewer Cap 63. Heater & Vent-Final �
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing � 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
16. Rough Electric Wiring � 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL '�
19. Rough Heating�& Air Conditioning FIRE DEPT. REQUIREMENT �
i
20. Rough Factory Fireplace APPROVALS Permit# �
21. Ducts, in Structure � 70. Underground Hydro '
22. Ducts, Ventilating 71. Product Piping O Gas OOiI
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Unde�grnd.StorageTank OGas ❑Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (StPuctural) & Monocoat � 75. Dry Chemical .
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding � � 77. FIXED SYSTEM FINAL � �t�
29. Insulation 78. FIRE PREV. FINAL '�
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION '
32. Electrical Power Meter-Final ' 80. FOOD CERTIFICATE ISSUED
33. Final Electric � tes:�$•Z'L' SO R.��T��1Q�a �(a(�_ '
34. Final Heating & Air Conditioning •��� p. vM�. (�•E�
35. Final Gas Pipe:T,est
�
36. Hood or Canopy
37..Final Factory Fireplace � "�l
38�. Final Plumbing � ' ' '
39.' Water Service-Final � . • � �
r
' 40. Gas Service-Final � '
� 41. Solar pomestic-Final �� , �'
' 42. Backflow Preventer . , [ , ; . � �. "
�43. Backflow Irrigation . � � �
;'44. Landscape Irriqatlon System � �
, . �
45! Sound Attenuation ' . ''� ' •
.r
46. Handicap Regulations -� �• r � � � '
47. FINAL STRUCTURE & BUILDING . . f�
48. Special Requirements Completed ;� `� � ;� . � .
49. Elearic Release to Edison � � ' '
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
�
Applicant to flll in a11 spaees eicept those within neavy eortler iines ana sign ali aDo/aPriaie aeclarations.
CITY OF COSTA MrESA CONSTRUoCfTION PERMIT PFR�IT NO. .. TRACT NQ LOT NO. IIN1T NO
ProjectAddress y %� �• �!� -c+%`
, Applicant's Mailing Address � '
Owner's Name �fy �6x✓ %�i0 %! ' Phone
Address
Arch/Eng. License No.
Address /�
Contractor's Name �2a,�/ �/� Phone
Address�mailing)��D�.� �
City License No. _3� 7� �
LICENSED CONTRACTOR DECLARATION
I her¢by a(firm that I am lit¢nzetl untle� provl5lon5 of Cha�te� 9(commencing
with section ]000) of Division 3 ot Ih¢ Bu5ine5i antl Professions Cotle, antl
my license is in full rt eitecL . '/
Licenzg Cla����f �—Littnse No.�A.� �
Date�_ � � ��+� .a y �
WORKERS' COMP NSATION DECIARATION
I hereby at�irm that I have a certiticate oi mnsent to self-insure or a certjiicate
M Work¢rs' Compensation Insu�ante, or d certlfi tl th�eJ�eo} ($Bctlon
800, Lab. ��^��/p4�C/
�olicy No. �G 9,�7/a 3 Company i���y}q�
8 Certifietl copy is hereby iurnizhetl.
Cer /ietl i with the city Builtlin9 Divis�r
Date�� Applicant
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(Thissectlon neetl no[ be cOmple[Ctl if the permit IS for one hUntlretl ($300) or
less).
I certi(y thal In tne pe�lo�mance O( the wo�k tor which tnis pe�m�t Is Issuetl, I
shall not employ any pe�son In any mann¢r So a5 to become subj¢Ct to the
Work¢rs' Compenzdtion LawS o( Califomia.
Date Signature
NOTICE: If,atter making this Ge<laration, you3houltl become subject to tne.
Workers' Compensation provisions of the Labor Cotle, you must torthwith
comply with suctt p�ovisions or this permit Shall be tleemetl revoketl.
