HomeMy WebLinkAbout2641 ELDEN AVE - Building Permits ELDEN AVENUE,
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a4418 - 8-1-61 reicc move-in res$3,50o1
15970 - 4-19-62 relcc move-in res4,5001
17663 - 11-7-62 reloc ove-_n re3,500 ;
3468 - 2-4-72 ?'_og. NC (:r.a )
I 7 2-1.6.74 Drain
2,450.
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�w CITY CF COMA MESA
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BUILDING DIVISION
>:j,,,,,' 1,8 DEVELOPMENT SERVICES DEPARTMENT PER IT NUMBER
�1• � � 1 PERMIT
101114111 . 04-01149
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 2641 ELDEN AV Status: ISSUED
Suite No C Applied: 11/01/2004
Vicinity: Issued: 11/01/2004
Parcel Nunmber: 43907121 ,� / .
Applicant CANNIZZO, TERESA A ISSUED BY:
Address: 2641 ELDEN AVE -
Phone: 949-646-6208
COSTA MESA,CA Zip: 92627
Owner: CANNIZZO, TERESA A
Address 2641 ELDEN AVE
Phone:
COSTA MESA,CA Zip: 92627
Contractor:
Address:
Phone:
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Zip:
License:
SCOPE OF PERMIT
UPGRADE ELECTRICAL SERVICE PANEL UP TO 200 AMPS. •
' FEE SUMMARY
Quantity - Quantity
ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0
Temp service test $0.00 Busway/100 ft $0.00 0
Res.a/c package $0.00 Standing Section $0.00 0
New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0
New Res(3+units) . $0.00 0 Transformers up to.1 kva/kw $0.00 0 .
Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0
Lighting Fixts $0.00 0 - up to 50 kva/kw $0.00 0
Recept Outlets $0.00 0 . " up to 100 kva/kw $0.00 • 0
Switches $0.00 0 - over 100 kva/kw $0.00 0 .
Non Res Appl $0.00 0 - Low Voltage Equipment • $0.00 0
Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0
Service to 200a $30.50 1 Misc.Conduit $0.00 0
Service to 1000a $0.00 0 Misc.Conductor $0.00 0
Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 .
Motors to 1hp $0.00 0 Circus(mech ride or lights) $0.00 0
Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0
Motors to 50hp $0.00 0 Fireworks Stand $0.00 0
Motors to 100hp $0.00 0 Other Electrical Fee $0.00
Motors over 100hp $0.00 0
Communication drops $0.00 0 . Investigation Fee - ' $0.00
Sub panel to 200a $0.00 0 Plan Check Fee - . $0.00
Pole Light Pkg $0.00 0 Reinspection Fee $0.00
Sign Circuits $0.00 0
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NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6100) .
DECLARATIONS - O -
WORKERS'COMPENSATION DECLARATION:
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I hereby affirm under penalty of perjury one of the following declarations: '
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is Issued.
❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed If the permit is valued at one hundred dollars($100)or less.) .
❑ I certify that in the perfor -rice of the wo which this permit is Issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws ofd.Ifomia,end ag a that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these ions.�
Applicant Signature: ' "nc 214i(n gig-- Date: //— I C CI
WARNING:FAILURE T• - CURE WORKERS'COMPENSATION•'A 4RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED
THOUSAND DOLIA-• 100,000).IN ADOMON TO THE COST.ipn PENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.LIC.II Class It
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑. I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or Improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such Improvements are not intended or offered for sale.If,however,the building or Improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). '
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license purs ..nt to the Cant Ctors License Laws.).
❑ I am e - ir under sec. Business and Professions Code for this reason:
Signatu :. I F . . 7^741 / Date: (/— I — 0 CI
Owner I s 'miffed by driver's license. 7.---0 No Driver's License No. ? Expires: 1r —2Z.7—O7
Veri'�lion of Ownership by(type of docu ,I.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet In depth Into which a person Is required to descend,will be made In connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341.Title 8,Califomia Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature end pressure).
