HomeMy WebLinkAbout565 18TH ST - Building Permits�
� CITY OF COSTA MESA
BUILDING DMSION
DEVELOPMENT SERVICES DEPARTMENT
PERMIT
(714) 754-5273 • Fax (714) 754-4856
Job Address: 565 W 1 STH ST
Suite:
Vicinity:
Parcel Nunmber: 42427129
SIGN PERMIT
Zoning:
� .�
ERMIT NUMBER
S898-00� 35
77 FAIR DRIVE, COSTA MESA, CA 92626
Status: APPROVED
Applied: 09/30/7998
Issued:
Applicant: BLAKE SIGN COMPANY
Address: 15661 PRODUCE LANE, UNIT 8 - -- - �_
��;. � -� ' � Plion'e: -(714) 897-5682- �� �
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HUNTINGTONBEACH,�CA"-�".� " � Zip: 92646 � � �"��----`,�`
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Contractor.. � BLAKE SIGN�COMPANY WCORP ������ � � "�
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Address: 15661 PRODUCER LANE �A � � � �'� ���,
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� � �� � SCOPE OF PERMIT_ _ A ' � ' �: ;
` � �INSTALL A 6' HIGH �24��5�>Ff .FREESTANDING;�NONILIUMINATED SIGN�AT THE POLICE WEST �
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+ � � SIDE STATION. � � - r -' � ' - ' ` � '
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Plan Check:
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Permit:
SMIP Com
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Inspection:, '
Total:
NOTES:
� FEE SUMMARY
� $19.01 ,r� �.i �✓,.,.1., ,_ ,�'!?r.
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$29.25 � .. _ - - f �
� $0.50
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���T� _C81C VBIUBtI0f1: � � $750.00 �
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EXPIRATION: This permit shall aulomatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a perlod of 180 days.
INSPECTIONS: In order for the work authorized under thls permit to be considered legal, such work must comply with all applicable codes, and all
requlred Inepectlons end flnel approval must ba oblained. Failure to obtain Inspections and tinal approval will result In the ezpiretion o( ihis pertnit.
FOR INSPECTIONS CALL: (714) 7545628
e
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WORKEqS' COMPENSATION DECU1AAnON: �
I hereby effirtn under penelry of perjury O�e oi ihe tollowing decleretions:
� I heve antl will meintein a cenifice�e of consent to setl-Insure for workers' compensetion, as provitled for by section 3700 of ihe Labor Cotle, tor the OeAortnence ot the
work tor which ihis Oermit is issued.
❑ I heve anA will maintain warkers' c�pe�setlon �nsurance, es required by secUon 00 of Ure Lebor Code, for Ne peAormarke of ihe work for which this pertnit is issued.
My w� er/5' compensation�1In ence cartier en pollcy number ere: 1 I
Cerrier. —?'K �` � � � Policy Number. N%vei� 7��ZSi� � �
(Th/s sectlon need nof be cromp/eted II fhe permlf /s ve/ued ef one hundrea dollers ($100) or /essJ —T
i
❑ 1 certify ihat in Ih��� a�0� �he woM fo� Permit is issued, I shell not employ any person in eny manner so es to become suh�ect to the workers'
compensatlon la af ibml e�d e ree t t If I shauld become subject lo Ihe wo compensatlon provlslons oi Sectlon 3700 of Ihe Lebor Code, I shell iorlhwith.
compy with the ns. , �+(% � j
AppllcaniSigneture: � _�) K Dele: q' 3�' / a
WAANING: FAILURE TO SECUAE WOA1(ERS �tiP'��T�� ���GE 15 UNIAW FUL AND S}U1L SUBJEGT AN EMPLOYER TO CRINdNAi PENALTIES AHD GYIL FlNES UP T0011E HUNOAED
TFiIX15AND OOILAFE (5100,000), IN ADDfTION TO THE COST OF dJMPEN5AT10N, DAMAOES AS PflOVIDED FOR IN SELTION 37060F THE LABO{i �E, INTEFEST, AND ATTORNEI"S FEES.
LICENSED CONTHAI
I �ereby effirtn that I a
force end efFect Lic. M
COnifettoYs SipnetUle
DECLARAT�ON:
•ed untler provisions of Chepter 9(commencing with Sec'�n 7000) of Divisian 3 af ihe Business end Professions Code, end my Ilcense is In full
� � Class N �i �%s
� .ov_ _ �,..%J / oare: �-30-�I8`
CONSTRUCTION LENDING AGENCY:
❑ I hereby atfirtn that Ihere Is a wnstrucqon lending egency for ihe pertortnance of �he work tor which Ihis permit is iuued. (Sec. 3097, Civll Code).
Lenders Name: � Lenders Address:
SlgnaNre: � Date:
OWNER-BUILDEH DECLARATIONS:
I hereby aHirm ihet under penelry of perjury thet I am E%EMPT FROM TXE CONTRACTORS LICENSE LAW tor the following reeson (Sec. 7031.5, Buslnese entl Professlons
Code: My ciry or counry wNch requlres e permi� lo consiruct, aller, impmve, demolish, or repelr eny slructure, prior to 14s lssuance, also requlres [he eppllcant far such permit
to tile e signed stetemem that he or she �s ��ceosetl pursuant to the provlslons of t�e Contractors License Lew (Cheptar 9(commencing wlih Section 7000) of DlWsion 3 of the
Business and Professions Coda) or thet he or she is axempt Iheretrom end ihe basis for the ellagetl exemptlon. Any violetlan of Sadion 7031.5 by any eppllcent for e pertnit
sub�ects Ne apv�icant to e civil penalry o1 not more Nan five huntlretl dollero (3500).):
i
❑ I, es owner of Ihe properry, or my employees with wages es Iheir sole compensatlon, WILL DO THE WOHK, end the siructure is not Intentletl or oHered tor sele (Sec.
7044, Business end Protessions Code: Tha Contractors Llcense Lew does not appty to an owner of property who builds or improves thereon, end who does such work
himseR or herseli or ihrouqh hls or her own employees, O��ded that such impmvements ere not intentletl or oflereG for sale. tl, haweve4 the building or Imprwement is
soltl within one year at completion, the owner-6uilder wlll �ave the burOen of proving that he or she did not builtl or improve br purpose ol sele.).