CONSTRUCTION LENDING AGENCV
I hereby af(irm lhat there is a construction lentling aqency for Ihe pertormante
of Ihe work for which this permit is issued (Section 3097 Civ. C.)
lRntler's Name
Lentler's AEtlress
OWNER BUILDER �ECLARATION �
I hereby affirm that I am exemo� from the Contractor•s License l.aw tor the
Tollowinq reason (Seccion 7031.5 Business antl Professlonal Cotle: Any city or
county which requires a p¢rmil to construct, alte�, improve, tlemOliSn o� repab
any scructure, prior ta Its issuance, also req Wres lhe applicant tor sucn permit
to /ile a si9netl sta[ement that he/she is IicenS¢tl pursuant to the Orovisions ot
the Contractor's License Law (Cnapter 9(commencing with 5ectiOn 7000) of
Division 3 of the Business antl Profezsions Cotle) or that ne/she is exempt
tltereftom antl [he basis tor the allegetl exemOtion. Any violation of Section
p.7031.5 by any applicant for a permit subjects tM1e applicant to a civil
;;�enalty ot not more than five huntlretl tlollars (5500).
LJ I, as owner of the property or my employees with wages as tneir sole
compensation, will do the work, antl [he struc[ure I5 not intentletl Or offetetl
for sale (SecUon 7044, Business antl Professional Cotle: The Contractor's
License Law tloes not apply to an Owner Of a O�ope�ty who builtl5 or Imp�oves
thereon, an� who tloes such wo�k himselt/ne�5elt or Ihrough hi5 or ne� own
employe¢5, p�ovitletl that such improvements are not Intentletl or ott¢retl fOr
sale. If, nowever, the buil0ing o� improvement is soltl within one year o1 com-
pletion, th¢ owner will have Ihe burtlen of proving he/she tlitl no[ builtl or im-
p�ova for the Ou�pose of 5ale�. �
❑ I, as owner of the property, am exclusively contractin9 with Ilcensatl con-
trattors to construct the projec[ (Section ]004, Business and Professions Cotle:
The Contractor's License Law d0¢5 no[ apply t0 an owner of property who
builtls or improves ihereon, and who contracts for such projects with a con-
traCtor(51 I�cense pu�suant'to the Conttacto�'s Ucense L.aw). I am aware that
proot of tlteir Worker'S Compensation insu�ance Shoultl b¢ provitletl to me.
❑ I am axempt untler Section B. & P. C. lor this reason
Date � Owner
1 hereby certify that I have rea
inf0/ma[iOn is Wrr¢tL.l agree to
Inspectlon Ou�poses.
Si9nature
Drivers' Limnse or 55 =
tl tnis applicatlon antl ztate tbdt tne above
comply wi[M1 all clty antl Counly o�tllnant¢5
�9 �onstruction, antl hereby aut�orize repre-
upon the above-mentionetl /P'roperty (o�7
' Date —N ���/
��
0
TVPE OF CONSTRUCTION Q`J�NEW U AOD L1 ALTERATION
%4-B
RE7AIR
❑ CONVERSION ❑�DEMOLISH ❑ OTHER q,p,�6
DESCRIPTIONOFWORK/USEOFBLDG. �
� - S Main Building:
E
TVPEOFPERMIT GRADING FOVNDATIO STRVCTVRAL T Front
❑ TENANT ❑ ELECTRICAL ❑ PLVMBING �MECHANICAL A Reaf
❑ OTHER C Right
PROJECT,DESCRIPTION 5c�. F7. oCCUaANcv K
CONSTRVCTIONTVPE VALUATION$ S Left
20NE GRADING CV. VDS. ACRES p�ng. Ref. #
Remarks: � • � r �f � � Planning Notes:
Preventer
Irrigation
7 Fountains
rains
Gas Service
Interceptors
Kitchen Sink
Lavarories
P—Trep
Roof Drains
ReinspeMion Fee
Outlets
$75
Boiler
Duct - Under Ground
Duct - Strucmral
Duct - Ventilating
6�a�li t System ❑ Multiple ❑
Firepl�Fact. Blt. ICBO #
Heating SVstem & Ducting
❑ ai oo,000 eru O i oo,000 ar
Reinspection Fee � S15
CMF OB65-46, rev. 10/84 White - Bulltlin9; Canary - AOP��tant: Pink - Accoun[ing; Goltlenrotl - Asussor
Showers
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
Solar Piping
Solar Tank
Swimming Pool w/Spa
Urinal
Water Closet
Water Heater
Water Service
Auto-Wash
Isue Fee
Hood or Typel �❑
Canopy Typell ❑
Refrigeration System �
❑0.700,OOOBTU ❑t00,000BTU
System Repair/Alteration
Fire Dampers •
Registers
Isua Fee
$ 3
$ 3
Auromatic Washer
Construction Pole Sub.