3 Does or will the applicant or present or future building occupant need to prepare en RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of en RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP Is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a gpermit for such construction or modification
from the South Coast Alr Quality Management District or from any other air pollution control district or agency? Yes U No
(Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If"yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health end Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
B (If'yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERT1FICA OF COMPLIANC D AUTHORIZATION OF ENTRY: I certify under penally of perjury that I have read this application and state that the information given is
correct ee to comply wit II state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
a -de ribned�p_roperty for spection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
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SignatuYIr:�1 j,=gal Owner(s) Dat
And/0 ruthorized Applicant Date
coos I INSPECTION TYPE PETE ItIMIALS gm L• INSPECTION TYPE PEE INITIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing p p 77
200 Final Re-Roof 210 Final Electrical ll(( //�4I r/1oV
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place • 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition • 250 Final Building/Ocduparicy
` • 14418
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COSTA MESA BUILDING-SAFETY DEPARTMENT (\ I,IA( 5 t
P. O. BOX 317 COSTA MESA. CALIFORNIA 1 liti-11111 XP1.
CITY Or CUSIN r:itSP
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
BUILDING G1/ •// f f4 Ge,fyL'
ADDRESS -1`)"' CiC.R.cq"�
COSTA ME . CALIFORNIA For Office Use Only
01 - /� I RECEIPT No. I /71240271
OWNER ' alit:Kd'M'r1
' MAIL 'J i /,.D RECEIVED� I ��RECEIVED// I . DATEISSUED
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ADDRESS 3 YI/A.vI"^' -G
j� TNT,-.4. it BUILDING
CITY •/�/ wit ADDRESS
ARCHITECT TEL. COSTA MESA. CALIFORNIA .
OR ENGINEER NO.
ADDRESS FIRE
ZONEIRTYPE GROUP !-
CONTRACTOR ®1j/yK�. APPROVEDPRDATE
ADDRESS ZONING alp,,,„ ,,_
ZONE 1:(q1 NO.OF USE OF NEW . I
CITY 1PLANE ////1111� I BUILDIN
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STATE TEL. LEGAL
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LIC.NO. NO. DESCRIPTION /n 1 7 6 S(�`�Fi/ /6 z tan/
SIZE //. �{ 'S/{, NO. OF BLDGL. �7
OF LOT (0 J� Sox NOW ON LOT / A.P.0-,04 D - 4? 7
USE OF •/7 / _ YARDS EVES
EXISTING BLDG. �(,�3�Ptitic-�-�' APPROVED ALLOWED
SETBACK LINE FROM / (CENTER LINE ST.) / OS; -3 or,--.I---
SETBACK
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CENTER OF STREET So REAR YARD 20 FRONT ',ry//A FT. /�ZP/�/•�jIN.
SIDE YARD I LEFT air I RIGHT 6- R.SIDE OI L.5.--- 3-FT. V IN. `,
DESCRIPTION OF WORKaA230 FT. IN. h0
L.SIDE ��ff
NEW I II ALTERATION I 1 ADDITION I REAR VI. 21,7eKT. 4532_a4 '<- TN
REPAIR I II MOVING I VII DEMOLISH I APPROVED/i.,7 n 1
APPROVED/0
(• ' ( DATE ,5--a---6,/
BUILDING NO. / HOLD FOR SPECIAL R_ L
SIZE ROOMSS STORIES pivt�T`:TS
EXTERIOR WALL `..////-- ROOF
COVERING SY�•fl COVERING ' 0 I . �" :, • S./• S
USE OF SW •I G Ai•WORK TO-BE PERFQR D 77.q
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I HEREBY ACKNOWLEDGE THAT I HAVE READ IS APP CATION
AND STATE THAT THE ABOVE IS CORREC AND AGREE TO COM- THE AMOUNT SHO UNDER VALUATION IS Fe HE HE
PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL CITY ORDINANCES D TE LAWS REGULATING
BUILDING CONSTRUCT VALUATION
SIGNATURE OF /, � PERMIT FEE $ /OP/ C4-0 H
PERMITTEEdh. ? -- a
$ '25� �/ PLAN CHECK $ `B
AUTHORIZED AGENT �- c-1—O o
N. TOTAL FEE $
r59FEE RECEIVED-a
COSTA MESA BUILDING-SAFETY DEPARTMENT DEC 111961 i140
P. O. BOX 917 COSTA MESA. CALIFORNIA 0 FINANCE DEPT. (�
CITY OF COSTA MESA
For Applicant to Fill In Completely APPLICATION FOR PERMIT 5
TYPE OR PRINT
BUILDING ao /, Ave BUILDING �`
ADDRESS
COSTA MES . CALIFORNIA For Office Use Only .'
(17....2
//' !%//��, RECEIPT NO. Pe IT•�NO.
OWNER (1 /'!// �C��rC1� I 3 R/g� /V¢ I I.� 9 / �
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CITY ( 2 �Y7(hL NEO'L✓ O/J/N vc�!/K'/ V�Cr�.r�✓(� __ "� •
BUILDING
ADDRESS
ARCHITECT TEL. COSTA MESA. CALIFORNIA o!
OR ENGINEER NO.
