HomeMy WebLinkAbout2155 CANYON DR - Building Permits CITY OF COSTA MESA
•
BUILDING DIVISION
fi m^ w 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
'k f��' FOR INSPECTIONS CALL: (714)754-5626
PERMIT NUMBER: P09-00034
PERMIT TYPE PLUM STATUS: ISSUED
APN: 42204148 DATE ISSUED: 02/26/2009
• ISSUED BY: RMD
JOB ADDRESS: 2155 CANYON DR CM Suite/Unit:
Vicinity: -
SCOPE OF WORK: PLUMBING PERMIT FOR 4 NEW GAS SERVICES AND 4 GAS OUTLETS FOR A 4-PLEX.
OWNER: KELLY, RICHARD K Address: 2155 CANYON DR
PHONE: 714-679-2536 - - City/State/Zip: COSTA MESA,CA
APPLICANT: KELLY,RICHARD K - - Address: 2155 CANYON DR :
PHONE: 714-679-2536 _ - City/State/zZip: COSTA MESA,CA
CONTRACTOR: OWNER-BUILDER License No. 000000
Address: - PHONE:
City/State: ZipCode.` 1 - - CELL:
ARCHITECT: Liiense No. PHONE:
ENGINEER: License No. PHONE:
/0043
•
PLUMBING PERMIT FEE SUMMARY • DL tail i n e-
PLAN CHECK FEE: . $0.00 leer Se61.-
PERMIT FEE: $68.85 /./ -a5—/(
TOTAL FEES: $68.85
EXi'ittED
PATE 4-.2-6, --// a --
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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
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.
CODE O. INSPECTION TYPE DATE ti TIMED CODE I INSPECTION TYPE DAT INTMALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
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/Occupancy
t
WORKERS'COMPENSATION DECLARATION: Owner ID verified by drivers license. Yes ❑No
I hereby affirm under penalty of perjury one of the following declarations: Driver's:License No. Expires: /1 _8:/Z
❑ I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of e.-property tax bill or deed): f
compensation, as provided for by section 3700 of the Labor Code, for the r
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 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a
number are: person is required to descend,will be made in connection with work authorized
by this permit,and that no building structure,scaffolding,falsework,a-demolition
Carrier: or dismantling thereof,will be more than thirty-six(36)feet high.(Chap. 3.2.Grp
(This sedan need not be competed dine perms B valued at one hundred dollars(5toe)orless.)
2,Art2 Sec.341,Title S,California Administrative Code).
Policy Number:
0 As owner-builder. I will not employ anyone to do work which would
CDr)I'certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless
issued. I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California, and agree that if I should
become supject to the workers'compensation provisions of Section 3700 of Applicant's Signature Date
the Lab I sh- /orthwith comply with these provisions.
Division of Industrial Safety Permit Number:
/
Awl! I's Signature Dame - HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: F• i RE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No
($100,000). IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST.AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. 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
LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is in full force and effect. a registration form for acutely hazardous materials? 0-Yes 0 No
Lic.# Class# _ (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
Contractor's Signature Date 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work fcr which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name: hazardous materials)? 0 Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the
Lender's Address: Costa Mesa Fire Department may require the preparation, certification and
filing with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
Signature Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes 0 No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Govemment Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits).
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 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? 0 Yes 0 No
applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes",the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
O I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation. WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec.7044,Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No
thereon,and who does such work himself or herself or through his or her own
8. (If"yes",attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
(❑—'I`as owner of the property, am EXCLUSIVELY CONTRACTING WITH
city ordinances regarding Hazardous Materials and Emissions.
LICENSED CONTRACTORS to construct the project(Sec.7044,Business and
Professions Code: The contractors License Law does not apply to an owner of Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
0 am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances rela'ng to building construction, and authorize representatives of
Business and Professions Code for this reason: the City of 1:to Mesa to enter upon the above-described property for
inspection .. o 's. I a,r-e not to occupy or allow occupancy of any building
authorize/ , :. until final inspection.
/J/ �-1A
Si fur '•- ' oante
d�46(3/07) .
And/or Authonzed Applicant Date
•
r CITY OF COSTA MESA
44- BUILDING DIVISION
Y%
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:'` • '
. -
❑ I havejnd will maintain a certificate of consent to self-Insure for worker'compensation,as provided for by section 3700 of the Labor Code,for th&performance of the '
for which this permit is issued.
. I have and will maintain workers'compensation in rance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My works compensation insurepLca carder a olicy number are: /'O l0 6 XS 57
7/� (/� � / r'L1i� PobyTJurnber:
is section eed not be completed it the permit is valued at one hundred dollars($100)or less.) . . .. - .
