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COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA. CAIIFORNIA 92626
� OCT 23-69Cp5p00 953 �¢****$.0�
APPLICAT�ON FOR BUILDING PERMIT
ForApplicanttoFillinCompletely qECEI DAT REE�� IVE �
BUILDING � ' �D �� DAT� I$��ED�
AODRESS �Vi ! ��yy�
OWNER ,I�, C A.P. NO. ��" //—O PEy � vL •
MA 1 L BUI L�ING
A�DRESS ADDRES$ 'L/� �� LC
S �✓4.L
CITV NO�. �TRACT LOT � BLOCKJ
CANSTRUCTION W A
LENDER ` �
��
BRANCH �
OWNER •/J
ADDRESS
U
ARCHITECT TEL. 5 f lf9
OR ENGINEER
FIRE
ADDRE55 ZONE TVPE GROUP
APPROVED
CONTRACTOR BV DATE
ADORESS �
TEL. ZON NO.OF USE OF NEW
CITY NO. '�/ P�� � BUILDI —��
STATE CITY ��+ADSAPPROVED VARDSAP ROVED
LIC. NO. LIC. NO. MAIN BUILDING ACCESSOFiV BUILDING
SIZE NO.OF BLDGS. (FROM C/L STREET)
OF LOT NOW ON LOT FRONT FT. FT.
USE OF
EXISTING BLDG. F
SIZE OF NO. OF
NEWBLOG. ROOMS STORIES L.SIDE FT. FT.
EXTERIOR WALL ROOF
COVERING COVERING REAfl FT. FT.
USE OF BUILDING AND WORK TO 8E PERFORMED D4STAN BET. BET. MAIN &
• � MAIN DGS. ACCESS. BLDGS.
/� !� VAF. # 0.4TE
¢ oO`,� C.U.P.y� APPiiOVED
11,. Q APPROVED Q i �� / C
µN (7
I hereby acknowletlea that I heva reatl this application antl state
thet the ebova information is correct entl aprea to comply with
ell lews ragulatin0 builtling constt�ction, end 1 aholl not employ
ony parson in vlolation ot Iha workmen's compansetion lews ot
[ha Smre of Celifomia. �
1 hereby cariity thet I am properly licenaetl es a contrector under SQ. FT. O
Ne State of Californ(a 6usiness end Prolauiona Cotle, Divisicn 3, THE AMOUNT SHOWN UNDER VALUATION IS FOfi
Chap[nr 9, nntl thet such licenses ara In fuli forca antl eftoct, ar I THE VURPpSE OF ESTABLISHING A PERMIT FEE ONLY: Q
am ozampt from tha provisions of thaSieta of Collto�nia Businecz VALUATION
antl Profoaslons otla, Divislon 3, Chapter 9. � m
PERMIT FEE 5 D O �"
Sipnatura of p � o ` /��/� ^ �J�` � m
Parmhtee Y�� �� �/�1 ,.•"! 1 5�/,J PLP,NCHECK 5 E
`o
Authorizotl ABant LL
TOTAL FEE 5 � OO
OWNER OR
JOB ADDRESS
GENERAL CON
AP No. 141-0'
INSPECTIONS
SOIL
GAS
W ATER
ROUGH PLUMBING
PROP. $Wft. LINE
SPRINKLING SVST
MISCELLANEOUS
ROUGN HEATING ANO AIR CONOITIONING
TEMPORARV SERVICE OR POLE
UNDERGROUN� � POWER �
ROIIGH WIRING
TRENCHES � FORMS � STEEL REINF
FLOOR SVSTEM
BON� BEAM ❑ STEEL REINFORCE ❑
SHEATHING
FRAME AND FLASHING
�ATHING - IN ❑ Ol1T ❑
PLASTER, BROWN COAT
STRUCTURAL, FINAL
HEATING, VENT., REFRIG. AND A.C., FINAL
PLUMBING, FINAL AN� GAS TEST �
BUILDING, FINAL
DATE
BUILDING PERMIT N0.
SUBCONTRACTOR
,� •