❑ 1, as owner of the pmperty, em E7CCLUSIVELV CONTRACTNG WITli LICENSED CONTRACTORS to construct ihe projacl (Sec. 7044, Business entl Professions
Code: The contredors License La'�' tloes not appty to en owner ot pmperry who builds or improves thereon, antl who contrecls for such pro�ect with e contrectar(s)
license pursuanf to the Conlracta5 �cense Laws.).
❑ I em ezempt ui
Signewre: _
Owner ID verifietl by
Vedfication of Ownei
Business and Protessions Code tor this reason:
rt's license. ❑ Ves ❑ No Drivefs License No.
by (type af daument, I.e. - properry tex bill or deed):
Date:
Expires:
DIVISION OF INDUSTRIAL SAFETY PkAMR CERTIFICATION: �
i
❑ I hereby certify Ihet no excevetlon INe (5) or mare teat ln tlept� into which a parson is required to tlescenq wlll be mede In connectlon with work euthodzetl by ihis
pertnit, end thatlno building sirudu�e, scattolding, felsework, or tlemolitlon or dismantling Mereof, will be more Ihan thirry-siz (36) feet hlph. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Ttle 8, Calllamia AdminlstraN�e Cotle).
❑ As ownervb�
pertnit to do
Signature: _
Division oflntlustrial
I will not employ anyone to do work which woultl requlre e pertnit from Ne Divlsion of Industnel Selery, es noted ebove, unless such person hes e
work hom Ihe Oivislon.
Date:
Pertnit Number:
HAZARDOUS MATERIALS AND EMISS�ONS CERTIFICATION:
1 Will the applicant or present or tuNte bullding occupent need to file and certity a Business Plen for emergency response ro release or Ihreatened releese ot e hazerdous
matedal? ❑ Yes ❑ No
(Section 25505 of �he Celifomia Health end Sefery Code requires, with some exceptions, that e Business Plan be filed with ihe Coste Mese Flre Depariment by avery
business which hes et any one time tlunng e reportetl year e quantiry oi hazardous materials equel to or greater than e welght o1500 pountls, or a volume of 55 gellons,
or 200 cuDic feet of comDressad 4a9 et stendard temperature end pressure).
2 ooes or vnn Ine epplicent or present or mwre ounamg occupam need ro me a regisiration rortn for acmely ha�rtlous matedels7 ❑ Ves ❑ No
(Sectlon 25533 of the Celifomla Mea�ih enC Satery Cade, wlth some exceptions, requires registratlon with the Coste Mesa Fire Depertment by eech Dusiness wNch at any
one time has on hentl e quantiry a� acutely hezertlous materiels equel to or greater ihen e weight oi 500 pounds, or e volume ot 55 gellons, or 200 cubic feet of
wmpressetl gas, et stantlartl tempefeture and pressure).
. .............................................................................................................................................................................................................................................................
3 Does or will the applicant or present or tuture builtling occupant need ro prepare an RMPP (Risk Manaqement and Prevention Program for ecutely hazerCous materials)?
❑ Ves ❑ No
a n an nmrr is p
.................................
5 Does or will Ihe
tmm the South i
(Section 65850.
.................................
6 Will any part of'
Qf yes', the fac.
.................................
7 N a pertnit from
epplwatlon, hav�
.................................
e pt yes^, anacn
CERTIFICATE i
regeMing Hezai
Signature: _
CERTIFlCATE OF Gy
correct I egree ta ci
abovatlescnbetl oro
Hadlih
that the Costa Mesa Fire DeDarimem may require Ihe
:er acuteN hazeNous materials with Ihe Fire Deoanme�,
sently required, has Sectlon 25534 ot the Califomia Haalth and Safery Cotle been lully complietl with7
...............................................................................................................................................................
ppllcant or presenl or tuture builtling occupant require tor the work which Is the subject of this e pllu
�est Alr Qualiry Ma�agement DisMct or irom any other eir pollution control tlistrid or aqancy7 � Ye:
of Ihe Celifomie Go�emment Cotle requires that Ihe requested infortnatlon be fumished on epplicatior
................................................................................................................................................................
e taciliry to be wnS��ucteC untler ihis permit be within 1000 feet iram the outer boundarles of e sc�ool'
y must meet the requirement of Sections 25534 antl 42303 oi the Califomia Health antl Safery Code).
............................:...................................................................................................................................
he South Coast Alr Oueliry Management Dlsidct or ather elr pollutlon cantml tlisidd or egency Is
ell af the disclosurBs prescdbed by Calflomla Heelth end Safery Cotle Sectlon 42303 baen mede7 [
ceAlflcation and filing with ihe Fire
noo-residentia�
or
suD�ect oi
COMPLIANCE: I certily ihat untler penelry ol perjury the information given above is crorrect. I flgree to comply wit� all stata lews end ciry ordinances
is Matenals end Emissions.
_____ . Dete:
JANCE AND A�110RVJ1TON OF ENTRY: I certify under penalry of perjury ihat I hava reed this eppllcation and state thet the intortnetion given is
with all stete lews and ciry ordinences releting to building conswction, and euthorize representetives of the Ciry ot Costa Mesa to enter upon the
for inspecllon purpose9. I agree not to occupy or allow occupancy of eny building euthorized by thls permit until tinal Inspedion.
