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Home My WebLink About2450 MARSEILLES WAY - Building Permits--,;r. • y�� • i •.:.�:: ; ; �"�, CITY OF COSTA MESA BlIILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT , /P98-00461 �� PERMIT NUMBER (714) 754-5273 • Fax (714) 754-4856 NG PERMIT � FAIR DRIVE, COSTA MESA, CA 92626 Job Address: Suite No Vicinity: Parcel Nunmber: Applicant: Address: Owner: Address 2450 MARSEILLES WY C84iC9bY/ GLOVER,JOSH UTANOVSKY, JACK M 219116 RAINTREE LN LAKE FOREST,CA PLUMBI Phone: Zip: Phone: Zip: 92630 r Contrector: CRODDY PLUMBING & HEATING Address: 2737 S. CRODDY SUITE D SANTA ANA CA ArchlEng: Address: ISSUE FEE BackFlow irrigation Backflow Preventer Bathtub Clarifier Syslem Connect (Ice,Soda,etc) Dental Units Dishwasher Drain, Floor Drain, Rainwater Drain, Roof Drinking Fountain Expansion Tank Gas Earthquake Valve Gas (1-4 outlets) Gas (Over 4 outlets) Gas Repipe Gas Service Interceptors (Grease, Oil) InterCeptors (Sand Auto ) AMT $22.00 $0.00 $0.00 $0.00 $0.00 $0.00 so.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 nrv Phone: 714 241-1474 Zip:. 92704 License: 529127 Phone: Zip: License: SCOPE OF PERMIT W.H. CHANGE OUT FEE SUMMARY Laundry Tub / Washer Landscape Irrigation P-Trap Pressure Regulator Process Piping (per 10 R) Receptors Septic Tank SewerCapforDemo Sewer Connect Sewer Private Line Shower Sink, bar Sink, wmmercial Sink, Floor Sink, kitchen ' Sink, service/mop Spa (private) Spa (public) AMT $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Qn 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 COMMENTS / SPECIAL CONDITIONS Status: ISSUED Applied: O6I09I1998 Issued: O6I09/1998 SumpPump Swimming Pool Trap Primer Urinal Vacuum Brkr BkFlow(1-0) Vacuum Brkr Bkflow(5+) Wash Basin Wash Basin Set Waste and Vent System Water Closet (Toilet) Water Heater / vent Water Piping (Inst or Rep.) Water Re-pipe Water Service Water Softener OTHER VIOLATION PLAN CHECK REINSPECTION TOTAL CALCULATED FEES: �� O 9p.t� 1� AMT $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.00 �b Qn 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 EXPIRATION: This permit shall eutomatically expire and become void if work is not commenced within 780 days, or if work is suspended or abandoned tor a period of 180 days. INSPECTIONS: In order tor the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inepectlona end flnel epproval must be obfained. Failure to obtain inspections and final approval will result in the expiration o1 this permit. FOR INSPECTIONS CALL: (714) 7545626 WOHKERS' COMPENSATION DECLARATION: � I hereby atfirtn under Denalty of perJury one o� the following decleretions: � ❑ I heve end will melntein e certificete al consent to self-Insure for workers' compensation, es providetl tor Dy aectlan 3700 of the Lebor Code, for the pertormence oi t�a j�'ork lor whlch Ihis pertnit is Issued. 0' I �ave arW will mflintein workere' compensetion insurance, es requiretl Dy section 3700 of the Lebor CoOe, for tha peAormance oi ihe work for which this pertnit is issuetl. My workers' compensation In'/sura [artle end policy number are: n G Gr,r Certier. ��L� ��/YL� F'olicyNumber. �/�lll /)/) U�%� (Thls sectlon need not tie cwnp/etetl!! Me pB�1t is v ed at one hundre0 dollers ($100) or less.) ❑ I certify Ihat in Ihe pertortnence at thB work for which �his pertnit I5 issuetl, I shall not employ eny pe;son in any manner so es to become subject to the workers' compensellon laws of Celito , entl e e that if I should becoma suG�oct lo the warkere' compensetion provlslons oi Section 3700 of the Lehor Code, I s�all Iorthwith Comply with UeSe DroviSi �h AppllcaM Sipnature: Uate: ��i — � — /.