Cooking Unit
D ishwasher
Drvers ❑Gas ❑Electric
o��� 5/2l/E7
Zone
Accessory Building:
Parking Req./Provided
ELECTRICAL� �
Transformer ❑ 15-50 KW
❑ 50+KW
Meter ❑up to 100 amps
. Meter ❑over 100amps -
Fan
F.A.U.
Fixtures
Device Boxes
Outlets
SwitCheS
Garbage DiSpoul
Generator �65 KW OS-75 KW
Sub Panel
MotOrs�0.1 HP �i'h-6
Inc. Soiar 09-15 HP 076-15+
Microwave
Pole Light
Standing $ections
Trash Compacmr
1 Reinspection Fee I$15 � ' Issue Fee
DEVELOPMENT SERVICES REQUIREMENTS:
ZoninB Approved By
Building Approved By �
Aonlication luued BV l
IC�o2' TL
FEES
S3
2
O
N
I
N
G
R
E
�
M
T
S
SUfv1FfARV OF FEES
i BUILDINGPERMIT $ SMIP $
— PLAN CHECK $ PERMIT
PLUMBING § ' ISSUANCE S
� PLAN CHECK 25% $ ENERGY P.C. $
ELECTRICAL $ GRADING $
PLAN CHECK 50% $ MICROFILM $
MECHANICAL $ • �V TOTAL FEE $ O �O"�
PLAN CHECK 25% $ �-� . � �
X77�r�=11'r io�,�
CONSTRUCTION AND PLANNING , POOL & SPA
APPROVALS Permit # Date Inspector qppROVALS Permit #� Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
�
2. Soil Pipe-Undrgrnd. � 53. Steel Reinforcement
3. Electrical Condult Utility�Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. . 55. Electrical Bonding .
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPFOVAL TO COVER-GUNITE
7. Footings . 58. Electrical Conduit-Undrgrnd.
..8. Foundation 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgrnd: 60. Backviash Lines, P-Trap, O Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing - , 65. Electrical-Final
� 15. Rough Electrical-Conduit 66. Solar System-Final
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit # �.
21. Ducts, in Structure 70. Underground Hydro �
22. Ducts, Ventilating 71. Product Piping � Gas ❑ Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing • 73. Undergrnd. Storage Tank O Gas ❑ Oil
25: Roof Sheathing 74. Overhead Hydro � �
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe "
28. Lathing&Siding 77. FIXEDSYSTEMFINAL 4�, .\"
29. Insulation 78. FIRE PREV. FINAL '
,
30. Drywall Nailing � HEALTH DEPT. REQUIREMENT � �
31. Plaster Brown Coat � 79. FINAL INSPECTION • .
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric t tes: ,Z2.� �py�- ��� a,s PfR.
34. FinalHeating�&AirConditioning 3oa0 U•�":� i�..'���:
35. Final Gas Pipe-Test
36. Hood or Canopy �
37: Final Factory Fireplace • '
38� Final Plumbing ' d ' �
39. Water Service-Final - •
40. Gas Service-Final � , �
�. '
.41�. Solar pomestic-Final ' . ` ' ',
, +
r42. Backflow Preventer . . .