ADDRESS FIRE
/ �� , ZONE TYPE GROUP •
CONTRACTOR -+C '.�arra.,�Q APPROVED DATEll-
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ADDRESS 3 3 3 4414,.."1--- So"- INCtfiI `
CITY .o<� .. //le'� ..e...- O V I NO. /I USE OF NHW .1.M., v
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rtiON (!� /1�G L(//, 1'\ �] F+
SIZE / / �/ 5C r NO. OF SLOGS. 2 A.P.NO. I I cj �G� ( II '- e( I
OF LO7 Cl1 CF /� J NOW ON LOT 1
USE OF ' _�� YARDS EVES
EXISTING BLDG. N,� -J/^ APPROVED ALLOWED
SETBACK LINE FROM h/l/ ?S!• a(CENTER LINE ST.) `� 0
CENTER OF STREET REAR YARD ! FRONT' •J/ FT. ,IA IN. .t..41
SIDE YARD ( LEFT 5' n I RIGHT 6] — R.SIDE % FT. IN. �ry
DESCRIPTION OF WORK 5
L.SIDE T. N. 00 l
NEW I II ALTERATION I Il ADDITION I REAR 2 FT. IN./ d
REPAIR II MOVING (V DEMOLISH APPROVED ' a ��// DATE et-// X12'
BUILDING NO. OF 1/
SIZE ROOMS STORIES L^
EXTERIOR WALLROOF
COVERING I COVERING
USE OF BUILDING AND WORK TO BE PERFORMED
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I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN U R VALUATION 18 FOR THE In
AND STATE THAT THE ABOVE IS COR' AND AGREE TO COM• PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. Q:
PLY WITH ALL CITY ORDINANCE AN• • ATE LAWS REGULATING .0‘19BUILDING CONSTRUCTI / VALUATION
SIGNATURE OF 4: PERMIT FEE Si*
PERMITTEF n
AUTHORIZED AGENT /
_ $ /L SO V f1 w PLAN CHECK 5 ' � �'
/ p
TOTAL FEE 4 A
°.:. .- i I.
I" 7663 FEE RECEIVED
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COSTA MESA BUILDING-SAFETY DEPARTMENT AUG "1 j l%3
' P. O. BOX 917 COSTA MESA. CALIFORNIA
FINANCE',DEPT. .
For Applicant to Fill In Completely APPCI 4'nS I'4 gptiggiT
TYPE OR PRINT BUILDING •
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BUILDING 0/ 4 1: 77,,e,-..- -
ADDRESS
COSTA MESA, CALIFORNIA For Office Use Only
RECEIPT NO. /�R/11 N_y(
OWNER L • �c1 nL ✓ _,L �j I I (O V {V
MAIL / 333 1' Air�7 LJ/ !_/. RHCgIYEgBY I pyre RR)'iVC I �SBl. UeLl.!
ADDRESS/` -,7P�,,,, Afar/ H...(!i/fl•1� ,O/YJ j/�� lT4T1
CITY ( �"'�/(L 9�Lco Pv NO.L I�. ADDRESS a( (r! .� /
ARCHITECT TEL. .-- COSTA MESA. CALIFORNIA
OR ENGINEER NO.ADDRESS •/ FIRE
ZONE //��.�� TYPE GROUP]79.
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CONTRACTOR i iv-P ei,-� APPROVE}JP//� DATJ/f✓ v-
llxf p ZONING wL, `
ADDRESS •ryyL(f'
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CITY YI PLANE BUILDING lie e
LIC.TE TEL.NO. / / ] NO. --� DESCRIPTION 9 o R. LI 1 / I/i a /1 Li �e. 2:...S1
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OF LOT (/ (/ 3c.� I NO. OP NOW ON LOTS A.P.NO. l f r -"16 -413 V (.
USE OF I� . /� cam- ! \
EXISTING BLDG. K(A{-C( APPROVED ALLOWED
SETBACK LINE PROM /`� r Y I (CENTER LINE ST.) ,J�
CENTER OF STREET /3 _O REAR YARD Lt)-O FRONT GJ V FT. IN.
SIDE YARD I LEFT /0 /, u I RIGHT 5 U R.SIDE 5 FT. IN.
DESCRIPTION OF WORK
L.SIDE / / FT. 3 IN.
NEW I II ALTERATION I V ADDITION I REAR I^!! FT. 4,1 •
/ IN. �1J
REPAIR I MOVING IflII�DEMOLISH I APPROVED ///r I/I �1 DATE /3 -4 :
BUILDING .O X 4-0 ROOMS ✓ STORIES / �{ (/�// (J J
SIZE
EXTERIOR WALL ROOF /� y
COVERING _ LL�tp I COVERING `-C✓•"- 7
USE OF BUILDING AND WORK TO/BE.PERFORM JI•
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rt 0 � Co l°a~' CA-U.-K.42.1 4
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O `7TION IS C--,Z11.