� WARNIN(3: FAILURE TO E WORKERS' OOfdPEN$ATION COVERAGE IS UNLAW FUL AND SHALL SUBIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FlNES UP TO ONE HUNDRED THOUSAND DOIURE (5100,000). IN ADDRION TO TME Q�ST OF �.1PENSATIqJ, UMAAGES AS PROVIOED FOR IN SECTIIXJ 3N8 OF TNE LABOR WDE, IMEREST, AN� ATiORNE`f5 FEES. LICENSED CONTRACTORS DECLARATION: I hereby eHirm thet I em licensetl under prod�oy5,a� Chepter 9(commancing with Section 7000) ot Divlslon 3 ot the Business an�P�yf�ssions Code, entl my Ilcense is in tull force and eHect. Lic. MT SB�LI ��/ Cleu x :5 �i Convacrors SignaWre: `,�!5 Care: — CONSTRUCTION LENDING AGENCY: ❑ I �ereby atfirtn that thera is e consiruction lending egency for the peAormance of ihe work tor which ihis pertmlt is issued. (Sec. 3097, Givil Coda). Lender's Name: Lendefs Address: Signeture: Date: OWNER-BUILDER DECLARATIONS: I hereby eXirm Ihat under penalry of per�ury tnat I em EXEMP7 FROM TNE CONTRACTORS LICENSE LAW for the tollowing reason (Sec. 7031.5, Business end Protesslons Code: My Ciry or counry whiCh requlres B pe�� to conslrucL alier, Improve, demoli5h, or repair eny struCture, pnar to its Issuence, also requlrea iha epplicent tor suc� pertnit to file e signeE statement that he or ahe Is IlcenseG Purouant to Ihe provislons ot Ihe ContreMors License taw (G�apter 9(commenang wit� Sectlon 7000) of Dlvlsion 3 of ihe Business anE Protessions Code) or thet he or she is exempt therefrom end tha basis for Ne elleged exemption. My vidaGon oi Sedion 7031.5 by any epplicant for e pertnit subJecis the epplicent to e civil penelry al not more Nan five huntlretl ddlars (5500).): ❑ I, as owner ai the property, or my emp�ayees with wages es their sole compensation, WILL DO THE WORK, and ihe structure is not Intantletl or oHered tor sale (Sec. 7044, Business antl Professions Code: The Coniractars Licensa Lew tloes not apply ta an owner oi Oroporty w�o builds or improves Iherean, antl who does such work himself or herself or ihrough his or her own employees, provitled thet such improvements ere not intentletl or ottered tor sale. If, however, Ihe building ar Improvement Is sold within one year ot completlon, the owner-builder will have the 6urtlen ol proving ihat he or she tlitl not bulld or improve for purpose of sele.). ❑ I, es owner o1 the property, am EXCLUSIVELV CONTRACTING WITH LICENSED CONTRACTORS to canstmct ihe D�a)ect (Sec. 7044, Business entl Pmfessions Code: The conirectors Llcense Lew daes not apply lo en owner oi property who builds ar Improves iherean, end who contrects for such project with e contrector(s) license pursuant to the Contractors LJCBnse Lews.). ❑ 1 am e:empt under sec. Business enC Professions Coda tor this reason: Signelure: Date: Owner ID verified by dnvers licensa. ❑ Yes ❑ No Dnve(s License No. Expires: Vedflcation of Ownershlp by (type of Oocume�4 ��e. - property tes bill or deed): DIVISION OF INDUSTRIAL SAFETV PERMR CEH7IFICA710N: ❑ I hereby certlty Ihat no excavatlon Ilve (5) or more feet in tlepth into whic� e person Is required to descentl, will be mada in connectlon wNh work euthorizetl 6y �his pertnit, and ihet no building slructure, scettolding, lalsework, or demolitlon or dlsmantling ihereof, will be more then ihirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Celifomla AtlmlNstretive Code). ❑ As owner-bulltler, I vnll not employ anyone to tlo work which woultl requlro e