� 43. Backflow Irrigation - � � . •
� 44. Landscape Irrigation System � _ �,, �� ��� �
�45. Sound Attenuation . ' -� � �t �
�46. Handicap Regulations � � � �� ,'�1 " � '
47. FINALSTRUCTURE&BUILDING � " � ' ' . � „y
48. Special Requirements Completed . � i •
49. Electrie Release to Edison . .� '",
i
50.-Gas Release to Southern Califomia Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date _
Aoo�icant to till in ail spaees ezceo� ihose within neavY eoraer lines antl sign all aporooriate tleclarations.
ciTY oF COSTa MESA CO/JN �STRUCqTION PERMIT
Project Address �r 73 �^-' • � /� S%�
Applicant's Mailin/9 Address
Owner's Name `� /(%����_Phone
Address '
Arch/Eng. License No.
Address
Contractor's Nam �j Phone �]�'�'�`'`�
Address (mailing) 9�9 � '�' �'%�'i�.0 X7i L
CityLicenseNo. �,� �f
LICENSED CONTRACTOR PECLARATION
I hereby aftirm that I am Ilcensetl untle� provi5ion5 of Charte� 9(cartimencin9
with se[tion ]000) of �IvlsiDn 3 ot tho Business antl Profes5ion5 Lotle, antl
my Iicense is in full t rce tl tfect. �/
LJCCf15 CI 55 ICCOSB NO. (
Dateb� y 519 t �
WORKERS' COMPENSATION DECLARATION
9ereby affirm thai I have a cer[ificate of conzent to sel/-insure or a certi(icate
Worker5' Compensation Insuranca, o� a ce�tlfietl copy Gthereof (Section
.r800. Lab. ����y0 � . 2C�rD�F+LLG �
I Policy No. '7 Company �� wiN_-_ iA1/
eCertifietl copy is hereby furnishetl. D
Ce�ti ' tl c y 5 f wi[h th¢ city BUiltling ��jO�.
Oate___����� APPlitdnt ��n
EXEMPTION F OM WORK�RS' COMPENSA ION DECLARATION
(Thissection neetl not be completed if tho permit is for one huntlretl ($100) or
less).
1 certity that iq the certormartce ot the work tor wnlch this perm�t iz �ssuea, 1
shall not employ any person in any manner so as lo become subjec[ to the
Workers' Compenzation Laws ot California. �
Date Signature '
NOTICE: It, atter making this tleclaration, you shoultl become subject to tne
Worker5' COmpensation provl5ion5 of lhe Labor Cotle, you mus[ fOrthwith
compty with such provi5io05 or� thi5 Oermit Shall be tleemeG revoketl.
CONSTRUCTION LENDING P.GENCV
1 hereby a�Orm that tnere Is a construction lentlin9 a9ency for the per(ormance
o� tha work for which tM1is permit i5 izsuetl (Settian 3097 Civ. CJ
LenEer's Name
Lentler's AtlEress �
OWNER BUILDER DECLARATION '
I hereby aHl�m that 1 dm BxFmO� i�om Ihe Cont�acto�'S License Law �or the
following reason (SecHon 7031.5 Business antl Professional Cotle: Hny city or
munty whl<h requires a pe�n+�t t0 Const�uc[, alteq improve, tlemolisb o� repai�
any structure, prlor to its iss�ance, also requires [he applican[ tor such permit
[o (ile a signetl statemen[ that he/she I5 licensetl pur5uant to t�e provisiOns of
the Contractor'S License Law (Chapter 9(commencin9 with Settion 7000) of
Division 3 ot the Business antl Professions-Cotle) or that he/she is exempt
the�ef�om dntl th¢ basi5 fo� Che alleg¢tl exemption. Any viOlation o� Section
7031.5 by any applicanf tOr a permit subjetts [he applicant to a civil
'� enalty of not more than tive huntlretl tlollars (E500).