� I � A^ O utl�orized Applicent
j�p�� INSPECTIONTTE �7E
1676 Fxed System Finel Flre Prevention
I
1286 Pool Spe Flnal
200 Finel Re-Roof
201 Final Block/Retalning Well
202 Final Fectory Fire Place
203 Final Sign I
204 Final Demolition
244G06 I
�O � Date /
� �''` - 9
Dete
��$ �� pSPECT10NME
206 Finel Mechenicel
208 Finel Plum6ing
210 Final ElecMcel
212 Final Fire PrevenUon
220 Flnal Planning Approvel
222 Final Site
250 Final Bullding/Occupancy
PP0.IECT ROOHESS: S 6 S i"� 1 8 TH S T
OWNEX'SNAME: CITY OF COSTA MESA
aoosEss: P U HOX 1200
COSTA INESA,CI� 92628
714 548-4165
AflLN/ENGINEEP: PEG.NU.:
AOOflE55:
UNIT:
UNIT:
PEXMITIEE: j{�C HEATING G AIR CON ( 714 ) 590-0972
aooness: 2951 GRACE LANE
COSTA MESA CA 92626
❑LENSEO CONTPpC70B OECIANATION: 1 here0y alhrm tllat I am IkenseC unCer V�ovisions al CtwD�er 9(commenGng wi�� Section
7000) ol Urvision 3 0l Ine Business antl Prafessions Code, an0 my licen5e is in lull force and ellect.
ciTruc.:006041 srnTeuc.:133298 cuss: C-20
Date: Signature:
wOXNEflS' COMPENSA7ION DEClABA7tON: I herebY aflirm tnat I nave a certiliWte al consenl to setbinsure or a cenifitate ol workers'
Campensaiion �s��ci ��v�nOeC CaDY �hereol (Setiion 9800. LaO. G� 1/ O 1/ 91
eoucv xo.: V E%P. ORTE: U
' tomraxv: SUPERIOR ,5,1
, CeNlied coOY is hereby IumiSlreG. L•] Cenilietl copy is IileU vnt� t�e cily BuilAinp Oivision.
Ddle: Applfcanl:
EXEMiTION Ffi�M WONNENS' fAMPEN511T10N OECUMTION: (ThiS SCCIion neetl tW be mmpkletl il lhe p¢rm� 6 ta ane MIMreO (5100) Or l¢55�.
I cetlity Itwi fn ��e petlorman[e ol I�e work lar w�ic0 t�is permit i5 isSueQ I 51wA not employ any Derson in arry manner so a510 �¢come
suCleci lo I�e Workers' Compen5aiion Laws oi Cali�omia.
Oate: Siqnature:
NOTICE: il, a�ler making ��is EeClaraii0n, y0u ShoulC EetOme SUUI�� �O I�e WOAerS' Compensaiion provisions ol Ihe LaOor
Cotle. you musllorih+nt� rAmON "^�� such prOviSions or iNs perrtui 51u11 De Ueemetl revoketl.
CONSiPUC710N IENUING RGENCY: 1 neR�y allirm ihat inere is a tanstruCiqn IenGinp a0e�7' lor ine ce��ormante of ine vrork lor
wttich thi5 Oermiiis iSsueC (S¢CIiOn 3097. Gv. C�.
LENDEfl:
auosess:
OWNEN BUILDEB �ECIAfl�TION: 1 �ereby a��irm ��a11 am exempt Imm tM Coniranors' State License Law far ihe louowinp reawn
(Seclqn 7031.5 Business an0 Prolessi0ital Coae: My Gly ol county vAG[h r¢Quires a Dermit lo conSlruEt, alter, impmve, demolish, ar
repair any SlmtlUre. pri0r �0 iis issuante. alsa repuire5 ihe apDlicani lor SuU permii lo lile a SiqnCG Slalemeni �ha� �d5�e 4 liC¢nS¢G
omsuam to �ne o�m+sions ol �ne Contracims' Slate lianse Law �Cnapler 9(wmmencing wit� Sectian 7000) of Oivision 3 oi the Business
anE Pmlesvons Cotle) or tAat ne/she is e+�emD� �herelmm anG i�e 7avs lar ��e allepe0 eMemO�ion. My vialation ol Section 7031.5 Dy
any apO�iWnt lor a Oermil suEjects t�e applicanl ta a civil penalty ol tqt moR itWn Irve huntlaG EdWrs (5500).
I, as ownet of Ine property of rtry employees wilh wa0es as I�eir SOIe comDen5ati0n. vn0 Uo tM woM1, and tAe
� sirvcture is not ime�MeO or ollereE fo� ule (Sec�mn 70aa. Business mU Pmieuional CoOe: Tne Contracrors' State Licenu Law
�aaes not aoPly �o an awner ol a property wlro builOs or improvCS inereon. anA wllo tlaes sucA wOrk nimsell/hersell or ihwupn
�k or her own emplayees, prmi0e0 tlut 5uc� im0�ovemen�5 are nOt intende0 or olhreC br Sale. It, tpwever ihe huiltlinA or
improvemenl i5 solC m10in one year ot completion. the owner vM have I�e Eurden of 0/ovinp �e/s�e NG not Euild or imDmve
, loi ihe Duro�se ol salel.
I, as mmer oi ��e pmperiy, am exdusiveN conirac�ing vnih IicensN cantractors �a wnstma i�e prolK� (��� ��. Bu5ine5s
❑ anJ Proleuions Coae: T�e Coniractars' $tale License Law tloes not appN �a an ovmer of p�aperry x1n OwIQn or improves tAereon
anE who coniracts for sucn o�oi��s vntn a convactorls) license pursuam ta �he Contracmrs' State L¢eme Lawl. � am aware
��E� 0��� ol I�eir Wurker's Campen5afion insurance snoulC be pmvidetl Io me.
� I am exemD� uneer Section: B. 8 P. C.
I, la� inis reason:
Oate: O+mer.
I ao hereey cenify inal I am aware of ane un0ers1an0 ine ieQuiremenis of Cdlifornia Meallh anU Salery CoOe Seclion5 25505, 25533, ana
2553d anJ IIWt I or any IUWre UuilOinA �upanl willAvill not (circle one) neetl to ComDN w+�h saiA slaie cOtles an0 I�e r¢puiremenis for a
Dermit for conslruction or mOEilicatiM tmm Ihe Air Ouahty Management DiSirkt. Pesitlential constru[tion aDDliWtiMs are exempt Irom
t�ese provisians.