THE
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I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UVALUATION IS FOR THE
LL
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL CITY ORDIN CEP ND STATE LAWS REGULATING
BUILDING CONSTRUCTION. VALUATION •D
.-y,�/— ��
SIGNTURE PERMAITTEF 012 ` �C•L �nl PERMIT FEE S /,5� N a,
$3 SQ 62.--PLAN CHECK $
AUTHORIZED AGENT / LI
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i.. TOTAL FEE $�/77 U.
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Condit'i'ons of approval:
1. All ;the:requirements of the Department of Building Safety.
2. That the applicant posts a bond in the amount of $3500.00.
3. That the Build2ngYbe completed 60-days after date of delivery.
4. Installation of residential sidewalks across the front of
this property and concrete driveway approaches by the applicant,
at his expense, under the direction of the City Engineer.
5. Dedication to the City of Costa Mesa, by the applicant, of all
land 30' from the center line of existing Elden Avenue for
street widening purposes.
• JAN -7-714-c--;,-„PPRItOO 237' irxtrsY35.00
37805
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
AP LI A ON FOR BUILDING PERMIT
For Applicant to Fill in Completely P
RECF V DATE RECEIVED DATE ISSUED
ABUILDIDDRESS SG 2641 i=4dE /4 N vs.
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OWNER ��,,ss�� / ,,''// ,J�1 Z J //L DVo_ri
(/(/r/Ti [vs/ �//.V/u� A.P. NO. 1 / / ���111
BUILDINGMAIL
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ADDRESS 20975g1/foizAL Pi-- ADDRESS 77 C 0E�?V I
0-U CITY COSTh /A?S NOI 11 Ill L6j44 7/7/ TRACT 37 G dT2i/ BLOCK
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CONSTRUCTION N W A R REPAIR MOVING DFMOI ISH
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-cn LENDER
JD BRANCH 1/]� /�/ �s�,CO
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J N OWNER •VSA. / " GNO /G.-S
Q ILIJ ADDRESS
m J /./. /1 C q10044-110
e�I ' I VALUE
J Q OR ENGINEER y1/N�s-V r- ST�t////YS NOL S/�v� USE � �� OI'�/T I N $�c;: 46-z)
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W ADDRESS /p2p A(assz/ZI/Y AV./E CoZONEat,GROUP ._
W Z Ad/ el r/040/ElC!/ Co- APPROVED DAT( 7-9/
J O CONTRACTOR BY /
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7;cc ADDRESS SZZ/ , ss4r c2ZO '4#-
tJ W TEL. ZONE NO.OF USE OF NEW
Z H CITY sa/a prem Noc5Z3,3:633 PLANS BUILDING
w O STATE CITY YARDS APPROVED YARDS APPROVED
(n CC LIC. NO. J572e/ A_ LIC. NO. MAIN BUILDING ACCESSORY BUILDING
D �/� (FROM C/L STREET)
SIZE INO.OF BLOCS.
OF LOT NOW ON LOT A FRONT FT. FT.
USE OF y�`.,
EXISTING BLDG. n/ ati,fra 5 • _B.SIDE FT. FT.
I- SIZE OF NO.OF
Z NEW BLDG. ROOMS STORIES L.SIDE FT. FT.
tel EXTERIOR WALL ROOF
COVERING I COVERING REAR FT. FT. •
J USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
CL
a MAIN BLDGS. ACCESS. BI nag..
o Cebi�isriaacrioyyiL
acsreia/ tam/ C URP# APPROVED i
ti pai.ip/No sysra/r/ APPROVED �J
RY DATE //
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I hereby acknowledge that I have read this application and state
D that the above information is correct and agree to comply with
cc all laws regulating building construction, and I shall not employ •
I_ any person in violation of the workman's compensation laws of
rA the State of California. m
Z . SO.
I hereby certify that I am properly licensed as a contractor under SO. FT. o
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR i
Chapter 9, and that such licenses . • irftull force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: e
cc
am exempt from 0 provisi• of the State of California Business .(
and Professions Cr.ia,D' .,•-,--xy:• VALUATION ��
r�s-�1�1� PERMIT FEE $
Signa / /t / f_ m
Perms -1•C•-'-'-�Lr � �� _ $9r/� �'T PLAN CHECK $ //. — E
Authorized Agent 7J 3 v�u
TOTAL FEE $ /