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30424
COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
JUN 18 69CNO01746 0*****5.00
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APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Completely
R ECEI ED BV
D ^EEIVE
pgT�UED
BUILDING 7-
Th
ADDRESS V,7 /
G/J
-r,
OWNER �1%S` lam'-' Gi.I�V 1J�
A.P. NO. _1 _ /S/ PoRMI O
MAIL
BUILDING
9 -
ADDRESS
ADDRESS J
TEL //rl
CITY NO. O-
TRACT
LOT BLOCK
CONSTRUCTION
W
LENDER
BRANCH
OWNER
ADDRESS
VALUE
S
ARCHITECT { TEL.
OR ENGINEER �1��'N 0.
FIRE
ADDRESS
ZONE TYPE GROUP
�'
APPROVED // _6
CONTRACTOR
BY ATE6_
ADDRESS
TEL.
E
NO. OF
USE OF NEW
CITY NO.
PLAN
BUILDING
STATE V" CITY
YARDS APPROVED
YARDS APPROVED
LIC. NO. LIC. NO.
MAIN BUILDING
ACCESSORY BUILDING
SIZE i NO. OF BLDGS.
(FROM C/L STREE )
OF LOT 6 0 ,Q NOW ON LOT
FRONT
FT.
USE OF
EXISTING BLDG
R. SIDE 3 FT,
FT
SIZE OF NO. OF
//
S T
NEW BLDG. ROOMS STORIES
L. SIDE T.
FT.
EXTERIOR WALL
COVERING
CROOF
OVERING
REAR FT. i
FT.
USE OF BUILDING AND WORK TO BE PER FORAt�D
DISTANCE BET.
BET. MAIN &
V , l+
MAIN SLOGS.
ACCESS. BLOCS.
VAR.+
DATE
C.U.P.
APPROVED
�f-•
APPROVED
I hereby acknowledge that I have read this application and state
that the above information is correct and agree to comply with
all laws regulating building construction. and I shall not employ
any person in violation Of the workman's compensation laws of
the State of California.
I herebycertify that 1 am
Y properly Ilcentatl of a contractor untlar
SO. FT.
THE AMOUNT SHOWN UNDER VALUATION IS FOR
the State of California Business and Professions Cotle, Division 3,
Chapter 9, and that such license& are In full force and effect, or I
THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
am exempt from the provisions of the State of California Business
antl Professions Code, Division 3, Chapter 9.
VALUATION
PERMIT FEE $
Signature of �j/�'�
l
Permittee (�le/I,•6%WLL^��•
$ /U//
VV
PLAN CHECK $ s�
Authorized Agent
TOTAL FEE $
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