Date: ADOlicanl:
I nereCy cenily Ihal I have ieatl Ih6 avv�ication an0 state inat Ine aEOve inlormaiion is wrrect. I aAroe to tAm07'�'��h atl city anA
a�tluwncez aM sia�e Wws relaiing Io OwWmq consimnion iA �ereEy aulhOr¢e repres¢nla�ivu ol �h6 Ciry �0 enler upon Iiie 26ove-me
pr0�etly ta� in5pection puCrpa5e5. / /-�/�,/
Date�ry�� f U Sf^ _ _ _ —/ , '
Dmer's Lrtense ai Social Securi�y .:
t6aba6 Wnne—Bun�ing; Green—Coae EnlarcemenC Canary—nppliwm; Pink—Revenue; GolCenroO—Asseswr
� CITY OF COSTA MESA — BUILDING PERMIT PERM NO: EM
PERMIT NO; EM 050259 PLAN CHECK NO; N GOVT; Y SUPP: N
CONSTRUCTION TYPE; PERMIT TYPE: ELE MEC PURPOSE: OTH
JOB DESCRIPTION : INSTALL EXFIAUST FAN SIDE WALL SQ FT:
CLAIM VALUE: CALC—VALUE: GROUP OCC; A-3 /
COMMENTS: MECHANICAL WORK ONLY
*�e*��t��t*�ex*�t�r�t�txx*�r�e*�t�r**�r*�rr�r�e***�t�**+r+�x�e�t*�r****�r**�**�*****�e*�e*�t*�t��t�******�t�t
Z O N I N G R E Q U I R E M E N T S
S E T B A C K S
------------ MAIN HUILDING ---------- --------- ACCESSORY BUILDING ---------
FRNT: FT IN REAR: FT IN FRNT; FT IN REAR: FT IN
LEFT: FT IN RGHT; FT IN LEFT; FT IN RGHT: FT IN
PARKING REp • PROV; PARCEL; 42427129 ZNE; REF NO:
PLANNING N(STES>
i
�e�******�***��***��*��e�**��**�,��+��***+��**���+�����*�«��*�*�+�*�+��********�*�+�+e***�
D E V E L O P M E N T S.E R'V I C E S R E Q U Z R E M E N T S
ZONING APPROVED BY DATE:
BUILDZNG APPROVED BY : DATE:
APPLICATION ISSUED HY• � DATE: �.(�Ci
iFlfififMlFlfitlfkiflFiFifiEifiEkltifiE3f iFiFifiFlElEifaFiEif ifik
iF if M�F±f 1f If If iE k IF iP if if k K 1F if 1f 1E If if if M IF iFif �E iFlE IE 1E if 1f iE if 3f iE iF if iE af if 1f 1f aF iE It M 1F if if if i! IF iE iE if k ik IE 1E if iF iF iE 1E 3f IE 1k �lF aF if iE ik iE iE if jE
LEGALZZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
PERMIT 350t 6'25i SMIP/NON—RES
PLAN
ISSUE FEE 15.00 15.00
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
TOTALS----> 0.00 0,00 0.00 0,00 ,00 .00
REVENUE DIVISION TOTALS--> COLLECTED; .00 OVER/SHORT: 00
BLDG PMT PLUMBING ELECTRIC MECAANIC FIRE SMIP/TOT GRADING PLAN—CHECK
i! iF if if if if iF k iF if lf iE 1E IF M if iE iF Ik iE M if Ik k k M if iE �F iF �f iF k iE if if it M IE �k jE iE 1F k±t if If it iE k if 1F �f iE 1F if k If if iF iE if iF iF iE iE iE aF M iF M k iE iE 1E �E iF iE if
I N D I V I D U A L F E E B R E A K D O W N
TYPE QTY D E S C R I P T I O N UNIT COST TUTAL COST
ELE 1 MOTOR/POWR APPARATUS 0.0 — 1,0 HP 3,00 3.00
MEC 1 VENTILATION SYS NOT UNDER PERMIT,EA. 6.50 6.50
END OF FEES
dl �D07594]—QD075S41 Y'r_o� ,�p
UATE: 12/11/90 iIr�E: UE:"s3
I EXEMPTIOfV VERIFIED /
� i � �
CONSTRUCTION AND PLANNING . P� SPA
APPROVALS Permit �h Date Inspector AppROVALS Permit # Date i Inspector
i
1. TemOorary Electricat SCrvice or Pole 52. Pool & Equipment Location � ,
2. Soil Pipe-Undrgrnd. - �- 53. Steel Reinforcement i� .
,3. Electrical Condui[ UtilitV-Undrgmd:.:� . 54. Forms I '