I, as owne� ot the properry or my em0loyee5 wilh wa9e5 a5 thel� sole
mmp¢nsatiOn, will tlo�the wo�k, antl th0 Struttur¢ is not intentletl Or otteretl
for sale (Sec[ion 7044, Business antl Professional Cotle: The Contractor's
LicenSe Law tloes not dpply tJ an owner of a property who builtls Or Improves
thereon, antl who tloes such work himsetl/herselt or through nis or her own
employeet, provitletl that sucP �mprovements are not Intentletl or olteretl for
sale. If, hOwever, the bulltling o� Improvemenf IS Soltl wlt�in one yea� of com-
pletlon, tha owne� will hav¢ Me burtlen of provinq hE/She tlitl nol builtl o� im-
prove for the purpose ot sale). . . :
❑ I, as owner oi the prooern, am exclusively contractin9 with Iicensed mn-
tractors to construct the vroje« f�ction 7044, Business anE Pwtessions Cotle:
The COntra<tor'S License LaW does nOt dpply to an owner ot property who
builtls o�;lmproves�tnereon, a�d who contracts tor such projetts wltn a con-
tractot(s) license pursuant to the Con[ractor's License Law). I am aware that
proof of IM1eir Wo�ket'S'ComPensation Insuran<e shoul0 be provitl0tl to me.
❑.I am exempt untler Settion B. &�P.•C. tor this reason
Da[e � Owner
I hereby certify that I have reatl this application antl state that the above
intormation ls wrrecf. f a9ree �o comply with all c{iy antl county ortlinances
dntl State laws relating to buil n9 construction antl hereby aut�orize �ep�e-
sentatives ot this cit to r upon the above-mentionetl or�pe�
inspection purposes. �
Signature � Daia
Drivers' License or 5� �
ri � aa __ - - -- �,.,.,.�.
.��i� A
TYPE OF'CONSTRUCTION NEW ADD ALTERATION REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHER A P,N,
DESCRIPTION OF WORK/USE�OF BLDG. i � S Main Building:
TVPE OF PERMIT � GRADING FOUNDATION STRVCTURAL T Fro�t
❑ TENANT ❑ ELECTRICAL ❑ PWMBING � MECHANICAL B Rear
❑ OTHER :
PROJECT DESCFIPTION 5�. FT. ocCUaArvGV ' C Right
CONSTRUCTION TVPE VALUATION $ S Left
ZONE GRADING CU.YDS. ACRES ping. R¢f. #
Rema�ks:' ,� ] r 9� r— Planning Notes:
Preventer
Irrigation
Clarifi2rs -
Dishwasher -
Drinking Fountains
Floor Drains
Floor Sinks
Gas Service Outlets
Incerceptars
Kitchen Sink
Lavatories
P—Trap �
Roof Drains ,
Reinspection Fee
$15
Boiler
Duct-UnderGround
Duct - Structural
Duct - Ventilating
�x�uu.,$ystem ❑ Multiple ❑
Firepl/Fac{. BIL ICBO #
Heating System & Ducting
❑ ai oo,000 eTu b i oo,000 en
Reinspection Fee I $15
CMF 0865-46, rev. 10/84 White - Builtling; Canary - Applicanq Pink - Ac<oun[ing; Goltlenrotl - Assessor
Showers
Service Sink � �
Sewer Cap
Sewer Connection �
Solar Collectors
- Solar Piping - ' . -
Solar Tank
Swimming Pool w)Spa
Urinal
Water Closet
Water Heacer
WaterService _
' Auto-Wash
Issue Fae
Hoodor Typel ❑
Canopy Typell ❑
Refrigeration System
❑0-t00,000BTU ❑700,000
System Repair/Alteretion
Fire Dampers
Ragisters
Issue Fee
FEES
$ 3
$ 3
Automatic Washer -
Construction Pole Sub.
Cooking Unit
Dishwasher
Dryers ❑Gas ❑Electric
Fan '
F.A.U.