pertnit irom the Divislon of IndusMel Safety, as noted ebove, unless such pereon has e pertnit to do such work trom the diNsion. Signeture: Data: DiWsion oi Industnel Safery Pertnil Number: Will the applicant or present or future DUIIOin9 occupant need Io file end certity e Business Plen tor emergency response m release or threetenetl release of e hazerdous material? ❑ Yes ❑ No (Sectlon 25505 of t�e Calitomie Heelth end Safery Code requires, wit� some ezceptions, ihet e Business Plan De filed with ihe Coste Mese Fire Depanment by every business which has at any one time tludng e reported year a quantlry oi hozerdous materials equel to or greater ihen e weight ot 500 pounds, or a volume of 55 gallons, or 200 cublc feet of compressetl pa9 et 8�endard tempereture entl pressure). ............................................................... . . .................................................................................................................................................................................................. Does or will �he epD�� or pr8seni or IV�ure building oCCupen� need to file e regisVation �ortn fOr etutely hezerdous me�enals? ❑ Yes ❑ No (Sectlon 25533 ot the Califomia Haellh end Seiery Code, with some exceptlons, requires registretlon with Ihe Casta Mesa Fire Department by each busineu whlch et eny one time has on �en0 e quentlry ol ecutety hazartlous meteriels equel to or greater then a weight oi 500 pountls, or e volume oi 55 gallons, or 200 cubic feet of campressed ges et siandartl tempereNre end pressure). ............................................................... .......................................................................................................................................................................................................... Daes or will t�e epplicant or present or fuWre Euilding occupant neetl to propare an RMPP (Risk Manegemnnt entl PrevanUon Proprem for acutery hazarCous materials)? ❑ Yes ❑ No l of ihe Califomle Health 9ntl Satery Cotle provides t�at the Casta Mesa Fire Depatlment mey require the preparetlon, certification antl filinq with the Fire an RMPP by businesses �+'hich ere requlreO lo register ecutoly heze�dous materlels with t�e Fire Department. ................................................................................................................................................................................................................................................., �resentiv reouiretl. �es Sectlon 25534 of the Californie Health entl Sefery Code baen fully comolietl wit�? ❑ Yes ❑ No 5 Does or will t�e applicent ar presen� ar fumre Dunamg wcupani requlra ror Ine wonc wmcn Is Ine suD�ect m tnis e pllcebon e germn ror such construcbon ar from �he South Coest Air Oueliry Menegement Disinct or irom eny other elr pollutian contml distdct or agency9 � Ves I„� No (Sectlon 658502 of the Calitomie Govemment Code requires t�a� the requested information be lumishetl on epplicetions for nomresidentlal builtling permits). ............................................................................................................................................................................................................................................................. 6 W II eny pan ol the faciliry to be wnsirucled under this permi� De withln t0001eet imm Ihe outer boundanes of e schaol? � Ves ❑ No (If'yes', the feciliry must meet Iha requirement of Seclions 25534 end 42303 0l lhe CalHomie Health end Safey Code�. a ............................................ .......................................................................................................................... rom ihe South Coest Alr Oueliry Managemen� Disitict or oUer air polWtion control dlsidct ar egency is have all oi t�e tlisclosures plescribetl �y CelNomia Health end Sefery Code Secllan 42303 been ma0e7 [ CERTIFICATE OF COMPLIANCE: I cefi�y Nai untler penalry ol per�ury the iniortnauon given e�ove is correcL I agree to compry wit� all state laws and ciry ordinances regertling Haiardous Matenals entl EmlSsbns. � Slgneture: Date: CERTIflCATE OF COMPLIANCE AND AllIHORVATON OF EMRV: I certify under penalry of perjury thet I have read this epplication end state ihat �he intormatlon given is cnrrect. I agree to comply with ell stete laws and ciry oMinences relating lo building construction, end euthorizu representatives ot the Ciry oi Costa Mesa lo enter upon the ebove-descnbed pmpetly tor inspectlon purposes.�l agree not lo occupy or ellow occupanty of eny bulltling authurized by ihis pertnit until final inspection. �Ul�i' i t 9a`Ow�er(s) /1 ��te i - / .j i L.L AnNOr Authorized�Applicant Date COOE I. IxSPECTIONTYVE 7818 Fixetl System Final Fire Preventlon 1266 Pool Spe Final 200 Final Re-Root 201 Finel BIocWReteining Wall 202 Final Feqary Fire Place 203 Flna151gn 204 Final Demolition 2M6<6 OAg Uf�ll65 ypypj ixsvernoH � 206 FInelMechenicel� 20B Final Plumbing 210 Final Elaclricel 212 Final Fire Preventlon 220 Final Planning Approval 222 Final Siie 250 Finel Building/Occupancy � I�� . • I� ► �� .y�,' i •.:..::: ; ; i � CITY OF COSTA MESA BIIILDING D/VISION DEVELOPMENT SERVICES DEPARTMENT PERMIT /I P98-00378 ,_� / ✓ PERMIT NUMBER �(�� (714) 754-5273 • Fax (714) 754-4856 pLUMBING PERMIT �� FAIR DRIVE, COSTA MESA, CA 92626 ,lobAddress: 2450 MARSEILLES WY Suite No Vicinity: Parcel Nunmber: 43914237 Applicant: Address: Owner: ULANOVSKY, JACK M ULANOVSKY, JACK M Address 219116 RAINTREE LN LAKE FOREST,CA Contractor: Address: ArchlEng: Address: ISSUE FEE Backflow irrigation BackFlow Preventer Bathtub Clarifier System Connect (Ice,Soda,etc) Dental Units Dishwasher Drain, Floor Drain, Rainwater Drain, Roof Drinking Fountain Expansion Tank Gas Earthquake Valve Gas (1-0 outlets) Gas (Over 4 outlets) Gas Repipe Gas Service Interceptors (Grease, Oil) Interceptors (Sand Auto ) AMT $22.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Qn Phone: Zip: Phone: Zip: 92630 Phonei Zip: License: Phone: Zip: License: SCOPE OF PERMIT COPPER RE-PIPE FOR WATER. FEE SUMMARY AMT Laundry Tub / Washer $0.00 Landswpe Irrigation $0.00 P-Trep $0.00 Pressure Regulator � $0.00 Process Piping (per 10 ft) $0.00 Receptors $0.00 SepticTank $0.00 Sewer Cap for Demo $0.00 SewerConnect $0.00 Sewer,Private Lina $0.00 Shower $0.00 Sink, bar 50.00 Sink, commercial $0.00 Sink, Floor $0.00 Sink, kitchen $0.00 Sink, service/mop $0.00 Spa (private) $0.00 Spa (public) $0.00 Qn 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 COMMENTS / SPECIAL CONDITIONS Status: ISSUED Applied: OS/15/1998 Issued: OSI15/1998 SumpPump Swimming Pool Trap Primer Urinal Vacuum Brkr Bkflow(1-4) Vacuum Brkr Bkflow(5+) Wash Basin Wash Basin Set Waste and Vent System Water Closet (Toilet) Water Heater / vent Water Piping (Inst or Rep.) Water Re-pipe Water Service Water Softener OTHER VIOLATION PLAN CHECK REINSPECTION TOTAL CALCULATED FEES: AMT $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.75 QTY 0 0 0 0 0 0 0 0 0 0 0 0 7 0 0 