4. Electrical Conduit-Undrgmd. �_ �- 55. Electrical Bonding � •
. I
5. Steel Reinforcemen(' 56. Ro�gh Plumbing & Pressure Test
6. Electrical UFER Grnd. � 57. APPROVAL TO COVER�GUNITE �
i
7.'Footings . 58. Electrical Conduit-Undrgrnd. � �
8. Foundation ' 59. Gas Pipe, O Undrgrnd., Test i ':
9. Water Pipe�Undrgrnd. 60. Backwash Lines, P-Trap, O Undrgrnd. ; �
i•
10. Structural Floor System • 61. APPROVAL TO DECK � i
11. Proper[y $ewer Line & House Connection 62. Backwash & fleceptor•Final �
12. Sewer Cap �� ;�, 63. Heater & Vent-Final �i
13. Roof Orains � 64. Plumbing System � Final
14. Rough Plumbing � 65. Electrical-Final � �
•�
15. Rough Electrical•Condu�t 66. Solar SYstem-Final � �
16. Rough Electric Wiring 67. Fencing & Access ApProval
r
17. Rough Wiring Sign 68. APPflOVED FOR PLASTERING . i t
18. Rough Electrical��T Bar Geiling 69. POOUSPA SYSTEMS FINAL
19. Rough Heating & Air CAnditioning FIRE DEPT. REQUIREMENT '
_ - �• -
2�.'Rough Factory Fireplace t. `� ` _ -- � ' APPROVAI'S, '-Permit # T
r. � - - �
21. Ducts, in Struc[ure . �.� .. �'� �. 7p, Underground.Hydro •
22. Ducts, Ventilating � ' 77, Product:Piping O Gas ❑'Oil
23. �,Gas Pipe-Rough & 7est -� � , - .1 �. .; , 72. Underground Flush= = �
24.-Roof Framing � • • .- ' 73.'Undergrnd�:StorageTank OGas ❑Oil
25. Roof Sheathing � ,�' �, ,. ` 74. Overhead Hydro .
26. �T-Bar Ceiling (Structural) & Monocoat _ 'n 75.= Dry Chemical ' • -
27. �Freme and Flashing, '� � 76. Dry Standpipe ' .�
28. � Lathing & Siding � �' • � •• � > 77. FIXED SYSTEM�F�INAL`
29. Insulation . � � . . ` � � '
, � I� 78. �FIRE PREV. FIIUAL . y
30. Drywall Nailing - - I �� ' HEALTH DEPT. REQUIREMENT
31. Plaster Biown Coai � ' �T � � ��{ ..79. FINAL INSPECTION ,' = r
32. Electrical: Power Meter.-Final � �(�,0 l• . B0: �FOOD CEFTIFICATE ISSUED ,. ��
.�33. Final Electric ' ' , �� ' � � � . �Noies: _ � '. ' - t ,
.�34. Final Heating & Air.Conditioning,; � 3 Lp�Q(� ��, :, i � ., ti _, . . � � �
35. Final Gas,Pipe-Test: . ' � �� � ' " ' " �'�
�'� �t •
�36. Hood or_CanoPY � �' ; . . ' > +� >: -j '
� r.
37. �Final'Fa�tory FireplaceF � � ' �`� ' - , ' .
�38. Final Plumbing . - . � � � � . � �� � �
39. WaterService-final• • � ,' �'''• --� � ' - '
�. .
40. Gas Service-Final ,. , ,,� � �. ., '.� _
�41. Solar pomestic•Final � •' - � r ,_ . . - . _
42. �Backflow Preventer,; ' I � (. � _ ' �
} � i
- _ � _,; ,
43. Backflow lrrigation' ' �� ' � ' ` , ' s- ;
44. Landscape Irrigation System.�;.. i , • - . ,�: � � � . ; `- �
. :� !
�45..Sound Attenuation� - � '� • � ' � � � � � E
� - �
46. Handicap Regulations - � � , • - � + I =' �
r
47. FINAL STRUCTURE & BUfLDING � "'` ' � , ;
r .0 •
�48:''FINALPLANNING � '. T • 7 � �:r . . � �; • � f �
49. -Eleciric Release to Edisan � � ^- � '�' � '
i t �� t �
50. Gas Release to Southem California Gas Co . � I���' � ' i- �• � I
,51. CERTIFICATE OF OCGUPANCY ' , ;• , .
No Date
I
I
ADD��Gnt to flll In all spaeas axcept those wlt�in Ifeavy OorEe� Iinas anA sign dll apD�opridte tlaclaratlonf.
CI7Y OF COSTA MESA CONST�{yj,UCTION PERMIT
� Projxt Address �� s ���w� s�` C M
!
� PP�icant's Mailing Address �A'n4� Q%� Z 7
Owner's Name ��U /�� � y U� (�N.(� ahone
Addr@ss 6yS /Y I2aSS 5�"' SANTYI. f1�/YA^
Arch/Eng. L ( ` icense N .C--��{�{-9
�97r/��LIi
Address ' _
Contractor's Nam � n
Addr@Ss (mailing) � l � �
Ciry License No.
LICENSED CONTRACTOR OECLARATI �
I he�Bby affirm Ihat 1 am licenzetl untle� p�ovislon5 oi Chart¢r 9(comm¢ncing
with y¢��ion �000) of Division 3 ot the 8uslness antl 7rofe55ions Cotle, antl
my Iieense is in tull force antl etfect.
Llcensc Class Llcense No.
Datc Si9natura
'•'00.KER5' COMPENSATION qECLARATION
voby aHirm that I hava a certlli<ate ol consent to sel/ansure or a cnrUticato
Worker5' Compensation �nsUrante, or a CerlHietl <Opy l�ereot (So�Hon
atl00� �b. C.) ,
PoI7cY No. Company
8 C@rtifletl copy is hareby (urnlsheC.
CCrtifietl copy is (iletl wich the city Builtling 07vlsion.
Da[e ApDlicant
EXEMPTION FROM WORKERS' COMPENSATION OECLARATION'
(ThliSectlon neetl not bo completetl if [he p¢rmit is fo� on¢ huntl�etl ($300) o�
lesz).
1 certity that In tpe pnrformance ot the wo�k for which lhis pa�m�t is ISS�etl I
snall not emplOy any' pe�sOn In any ma�ry�¢r sa as to bncpp�e jubject to t�0
Workers' Compens�tlyn Laws of CaU(oyrra. // r //_// _
'NOTICE: If, after making this tloclaration, you should become su�7ect to tha
WOlkeri' COTPenSdtiOn prOVI510n5 Of Ihe LdbOr C�:tle, you must forthwitb
comply witn such provlsions or this permit snall be tleemetl revoketl.
CONSTRUCTION LENDING AGENCV �
I hersby aHirm that tnere is a construction I¢naing agancy lor the performance
of [he work for which thi5 Oetmit is issuetl (SectiOn 3097 Civ. C.)
Lentler's Name
Lenaer's Aatlress
OWNER BUIIDER DECLARATION
I hereby a1Brm tha[ I am axamD� �rom tho Contraclor's �Icense law for the
following reason (5eclion 7031.5 Business antl Profesilonal Cotle: Any city oi
couqty which requires a permil to construct, alter Improve, tlemolisb or ropal
a�v .���r��.a vi�. �n us Issuance. also reaulrez t{�e aoolicant for such permll
antl the basis for the allegetl ezemption. AnY violation o1
� any applicant for a permit subjects tha applicant to
mt more than tive huntlr¢d tlollars (5500).
d5
employnos, provitletl t�at such improvements are not Intentletl or o��erea tor
sale. �t, howeveq [ba builtling or imp�ovement Is soltl within one year of com•
pietlon, tM1e owner will navo tho burtlen oi proving hc/sne EIO not bulltl or im-
�rove br tho purpose ot salo).
t, az owner of tM1e ptopertY, am excluslvely conlratting wifb Iicensetl con-
Vactors to cons[ruct Ihe Project ISectlon 7044, Businezs antl Protasslons Cotle:
Tho Conlrat[or's Licenta Law does not apply to an owner of O�operty wh0
bui�tls or Imoroves thereon, antl who contracts tor sucn projects witn a con-
tracpor(sl license pursuant�to the Contractor'S Licanze Law�. 1 am awar¢ Ihat
p�oOt of thei� Work¢r's Compensatlon inSU�ant¢ ihOultl 0¢ Orovid¢tl to me.