Fixtures
Device Boxes
Outlets •
Garbage Disposal
Generetor �0.5 KW �5-15
0278 6/24/E7
� Zone
Accessory euilding: �
Parking Req./Provided
ELECTRICAL
Transtormer ❑ 15�50 KW
❑ 50+KW
Meter LJup to 100amps
Meter ❑over 100 amps
Sub Panel
Motors�0-7 HP 01Yz-8
Inc.Solar 09-15 HP �76-15+
Microwave
Pole Light
(iange -
Standing Sections
irash Compactor
630^' T;.
FEES
Z
O
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M
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I Rainspection Fee I$15 � I Issue Fee � $ 3_ L
DEVELOPMENT SERVICES REDUIREMENTS:
2oning Approved By Date
Building Approved By Date
Appliration Issued By nate��
SUMMARV OF FEES
BUILDING PEFMIT $ SMIP .. $
PLAN CHECK $ PERMIT
PLUMBING $ ISSUANCE $
PLAN CHECK 25% $ ENERGY P.C. $
EIECTRICAI $ GRADING $
PLAN CHECK 50% $ MICROFILM $
MECHANICAL $ � TOTALFEE $ �3•Ov
PLANCHECK 25% $ l2.De7
s�x�r=63,�r
CONSTRUCTION AND•PLANNING � POOL & SPA
APPROVALS Permit # Date Inspector AppROVALS Permit # Date Inspector
1. Ternporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. � 54. Forms '
4. Electrical Condui[-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement � 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. � 57. APPROVAL TO COVER-GUNITE
7. Footings I 58. Electrical ConduibUndrgrnd.
8. Foundation � � 59. Gas Pipe, O Undrgrnd., Test
9. WaTer Pipe�Undrgrnd. 60. Backwash Lines, P-Trap, O Undrgrnd.
10. Structurel Floor System 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap , 63. Heater & Vent-Final
13. Roof Drains �� 64. Plumbing System � Final
14. Rough Plumbing � ' � � 65. Electrical-Final
15. Rough Electrical•Conduit 66. Solar System-Final
16. Rough Electric Wiring , 67. Fencing & Access Approval
17. Rough Wiring Sign - � 68. APPROVED FOR PLASTERING
18. Rough Electrical•T Bar Ceiling , 69. POOUSPA SYSTEMS FINAL
79. Rough Heating & Air Conditioning . FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit # _ �
r+
21. Du�ts, in Struc[ure � 70. Underground Hydro
22. Ducts, Ventilating , 77. Product Piping O Gas ❑ Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Freming � ' , 73. Undergrnd.StorageTank OGas ❑Oil �
25. Roof Sheathing • � 74. Overhead Hydro
26. T-Qar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing - � 76. Dry Standpipe , '
� 28. Lathing & Siding ' 77. FIXED SYSTEM FINAL � `,�
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing . HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat . � 79. FINAL INSPECTION � -
,'. ' •
32. Electrical Power Meter-Final i 80. FOOD CERTIFICATE �SSUED
33. Final Electric otes:(Z•Z2•8'8 �' ,R/A�i�ltp�p q�,ore., gog D
34. Final Heating & Air Conditioning U. �1i(� `��,p
35. Final Gas Pipe;Test
36.'Hood or Canopv . �
37.� Final Factory Fireplace . ' � �, /��
38. Final Plumbing i � �
39. Water Service-Final •
.r
g0. GasService-Final .- � ' - �• '
� ..
�41. Solar pomestio-Final � � � •� � '
I �
�42. BackflowPreventer �'Y • �
�
�43. Backflow Irrigation ' : � �
'44. Landscape Irrigation System � � . � � '
45. Sound Attenuation ' � � ��' � �.
� , ' �..