❑ I certify that in the'performance of the • r which t 's permit is issued,I shall not employ any person in any manner so as to become subject to the workers'•
compensation laws of California,and .• that If I s Id beco a subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these.provisions. O (o
glgnatu faDa —S C —[ c
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37116 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I herebcy@fffmrttiall am Ijeensed un pr is'jr1 Qp_epli 9(commencing with Section 7000)of Division 3of�theBusigess and Pro sion5.0 and my license is in full
.:'. f /�7 T 11�-tM' 7
force andettect,.L•ic': 4 '
Contraclofs Sigpature:---) 2 TI,late:J 1 U -' j—� 6
yb-21
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).
Lender's Name:- Lender's Address:
Signature: ___/ _ rr'. Date:
OWNER-BUILDER DECLARATIONS:
J
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 pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,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,California 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 Califomia 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).
ail ta ..l.cant.
2 Does or will thee applicant or
present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes 0 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 and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an 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 appermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? IJ Yes ❑No
i
(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 and 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
8 (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:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until
final inspection:
tura Of Le ne
. — /z4 /
f`
rAuthorized ApplicehDate f
goes t 1NSPECTIONTYPE PAIS INTRIALE .. CODE if INSPECTION TYPE PATE IKTRIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final ! -,L .208 Final Plumbing . . ... -
200 Final Re-Roof -`Fit 2ZJO1 210 Final Electrical • .
201 - Final Block/Retaining Wall . / .212 .. Final Fire Prevention - -
202 Final Factory Fire Place ' ' 220 ' Final Planning Approval - .1 . .
203 Final Sign 222 Final Site . . - I.
204' - -Final Demolition ' '• • - •250- ' Final Building/Occupancy • . . . ' -
‘i) OWNER ARTHOFER, DAN t. MARK HOWARD DATE 7-18-72
'JOB ADDRESS 2155 Can Drive , A-D BUILDING PERMIT NO. 34577
`In GENERAL CONTRACTOR owner DESCRIPTION or WORK 4 plex w/att gar
QAP No.115-031-44 LOT TRACT FIRE ZONE . VALUE $56,700.00
INSPECTIONS Si nature Date GROUP H&J TYPE V ZONER4/CP
`\i7501E n 7'.,,LJ7J'J.- PERMITS ISSUED
GAS SUBCONTRACTOR Date I Number I Signature
\\'WATER !/ �/�,6�I - P umbin•
ROUGH PLUMBING fP!'F iir �0/4r/t AswosartaitlI/ a,
PROP. SWR. LINE 0 HOUSE CON. 0 /'�,SAWIC�,� / ���T�-ll�l /�J .
SPRINKLING SYSTEM - , . / ��17/
MISCELLANEOUS 1.11=111111=M
ROUGH HEATING AND AIR CONDITIONING /14 4,10-6-73.,,
S`o c.�,
TEMPORARY SERVICE OR POLE ,/E ?•12 77- z,. ' —_ -' J_ __ _ .
UNDERGROUND ❑ POWER I] • r� 1'
ROUGH WIRING
�f` S Hpp atinq and Vent. ,
TRENCHES 0 FORMS ❑ STEEL REINF. 0 ` 1n�( altn.Ia. Ro -# , ���/'j /J 'Z/
FLOOR SYSTEM q y- Y 4JJ""�� /// /
BOND BEAM ❑ STEEL REINFORCE ❑
SHEATHING /�/a' /0-`Z-72
a -
FRAME AND FLASHING a — �
t9�
LATHING — IN E9.-" OUT [ -/ �•-•-� C IO ^ --tr.--
PLASTER, BROWN COAT ' r/A.0-4 l9C",.,r
STRUCTURAL. FINAL Electri �/ �f ,,•'//n,
HEATING, VENT., REFRIG. AND A.C., FINAL id_ , . ..-72m7.�" ,,, k /77- J ,J44 r,,y/
PLUMBING, FINAL AND GAS TEST r ,( If ,. . llyr,n a.,.v Ae.�,I /,7 7.2, 3,/?'O7 -_ """CC..
ELECTRIC, FINAL I! - .42::-.?..
:_ ._ ,VA. Z �.. c_Ag je7/ /7.2- -- -3"----
34577 , FAIL),, �:r*
,, / 'rn 1 7??h;. 0 619* *84.97
,-
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Completely d
REC ]p� rJJjY DATER EIIVED D TE I UED
BUILDING �a - ' I 'l /r / / / 7 2.
ADDRESS/}04 /i5��z111s CA- J' °....) (�,0�J�R �7, V•�( PERMIT NO.