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 1 BO 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 requlred Inapectiona end final epproval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5826 � WORKERS' COMPENSATION DECLARATION: - I hereby eff�rm under �3nelry of per�ury one oi t�e tollowing declarations: ❑ I heve end will malntein a ceniilcete ot consent to selt-Insure tor workers' compensetion, as provltletl for by sectlon 3700 of the Lebor Code, for the pertormence of the work for wNch this pertnit 19 i9suetl. ❑ I heve arid will meintain vrorkere' oompensallon insurence, es required by secUon 3700 ot the Lahor Co�k�, lor the peMortnance of tha wwk fa which this pertnit is issued. My workers' compensation Insurance carrler entl poliq number ere: Cartier. Pollty Number. (Thls sectlm need not be complefed i/ Me permit Is veluetl et me huntlred tlollers (S100J or less.) ❑ I certiy that in Ihe perfortnence of Ihe work for which this pertnit is iuueO. I shall not employ eny pnrson in any manner so as to 6ecome subject to lhe workere' compensation laws of Califomia, end egree Ihet tl I shoultl hecome sublect to Ihe warkers' compensetion provlsions of Sectian 3700 of the Lebor Cotle. I shall tonhwlth comply with these provisions. Appllcent Slgneture: Date: WARNINO: FAILURE TO SECURE WORNERS' CAMPENSATION COVEMOE IS UNUWFUL AND SHALL SUBIEGT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDREO hKK15AND OOLURE (E700,000�, IN ADDfTION TO THE WST OF GYMIPENSATION, OAMAGES AS PROVIDED FOR IN SECf10V 3'1080F THE LABOR ODDE, IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS UECLARATION: I hereby eHirm that I am licensed under proWsions ot Chapter 9(commencinq with Section 7000) ot Divislon 3 ot Ihe Busineu and Professions Cotle, end my Ilcense is in full toroe end aflect. Lic. p Gass a Contrectofs Signeture: Dete: CONSTRUCTION LENDING AGENCY: ❑ I hereby atfirtn ihet Ihere is e ConSiruCtlon lending egency lor the peAortnance of tha work for which Ihis permit is iuued. (Sec. 3097, qNl Coda). Lentlers Neme: LenAefs Atltlress: Signeture: Date: OWNER-BUILDER DECLARATIONS: I hereby eHlrtn t�et unCer penalry of perjury thet I am E7(EMPT FROM 7HE CON7RACTORS LICENSE LAW tur the following reason (Sac. 7037.5, Business and Protessions Cotle: Any Gry or wunry which requires e pertnii to conslruct, elter, improve, demolish, or repair any 5truclure, prior to ILs Issuance, elso requires the epplicani for such parmit to Ble e signetl statement that he ar she is Iicensetl pursuant ro the provisions oi the Contrflctors LJcensa Lew (C�epter 9(commendng with Sectlon 7000) of Division 3 of iha Business and Professions Code) or Ihat he or sha is exempt therefrom end Ihe basis tor the allegeA exemptlon. Any violatlon ot Sactlon 7037.5 by eny epplicant for e pertnit subJects t�e eDP�icant to e civil penalry of not more Ihen five hunCred tlollers ($500).): ❑ I, es owner of the Droperty, or my employees wlth waqes as their sole compensation, WILL DO 7ME WORK, flnOlhe structure Is not intentled or oXeretl for sale (Sec. 7044, Business and Professions Cade: The Cantrectors License Lew tloes not eppty to an owner ol property who bulltls or Improves thereon, and who does such work himself or herselt or through �is or her own employees, provided Ihet such Improvemems ere not Intentletl or oRered for sale. If, however, ihe bullding or Improvemem is eold within one year af completion, the owner-builder will heve the burAen oi proving Ihet he or she dld nol builtl or improve for purpose oi sele.). ❑ I, es