❑ I;m exempi untler Sectlon, 6�S G��. for this reason
I have reatl tnis appllwtion a}St1-state that Ihe above
I agreo to comply witn all cI4J and county ortlinancns
to � iltling tonstructlon, antl hereb authorize repre-
� lo t up n[he above-menl 8G pro00rty for
p„a /z—i�—Pi
or 55
TVPE OF CONSTRUCTION L1 NEW LJ AOD U ALTERATION 1� REPAIR
❑ GONVERSION ❑ DEMOLISH ❑ OTHER A.p # -
DESCFIPTION OF WORK/USE OF BLDG. S Main Building:
E
TVPEOFPERMIT GRADING�y pOUNDATION STRUCTURAL T Front '
� � TENANT Q ELECTRICAL LJ PLUMBING� O MECHANICAL B Reef .
' ❑.�OTHER _ A
PRWECT DESCRIPTION 54. FT, oCCUPANCv C Right
K
CONSTRVCTIONTVPE VA�UATION$ g Lefl
ZONE GRAOING CU. V�S. ACRES P��, pef. #
Remarks: ' � ' Plannina Notes:
Bar Sink
Backflow Preventer
Backflow Irrigation
Clarifiers
Drinking Fountains
Floor Drains
Floor Sinks
Gas Service Outlets
Interceptors
Kitchen Sink
Roof Drains
Reinspection Fee I $15
Duc[-UnderGround
Duct - Strue�ural
Duct - Veniilating
Exhaust System ❑ Multiple
Firepl/Fact. Blt. ICBO #
Heating System & Ducting
❑a700,0008TU �100,000
Reinipection Fee � 515
CMF OBfiS-46, rev. 30/84 Wnite � BuilEing; Canary • Applicynt; Pink - Accounting; GolOenrotl • Assassor
FEES
Showers
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
Solar Pipin9
Solar Tenk
Swimming Pool w/Spa
Urinal
Water Closet
Water Heacer
Water Service
Au[o�Wash
laue Fee � $ 3
5970 12/17/85.
Acceuory Building:
Parkin9 Req./Provided
ELECTRICAL
Automatic Washer Transformer ❑� 75-50 KW
Construction Pole Sub. � 50 + KW
Coaking Unit . Meter ❑up ro f00amps
Dishwasher : • . ' Meter ❑over100amps
Dryers ❑Gas'DElec[ric SubPanel
Fan �- Motors�0.7 HP �1Yh-8
F.A.U. Inc.Solar �9�15 HP �16-15+
Fixmres Miaowave
Device Boxes Pole Light
Outlets Range
$wiLcheS
Garbage Dispoul
Generator 00.5 KW �5�15 KW
500' T[�
il
f
2ona
; Standing Sections
Trash Compactor
Reinspection Fee $15 lssue Fee
IANICAL � FEES
Haod or Typel ❑
DEVELOPMENTSERVICESRE�UIREMENTS:
Canopy Type II ❑ Zoning Approved 8y
Building Approved By — �\
Retr'igerafion SYstem
00.100,OOOBTU �700,000
Syztem Repair/Alteration �
Fire Dampers
Registers
Iswe Fee I S 3
2
O
N
I,
N
G
R
E
Q
M
T
S
FEES
53
SUMMARV OF FEES
BUILDING PERMIT $ SMIP ' $
PLAN CHECK $ PERMIT
PLUMBING $ � ISSUANCE $
PLAN CHECK 25% $ ENERGV P.C. $
ELECTRICAL � $ GRADING $
' PLANCHECK 50% $ MICROFILM' $
MECHANICAL $ TOTALFEE $ 5'�
PLAN CHECK 25% s ;
_'CO{SSTRUCTION AND PLANNING POO' Q SPA �
APpROVALS . Permit # Date Inspector AppROVALS �_.mit # Date Inspector
•� 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
r2. Soil Pipe-Undcgmd. - 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, � Undrgrnd. •
10. Structural Floor System � 61. APPROVAL TO DECK !
,11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final �
� 12. $ewer Cap �; - 63. Heater & Vent-Final �
13. Roof Drains 64. Plumbing System - Final . , .
14. Rou9h Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final .
16..Rough Electric Wiring . 67. Fencing & Access Approval � .
i
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
78. Rough Electrical-T.Bar Ceiling ' 69. POO VSPA SYSTEMS FINAL � -
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough-Factory fireplace � APPROVALS Permit #
21. Ducts, in Struc[ure 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. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation . 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
�31. �P.laster Brown Coat 79. FINAL INSPECTION ,
; �
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
� 33. Final Electric Notes: �
34. Final Heating &,Air Conditioning � ' ' �
35. Final Gas�Pipe•Test�•� , � � �
i
36. Hood or Canopy � . . .
37. Final Factory Fireplace � � �
38. Final Plumbing � , ��Z ��' G� � '
39. Water Service-Final �• � � (,�/J � ,
40. Gas Service-Final �
41. Solar pomestic-Final
42. Backflow Preventer
43. Backflow Irrigation - , '
•44. Landsrape Irrigation System
45. Sound Attenuation - - �
46. Handicap Regulations , �
47. FINALSTRUCTURE&BUILDING
48. Special Requirements Comple[ed � �
49. Electric Release to Edison �
50. Gas Release to $outhern California Gas Co ' �
51. CERTIFICATEOF'OCCUPANCY . �
No. • Date , !
�i Applicant to flll�ln ali spaees axcept tnosa wlthin neavy bortler Ilnes antl sign all aooroDriata aeclaralions.