46: 'Handicap Regulations , � ' � � �
47. FINAL STRUCTURE & BUILDING i ���` � � j� , t
48. Special Requirements Completed . ' ' ,
.t' �'
49. Electric Release to Edison - � ' .
50. Gas Release to Southern California Gas Co '�
51. CERTIFICATE OF OCCUPANCY ,
No. Date
/
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For Applicant ro Fill in Completely — Use Ink Only
iIIDINGf'-��' •u�,�/�j�I�`
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CONSTRUCTION ,�
LENDEF
BRANCH '�
ADDRESS �
ARCHITECT
CONTRACTOR /JO3C GL//I%Y l�v��C �T
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ADDRESS �(X'I f � J�%%��LL: � E,'�
TEL.
CITY��C���i J,Jc;f/y2 NO.f�B��(
LIC.NO. .0 Q� UCVNO.�
SI2E NO.OF BLD
OF LOT yLi ��� f� NOW ON LOT I
USE OF r ,� ,�, ,;�
E%15fING BLDG. U/ t /�7
Separate permits are required for
electric, plumbing and heating work.
USE Of BUILDING AND WORK TO BE PERFORMED
; FAIL 1. {F ��it.. r�
P{� Z.{-%�[MSf�� Z07 ''Z�.SV
APPLICAT[ON FOR STRUCTURAL PERMIT
RECE�O AV DATE RE=EIVED DATE ISSUED
�I 4
� � � P 'IT
A.P. NO. �O �
BUILDING �� �j 1 , • I �� �
ADDRE55 3 �
TRACT / `�I V �LOT �. BLOCK
OWNER
VALUE
FIRE
ZONE
APPROVED
NO.OF USE OF NEW
2� PLANS � BUILDING
RDSAPPROVEO VARDSAf
ROM
DISTANCE BET
MAIN BLDGS.
VAR. gW
HOLD F� R '
I hareby acknowleAga thet I have reatl this application antl stata
ihat the ebove Infofmation Is corract antl agree to comply wiN ,
all �aws reguletln8 builtling consvuction, and I shall not amploy
any person In violat�on of tha workman's compensetion laws of
Ma State of Celiforn�a.
I hereby certify thaT � am properly Iicenaetl es e contractor untlar SQ. F'
the Stata of Callforn�e Busina5a and Profezsions Coda, Oivislon 3, THE AMOUNT:
Chnpter 9, antl Mat zuch Iieenws ere in full force antl et}ect, or 1 THE �UFPOSE O
am oxampt from the ProvlSlons ot the State of Californla Buziness VALUATION
end Professions Cotle, Divicion 3, Chapter 9.
51 natura of � �
Parmittae $ /� �
I
Authorizetl ABent
BET. MAIN &
ACCESS. BLD
DATE
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VN UNDER VALVATION IS FOR m
'ABLISMING A PERMIT FEE ONLV: �
PERMIT FEE $ d
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PLAN GHECK E O m
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TAX § / f
V
TOTALPAID y �
COUNTY OF ORANGE
BUILDING D&PT.
636 No. Broadway
Santa.Ana� California
Phone: KI 2•6211
2.
3.
4.
5.
, Application for Building Permit ,
AND FOR A
Certificate of Use and Occupancy
OW[�'ER'S NAME.________�./.
- - -
Permit No.._� ���-�'-'
-
Date-------�7--- �/�----�' __-'----------"'-----------
-�-�-°L-- - ---- - PH� �-y�--�- -�--1--=---
MAILI[VG ADDRESS------�-_�S-/{----7J-------�'`�=---� -Cf----v�---�� -�- ----- -- ------_CITY ---�.`sv"C�I �-----
I�'ame ...
Address
City '
State
L;c No.
(Archirecc or Engineer)
Phone
Name
City -__-.
$tate
Lic. No.
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PROPOSED USE: _- ---- Q(/.4S/.� NC`�7- -- ------- -----------=--------- - --- -- - ---------- -- - -..... ...-- -- -----
/ �/ �r.�
�'7 `-� .LI . - �v S� � cl.