ownar of the propeny, em EXCLUSIVELV CONTRACTING WITH LICENSED CONTRAC70R5 to constmct the project (Sec. 7064, Business antl Professions Cotle: The contractors License Law does not epply to an owner ot properry who bullds or improves Ihnreon, and who contrects for such proJect with a contrector(s) Ilcensa pursuant ta the Cantrectors License Laws.). ❑ I em exempt under sec. Business end Pratessions Code for this reason: SigneWre: Date: Owner ID verifieA by dnvefs license. ❑ Ves ❑ No Drivefs license No. Verlticatlon ot Ownership by (rype at document, i.e. - properry tax bill or tleetl): DIVISION OF INDUSTRIAL SAFETY PERMR CERTIFICA710N: Expires: ❑ I hereCy cently Ihat no azcavatlon Ilve (5) or more feet in depth imo which e persan Is requiretl to tlescenq wlll be mede in connectlan wlth work authodzed by t�ls permit, enC that no building swcture, scettolding, falsework, or demolitlon or dismantling thereoi, will be more t�an thirty-six (36) teet high. (Chep. 32, Grp 2, Art 2, Sec. 341, Title B, Caltlomia Atlministretive Code). . ❑ As owner-builder, I wlll not employ enyone to tlo work which would requlre e pertnit from the Divislon of Industrlal Safery, as noted ebove, unless such person hes a pertnit to do such woAc fmm the diWslon. Signelure: DMsion of Industnal Safary Pertnit NumDer: Date: CERTIFlCATE OF COMPLIANCE AND AUfHORVA710N OF ENTRV: I ceAiy under penalty of perjury thet I heve reatl ihis epplicatlon end state thet t�e infortne�ian given Is conecL I egree lo comply with all stete laws entl cIry ordinances relating lo building consWction, end euthorizn representetives ot the Ciry ol Costa Mesa to enter upon Ihe above-describetl property for inspection purposes. I egree not to occupy or allow occupanq of any building authorizad by this pertnit until Final Inspection. _ cooe �. wsvecnoNTrve 1816 Flxed System Finel Fire Prevention 7266 Pool Spe Final 200 Finel Re-Root 207 Finel BIocWReteining Wall 202 Finel Factory Fire Place 203 Final Sign 200 Flnel Demolition 2A48d8 P�ff II�� 5 -/S °� �' Dala ' cooe� iNsvecnoNpy� 206 Finel Mecl�enicel 208 Flnel Plurtbing 210 Finel Eleclricel 212 Finel Fire Prevenlion 220 Finel Planning Apprwal 222 250 Final Site Finel Building/Occupancy � INIIDd� � CITY OF COSTA MESA BUILDING DIVISION OWNER-BUILDER VERIFICATION A city or county, which is required to give notice pursuant to Section 19830, shall attach to such notice, and, as a condition precedent to issuing a building permit, require the completion and require the return of, an owner-builder verification. Attention Property Owner: An 'owner-builder' building permit has been applied for in your name and bearing your signature. Please complete and return this information in the envelope provided at your earliest opportunity to avoid unnecessary delay in processing and issuing your building permit. No building permit will be issued until this verification is received. 1. I personally plan to provide the major labor and materials for construction of the pro- posed property improvement. � Yes ❑ No � I(have/have not) �QyQ 1/� signed an application tor a building permit tor the proposed work. 3. I have contracted with the following person (firm) to provide the proposed construction: Name Address City Phone ( ) Contractor's Lic. No.. 4. I plan to provide portions of the work, but I have hired the following person to coordinate, supervise and provide the major work: Name Address City Phone ( ) Contractor's Lic. No. , 5.