CITY OF COSTA MESA /(�`O STR)��7JCTION PERMIT P AMIT JNO. TRACT NO. LOT NO. UNIT NO. A P# 2one
Project Address Se� y�/i /�+h S�- �S v "� 2 S Main Building: Accessory Building:
Applltant's Mailing Addre55 �'Q L3e X 7ZJ' �/,/t.r�r+1E 9/ZG� TVPE OF CONSTRUCT� NEW ADD ALTERATION REPAIR
Owner'SName � V��y nF OLflrv4.' !� $�%n/� � CONVERSION DEMOLISH ❑ OTH R . ' T Front 0
J�5,3 E ���t s/Y� AN� one9?7Q� � DESCRIPTION OF WOFK/USE OF BLDG. ��`�S ��- A Rear N
Address /f/ (�
Arch/Eng. License No. TYPE OF PERMIT GRADING FOVNDATION STRVCTURAL � K Right G
Addr@is {. ❑ TENANT ❑ ELE CTRICAL ❑ PLY MBING ❑ MECHANICAL S Left R
Contractor'sName �V,I,�Kt�d6,, �U�Pil1�/✓� PhonA �y'�a-9yy � o7HER `�,�� �_p.t,b l i ��, U� ping. Ref. # Parking Req./Provided E
Addrpss (mailingl �.�.SL Z-r h/ /G q Z4J� PROJECT DESCRIPTION So. F7. OCCUaANCv Planning Notes: n
C O N STFUCTION TVPE VALUATION $ M
CiryLicenseNo. 7'� S T
�ONE GRADING GU. VDS. ACRES g
LICENSED CONTRACTOR DECLARATION
1 her@by altirm Ipat I am Iicensetl untlor provislons of Chart¢r 9(commenGinq Remd�ks:
wilh section ]000) o/ Division 3 ot tne Business antl Pmtessions CoOe, antl -
my Iitense is in fu11 rc nA eitect. YZ FEES
L RICAL
Licens$. C�laS ���� LI_ cense No. ��a�v
Date y� 5'g t _!��—�' PLUMBING FEES %�utomatic Washer Transformer ❑ 15�50 KW
WORKERS' COMPENSATION DECLARATION Construction Pole Sub. ❑ 50+ KW
�ruDy affirm thal I nave a ttrtlticata ot consent to seli-insure or a certHicate Ber Sink Showers
Norkers' COTpenidtion insurdnce, o� a ce�titi¢tl copy th¢�eOt ($BCtiOn Cooking Unit M¢l2� ❑Up LO 100 drttp5
�o, �ab. c. ,/ 1/ � / L• Backflow Preventer Service Sink
�Qy7.f� Uj'I/�7(',Q �/4P�,U� Dishwasher Meter ❑over100amps
Policy rvo. Company Backflow Irrigation Sewer Cap
C2rtiried coDr is nereey rurnisnea. ,/� Dryers ❑Gas ❑Electric Sub Panel
� Cert�' j'Ptl$9� Y' J� eC with [he <ity Builtling Divis /� Bathtubs Sew¢� Connection
ate O �7'�7 Applicant �`� Fa�
E%EMPTlON FROM WORKERS' COMP@NSATION DECLARATION Clelifief5 Solar COIIeCtOrs MoLofS �Pl HP O1'h � 8
I ss�s section neetl not be completetl if the permit is for one nuntlretl ($100) or Dishwasher Solar Piping � F�A�U� Ina Solar 09�75 HP (�16�15+
1 Cer(ily Ihat in tne plrformance ot Ihe Work fOr whl�h this perm�t ii izsuetl I FI%[Ur¢5
shall not employ any parson in any manner so as to become suoject to l�e Orinking Fountain5 Solar Tank Miuowave
Workers' Comoansation Laws of CalHornia. DeVice Boxes
Date Signature Floor DrainS Swimming Pool w/Spa Pa� �9h�
NOTICE: If, atter makin9 this tleclarat7on, you shoultl become sub)ect to the Ufinal Outlets y
Wo�ke�s' Compen5dtlon provisioni ol [he Ldbo� COOe, you must �orthwitb FI00� $i�k5 Ran e
comply with such provisions or tltls permit 5hall be tl<emetl mvokatl. Switch¢S
CONSTRUCTION LENDING AGENCV - GeSSefVic.0 OutI8t5 WeLelCloSEt Sign
I horCby afflrm that lbere is a construction lentling agency for the performance
of tne work tor wnlU tnls permit Is Issuetl ($ection 3097 Clv. C.) Interceptors Water Heater Garbage Dispo581 Standing $ections
1_entle�'S Nam¢
Lentler's Aetlress Kitchen Sink Water Service Generator �0-5 KW �5-15 KW Trash Compactor
OWNE0. BUILDER DECLARATION
I h¢reby atiirm ihat I am exempt from tho Contractor's LltMse Ldw for [pe LevBlOfieS AuIO�Wash
. follo�ving reason (Section 7031.5 Buslnass antl Profezilonal Cotle: Hny city or
Coupty whicll IlqUirai a permit to cOnStruct, altef, IIi�D�ovB, tleT011ih Or fapdif P—TfBp �pUOdfy Tf2Y5
any sllutlufe, prlor l0 i[5 iz5uance, also lequires tha applicant (Of Sutb perTit
to tile a si9netl statement tnat he/shc is li<ensetl pursuant to the orovisiorts of qoof Drains
[he Con[ractor's License Law (Ghapter 9(commencing with Section 7000) o(
�sion 3 of t�e Business antl Professions Cotle) or that he/she is exempl Reinspection Fee $15 laue Fee
eirom antl the basis tor [he alle9etl exemption. Any violation oi Snctlon $ 3
1.5 by any apP��tant fOr a Pe�mi[ subjects Ne aOP��cant lo d ciVil
�enalty o( not more than tive huntlretl tloiiars (5500). 3 DEVELOPMENT SERVICES qEQUIREMENTS:
LJ I, as owner ot tne o�opertY or my employees with wages as their sole Reinspeetion Fee $15 Isue Fee $
compensation, will tlo the work, antl tM1e structure is not intenQeC or olferetl Zoning Approved 6y �ate
lor sale (Section �044, eusiness ana Professional Cotle: The Con(ractor's MECHANICAL FEES Building Approved By Date� R�
Li<onse ldw tloCS not dpPty f0 an own¢t of a property who builtls or lmp�Oves
thC/¢on, antl wh0 tloes such work him5elt/he�selt o� Ibrough pis or har OWn goiler HOOd o� Typ¢ I ❑ APP���tioa Issued By - -_- -��� --- Dat
