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COSTA MESA BUILDING-SAFETY DEPARTMENT
P,O. BOX 1200 COSTA MESA, CA�IFORNIA 92626
For Applicant to Fill in Completely — Use Ink Only
BUI�DING � ? � w !.S S �
ADDRESS J � �
/�. �) ^
OWNER `RI��,S aI�'�.LIZ IT
MAIL
ADOFESS �AM"' �
CITV i3O��T � M17�Q NQL.
BRANCH
ADORESS
CONTRACTOR
ADDRESS
CITV
STATE
LIC. NO. �
SIZE
OF LOT
VSE OF
6
�
L.
!� J �
NOL-�3I %��/
CITV /
LIC. NO.OQ�p
NO. OF BLOGS.
NOW ON LOT
Separate permi[s are required for
elec[ric, plumbing and heating work.
USE OF BUILDING AND WOfiK TO BE PERFORMED
F+ �Z E. S i1 PPP_.�sS� a.l sv s i
I hareby ack�owletlge thet I have reatl this application and stete
ihat tha ebo�e Information is carrect and a0rea to comply wlth
all laws regu�ecln8 builtline conso-uction, antl I shall not employ
any person i� ��olation of the workman's compensetion laws of
the State ot CaliSomia.
I hereby cert�ty that I am properly Ilcensed as a contrettor untlar
ihe State af California Business and Professions Cotla, Division 3,
Chapter 9, antl that such Ilcenses ere in full force end affect, or I
am exampt f�om the provlsions of the Stata of Celifornia eusinass
antl Professio�s Cotle, �ivision 3, Chapier 9.
Sleneiure of �� �A �/^„/�
Permittae �6(�� � U' 1 —�r� —
r:PR 28-76vF:u001558t u*a,.=
cyt:. 5.50
APPL[CATION FOR STRUCTURAL PERM[T /�
RE I i D BV TE �E DATE ISSUED ,`
/ PERMITNO.
A.P. NO. r �
BUILDING
ADDRESS
TFACT �OT BLOCK �
W AD ALT R P
OWNEF
S �
4� _�
FIRE
ZONE TVPE GROUP y
APPROVEO � / �
gy DATE G. �
ZON NO.OF � USE OF
PLANS BUILDIN
YARDSAPPROVED VAROSAPPROVED
MAIN BUILDING ACCESSORV BUILDING
VAR. ai`
C.U.P. �1
n
m
i
0
SQ. FT. a
THE AMOUNTSNOWN UNDER VALUATION IS FOR m
THE PURPpSE OF ESTABLISHING A PERMIT PEE ONLV: .
e
VALVATION pEFMIT FEE S � /� a
/ / (Y�f/ N
/ / C'/_ � . . m
PLAN CHECK E ^�
0
�� LL
$ TAX S � �Q �
u
TOTALPAID 3
��:, :_�, 19347
COST.4 MESA BUILDING-SAFETY DEPARTMENT
P.O. BO%9f7 COBTA MC9A, CALIFORNIA
For Applicanf fo Fill In Complefely
TYPE OR PRINT
BUILDING
A��RESS ♦
COSTA MESA. CALIFORNIA
1 M,",:.e«Q T�Q �
-S� 9 —
s�n�e ��e�.
LIC. NO. NO.
SIZE C V� � I NO. OP BLOOB.
OF LOT � �� No�
EXIST�N68LD0. �. � �MEI: C/A
BBTBACK LINE PNOM
cHNTER OP BTREBT T REAR
��
BIDE YARDI LEFT ' ' I'R16HT
DESCRIPTION OF WORK
E%TERIOR WALL I 1
COVERING 1
U6H OF BUILDING MID WOXK
. �o o D TO --
�„�. �
� AP�R 2 5' 1963
�fINNNCE DtPI
ciTr oF cosrti m�sa
APPLICATION FOR PERMR
BUILDING
For Office Use Only
P8C81P� NO. PERMIT NO.
,�' o� "
ZONj.�_ � NO. Op �
` PLANe
i
L80AL ,.-/,j�J �
�
NOTE: NOEAVEOVERI
90' TO SI�E @ REAR P
EAVES
ALLOW ED
YARDS APPROVED
MAIN BUILDINO
DISTANCE BET
MAIN BLDGB.
VAR. �{
�
� �.OT � �/.l(1
�- .�.5
BHALL BE LESS THAN
(U.B.C.REqU1REMENTI
YARDSAPPROVED
ACGESSORY BIIIL�IN�
BET. MAIN Q
ACCE63. BLI
DATB
1 H8R8BY ACKNOW{.EOOE TH�T 1 MAV! RP.�D TN18 APPLIWTION TXH AMOUNT 9XOWN UNDHfl VALUATION IH FOq TXH
•NO BTAT! THAT THE ABOVB IH COHRECT AND A6REE TO COM- PIIRPO6E OR 68TABL�8NIN0 • PERMIT FEE ONLY.
PLY WITX ALL C�TY OPOINANC ANO BTAT B qEOULATINO ypLUATION
eU1L�irvOcoNeTxu N. " PERMITFEE $� �
P RMITfEEOP � .'q �
AUTHORIZED A6ENT , � $/✓ � y O�
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