OWNER Yz IM 'hf/ l Wrl2s/LhvAgp - A.P.NO.HS- W1 _z f 1
n,I f a/,r//^IJ/ [,s ADDRESS a I55 CAN 'cx,J ID 2
Zu,ui ADDRES/1S/1,17 ��1//(/9(/T/ taw ^t/ II ��p
k op2 0 CITY COSTA- 14134 NOL _ ,r /� TRACT C S 3 'LOT I • BLOCK
ZQ CONSTRUCTION �1� ���1��)� ,/// NEW ADD ALTER REPAIR MOVING nEMOI ISH
ON LENDER iI4IQL £IVI�k A
Ct. CO
J 0 BRANCH LOU11.414 (l��r•..���� 1'w "�/� nnii
J LB to ADDRESS OWNERCAN A( rtOFFE-R.i0�rMc uD W A4240
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0E- CITY — NO. Ry LP PVNS L BUILDING y �—F
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W O STATE .n/ - B.•S 3_ ,CITY • YARDS APPROVED YARDS A'PFWWLB?r
U)CC LIC. NO. "/�(Til'O G I LIC.NO. MA UILDING ACCESSORY BUILDING
DSIZE i NO (FR. S.� • -+
OF LOT NOWOF ON LOTBLOGRONT FT.
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VEXTERIOR WALL ROOF COVERING (COVERINGFT.
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APPROAPPROVEDNDATE 7Iltll/Z�
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UI hereby acknowledge that I have read this application and state t� _
that the above information is correct and agree to comply with t.s-
CC all laws regulating building construction, and I shall not employ BOLD FOR SM: AL ar✓�
i_ any person in violation of the workman's compensation laws of
Z / `r /f� 6a4 T /
the State of California.
ZI hereby certify that I am properly licensed as a contractor under O SD. FT. c
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR i
Chapter 9, and that such licenses are In;full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: e
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am exempt from the provisions of the State of California Business r
and Professions o,Divi •is C :r 9. VALUATION y
��/ /� PERMIT FEE S w
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D
Signature o S ao m
Permittee /S ``�,�_ $ ! PVN CHECK $ E
LL
Authorized Agent \ TOTAL FEE $ (,
31.x77 ,Q_7_� '"OOiva6 a t*162.00
•
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 .
APPLICATION FOR BUILDING PERMIT
For Applicant�✓ to Fill in�C/omple"te'ly RECEI D B DATE ITEC VED DATEJISSU 0
BUILDING '1 /✓�CG/v VQN 0 i_ . 7_ 7 / //7
ADDRESS �7C(., ( /
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^a� `,Q/.h to 0�/Ma //W /�./A./P.NO. PERMIT NO.
OWNER
MAIL BUILDING
Z ADDRESS ADDRESS
W W , TEL. TRACT LOT BLOCK
0_U CITY NO.
ZZ
4 CONSTRUCTION NEW ADD ALTER REPAIR _ MOVING QFMOI LSH
O y LENDER
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am
J 7 BRANCH '
J W OWNER
CO J ADDRESS VALUE
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ARCHITECT TEL. USE $
Q OR ENGINEER NO.
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WQ ZONE TYPE GROUP
IL ADDRESS
a LY APPROVED
W Z CONTRACTOR 014.)/1.)e.<- BY DATE
J 0
mZ
JCC ADDRESS
W W ZONE NO.OF USE OF NEW
O= CITY NO.
_ PLANS BUILDING
Z 1—
W O STATE CITY YARDS APPROVED ' YARDS APPROVED
to K LIC.NO. LIC.NO. MAIN BUILDING ACCESSORY BUILDING
SIZE NO.OF BLDGS (FROM C/L STREET)
OF LOT NOW ON LOT FRONT FT. FT.
USE OF
EXISTING BLDG, R.SIDF FT. FT.
I— SIZE OF NO.OF I
ZNEW BLDG. ROOMS STORIES L.SIDE FT. FT.
f..1 EXTERIOR WALL ROOF ,
_ COVERING COVERING REAR FT. FT.
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C.U.P k AATE
APPROVEDO
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APPROVED
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0 I hereby acknowledge that I have read this application and state
M that the above information is correct and agree to comply with
cc all laws regulating building construction, and I shall not employ
any person in violation of the workman's compensation laws of
fn the State of California. co
Z I hereby certify that I am properly licensed as a contractor under SO. FT.
1.9
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR s
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: 2
am exempt from the provisions of the State of California Business VALUATION
and Professions Code. Division 3,Chapter 9. \
Y26�` m
L PERMIT FEE $ N
TS D
Signature of m
Permittee $ OO PLAN CHECK $ E
Authorized Agent TOTAL FEE $
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