JOB LOCATION.---�--✓-`--`��-�---�- - -----1-�--� �- -------------- --'--- ---- ------------------- -� ------------- ------------
(House [Jo.� (IVame of Street) ' � (Town or School District)
,�/ i �
LEGAL DESCRIPTION: Lot..-'---'--�'�-------------------------Block/�.'--_�/.%�--_/�---'-----,-----Tract.-----'--.��-._----.
(M¢res and Bounds Description—Uee resene side of form)
CORIVER LOT ( ) INTERIOR LOT (iC ) THROUGH LOT ( ) SLOPG OF LOT (
��vo . � . �/
SIZE OF BLDG.:'?.,__k_�'�._._ AREA:�r�___._�_`�a._.__SIZE OF LOT:.__�P.__k___J 3� AREA: _.._..__
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6. HEIGHT OF BLDG.: _._.._._..._ .............._._..___CEILING HEIGHT:.____.____��________.___._.____.. NO. OF STORIES.._.___. �__._...____
�. NO. FAMILIES .............._�._._._..._________...Size of Smallest Bedroom: __��__k__L_z'__ Size of Kitthen: _��._:Y___�_.________
8. EXTERIOR WALL CONSTRUCTION:_� �^2_.S'_.______.___INTERIOR WALL COVERING .___���'�_��1...__.___
(Frume, Sm<co, Ecc.) (Plaecer-Drywall, Em.)
_ /
9. SETBACKS: Front Yard from Cencer Liae of Stree[-----�--d� '---__'--_------_----------------'-----------_'-_-_"------_-'-------------------_'--_'-
( �
Nearest Side Yard.__._�_____________Rear Yard.__J_�_______.Distance in Feet Between Bldgs. on Same Lot .__.__..._._____._._....._.....-_.
tG. A COMPLETE PLOT PLAN IS REQUIRED, SHOWING ALL STRUC'I'URES AIVD USE OF EACH.
11
12.
For (a) Footing: Width----_--'---'-__-"__-'___--Depth in Ground.---_-__.__-_._-_--_--.Width of Wal�-_------_------_'--__
Accessory
Bldgs. and (b) Size of Scuds:.----�1� S acin _--------_--'_"CC Material of Floor-----------'--------._'--'-'-_-
$imi(ar . Q�-N-_' p g.__________._
Structures: � y�
(c) Size of Floor Joists:.-------------------.-----lt�cing�------------.-----------'�CC
C V ��j
(d) Size of Ra£ters: ------------------------------- -Spacing � � j�( /�__"CC �
_.'-------- -- -- -- �o .-
' _' � /� V ,
VALUATION OF PROPOSED W K: �ding all labor, plumbing, electrical wiring, hea[ing,�i2e�sprinklers, paint-
ing and sewage disposal $.---'-'_'_�-��_---'_-_----------_---
1;. I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE IIVFORMATION IN
THIS APPLICATION IS CORRECT AND THAT THE CONSTRUCTION WORK WILL CONFORM TO ALL
LA\�US OF THE COU[VTY OF ORANGE AND THE STATE OF CALIFORIVIA APPLICABLE THERETO.
�� L Signed:
PlansFiled:_-----��---L----------------------------- BY.
FEES:
Bldg. Permit
Plan Check
Total - -
Receipt No. �
Paid to
DaCe ---------
DATE------ -]� -f--��J - --�
FOR DEPARTMELVTAL USE ONLY
/
GROUP_�-_ __
TYPE ---- --------
----- --- ---
DIST. � /.�
MAP--'�1-!-- ----- --�---
SHEET NO.__.____,)__..___
SM.-9 S0 •
(Au[horized Agen[)
APPLICATION_./� .: �
Z O N I IV G----------- --- �--
PLANS AND
SPEC'S --------------------v-
CORRECTIONS '
'/l�'L5 BY
�-IEALTH ----------------- ---
FIRE
MARSHAL .__.____
STATE --- ------------- - --------
ENGINEER
CAL..--- -----------------------
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VSPECTOR �
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