employees, provitlotl tnat such Improvoments are not Intentlatl or olieretl (or — - ,
sale, Ii, howeveq Iho bullCipg O� Imp/ovBment Is Soltl wlthin onG year ot cOm- �OOPy Typ2 I I ❑
oleqon, tne owner will have the burtlan oi provin9 no/sho ditl not bulitl or im- Duct - Under Ground SUMM RV OF F ES
orove �or the purvosa of salej. BUILDING PERMIT $ 7 S��U SMIP $ • s�
� 1, as owner ol the properry, am ezcluslvery contractin9 wlth Ilmnse0 con- Duct - Structurel Refrig ion System p�.,qN CHECK
iractorsto tonstruct tne oroject (Sectlon �O4a, Business ana vrotessions Cotle: $ �y PERMIT
1 Tne Convactors LJcense law doez not appry to an owner ot pmperty who Dutt - Ventilating 100,0008TU ❑700,000 BTU • —� � f ISSUANCE
builtls or improves lhereon, antl who con[racts for sucn orolects wl[h a con• PLUMBING § D $
tractm�sl hcense pursuam io ene conVactors Ucenso Law). i am awara tnae Exhaust System ❑ Multiple ❑ System Repair/Alteretion P�N CHECK 25% $ ENERGV P.C. $
prool 01 thelr Worker's Compensatlon Insuran<a shoultl be vroviaetl to mn. EIECTRICAL GRADING $
❑ I am eaempt untlor Section B. & P. C. ror tn6 reason Firepl/Fect. BIC ICBO � Fire Dampels $
Date owner Heating System & Ducting Registers PLAN CHECK 5096 $ MICROFILM $
i h0reby certily that I have reaC tnis appllcation antl state tnat the above ❑6100,000 BTU O100,0008T , MECHANICAL $ TOTAL FEE $ 3• S �
IMormation is correct. I a9ree to comply witn all tlty ana county ortlinances PLAN CHECK 25% $
anC Rate laws relai7ng to bulltling conslruction, antl bereby autborize �epre-
Sentdtives Ot tpi5 cj� y��Ya� r upOn thC abov8•TentiOnCO plop¢rty fOr
inspectlon pur0o�/}r /wL � Date�
Slgqature VY� �� Reinspeetion Fee S15 Issue Fea $ 3 ' 01 C0�39L03-OLT03?645 ��I�'i �;y,:: •
I Oriyers' License or 55 # �' . OiTE: OFiD4lE9 TjpF2 S i S i'
09ti5-46, �e+'. �/98 �'"��te - tlunam9; Canary - qppuwnr, rinK - AccounLn9: �maenroa - tasseasor
I CONSTRUCTION ANDPLANNING
APPROVALS Permit #
�
� 1. Temporary Electrical Service or Pole
2. Soil Pipe�Undrgrnd. .,
3. Electrical Conduit Uti�ity-Undrgrnd.
"" � 4.' Electrical Conduit-Undigrnd. ��
�!5.�Steel Reinforcement:.�•
s� Electrical UFER Grnd.
7. Footings, " '� : •
8.�Founda[ion � '
9.'Water�Pipe-Undrgrnd. ";'
10: Svucwral Floor System
11. Property Sewer Line.& House Connection
12�Sewer Cap . " �
13.'Roof'Drains ,
14. Rough Plumbing� �
15. Rough Electrical-Conduit
16! Rough Electric Wiring
17�, Rough 1Niring Sign
I r .
1 S. Rough Electricai-T Bar Ceiling
�� _.
19: Rough Heating & Air Conditioning
20t Rough Factory Fireplace
2P! Ducts, in Structure
�
22. Ducts, Vencilacing
23. Gas Pipe-Rough`& Test
24. Roof Framing '
- 25. Roof Sheathing �
26. T-Bar;�eiling (Strucwral) & Monocoat
: v.. -
27. Fram'�and Flashing
28. Lathrrig;& Siding
r-.
29. Insulatio� �
30. Drywsll�Nailing
31. Plaster Biown Coat
32. Electrical Power Meter-Final
33. Final Electric
34. Final Heating & Air Conditioning
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. Backflow Irrigation
44. Landscape Irrigation System
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
51. CERTIFICATE OF OCCUPANCY
No. Date
I-
(�
Date� Inspector
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POO' SPA
APPROVALS Permit #
52. Pool & Equipment Location
53. Steel Reinforcement
54. Forms
55. Electrical Bonding
56. Rough Plumbing & Pressure Test
57. APPROVA� TO COVER-GUNITE
58. Electrical Conduit-Undrgrnd.
59. Gas Pipe, � Undrgrnd., Test
60. Backwash Lines, P-Trap, O Undrgrnd.
61. APPROVALTODECK
62. Backwash & Receptor-Final
63. Heater & Vent�Final
64. Plumbing System - Final
65. Electrical-Final
66. Solar System-Final ,
67. Fencing & Access Approval-
68. APPROVED FOR PLASTERING
69. POOL/SPASYSTEMSFINAL
FIRE DEPT. REQUIREMENT
APPROVALS Permit #
70. Underground Hydro
71. Product Piping OGas ❑Oil
72. Underground Flush
73. Undergrnd. Storage Tank O Gas ❑ Oil ,
74. Overhead Hydro
75. Dry Chemical
76. Dry Standpipe
77. FIXED SYSTEM FINAL
78. FIRE PREV. FINAL
HEALTH DEPT. REQUIREMENT
79. FINAL INSPECTION
80. FOOD CERTIFICATE ISSUED
Notes:�///,/7� /�l/J /lsJ'7I
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Date Inspector
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APPLICA FOR BUILDING PERMIT COUNTY�OF "�,, j�
APPLICANT TO FILL IN AREA WITHIN HEAVY LINES ONLY. oRAN�E
BUILDING � jJ �`��C�� DESCRIPTION OF WORK
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CHECRED 9Y O�TE O�TE CLEAREO � p,C, $
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