�% I will provide some of the work but I have comfaMe� (hired) the following persons to pro- L� vide the work indicated: Name Address Phone Type of Work �'w� lr� �rr�s �1g�{stl�v..� MAe 3�803�< < 2cpe p� I hereby affirm that I have received a copy of Ihe information set torth in Section 19830 of the State of California Health and Safety Code and have complete the above information to th best of my per- son/al knowledge, in mp ianc witf is tate law. ` Signed: Date: ��/ / Name: �� /�!� Ll�/��v•i�. 1 Printed or Typed) � i C.D.L # or S.S. # 754-5273 1042d8 • DECLARATION OF ..JTHORITY FOR AGENTS OF PROPERTY OWNER TO APPLY FOR PERMITS Bldg. Permit # This Permit # �`fSo N�A25Al�L;�S C��/ Sireet Address AP Number I(we), �� i� GIL I �1 �/S �-�- 1�Q Y 5�-T , declare that I am the Owner of Title of the above referenced real property, and that I(we) hereby authorize: �M-I LGt� �L�Jt2E�S �!`f� �78 -83� � Name Telephone No. �l S�f°S V�rz.�� M�rt D� Street Address � sca[e `� Zb up to obtain permits in my behalf, as owner/builder, for �JP�C`-�IL �jEPI� at the above referenced property. 2. Should any person become an employee engaged in the improvement of the property, I(we) shall im- mediately provide Worker's Compensation Insurance coverage and cause a certificate of that coverage to be filed with the Building Division of the City of Costa Mesa, as required by State of California laws. 3. As ownerlbuilder in fact, I understand and accept that my responsibilities do not transfer to any other per- son, company or corporation. 4. I agree to indemnify and hold the City of Costa Mesa and its employees or officers harmless from any claim resulting in damage or personal injury to myself or any other parties as a result ot work authorized by the permits from the City of Costa Mesa. 5. I declare under the penalty of perjury that the foregoing is true and correct. Executed this '_�f� day of --� / � %i/�! �J ✓,l' % � rinted Name / Signature 19�, at �l: � California. NOTE: This authorization does not grant authorization to perform the work as owner, it solely provides for limited power of attorney to secure this permit in any behalf. a � . __' '_ _ -�� 0�19�66 Iflev. 1/91) OWNER DOYLE &.SHIELDS JOB ADDRESS 2 50 Marse� INSPECTIONS Co..Inc. DATE IGROUP DATE 6-3-63 BUILDING PERMIT vai.uE � 19, 5� �LSCRIPTION OF WO TYPE V Z G„_ , ��I SUBCONTItACTOR I DAT� NUnfBER V I ' l9682 COSTA MESA BUILDING-SAFEfY DEPARTMENT P. O. BO% 91] COSTA MBBA� CALIFORNIp For App�icont to Fill In Completely TYPE OR PRINT ILDINO Il ll ('lf� ' yy� ^^ AO `Yl ]RESS S� T J\l 0� u1! 1 COSTA MESA. CALIFORNIA MAIL g31 So. Manchester Ave. ADDRE68 c�rv Anaheim Ca1if No PR 28 �ocv��EvT Hai C. Tan u�'-571-2 aao FIRE F E RECEIVED dUN 3 1963 FINANCE DEPT. CITY OF COSTA MESA APPLICATION FOR PERMIT BUILDING For Office Use Only RHclIIT NO. @F�tN! ra rtac¢rvao oere �ssue =�i...( 2 JUN 3 1 63 AD�RE53 4100 West Commonwealth ZONING � Z NO.OI U880PN � J �UNG BUILO�N CONTRACTOR SamG oss�w„�,e„ Lot 98 Tract 3433 ADDRESS A. P. NO. � CITY 5'ai[�e NOTE: NO EAVE OVERHANG SHALL BE LE59 THAN LIC.TNO.ISZ�ZSO�B�1 NEL. PR ZHOZO 30'TO&IDEQREARP,L. EAVES OFLOT 33 X SB.SO I NowoNLOTe.�� ALLOWED (U.B.C.REqU1REMENT YARO9APPROVED YARDSAPPROVED USEOF � MAIN BUILOING ACCESSORY BUILDIN6 EXISTIN6 BLOp, �� ( FROM C/L BTREET ) SETBACK LINH FROM ZO � SO , FRONT �� FT. PT. CENTER OF BTPEk} REAR YARD SIDEYARDI Lgp7 �� R16HT �� R.SID6 FT. FT. DESCRIPTION OF WORK L.SIDE � Fr. Fr. BUILDI13t� x SJ.SO NO.OF '� '� SIZE ROOMS STORIl9 EXTERIORWAL ROOP SH��GL2 GOVERING O GOVERIN6 II USE OF BUILDfNG AND WORK TO BE PfiftFORMED ' h attached ara E odel 42 G I HEREBY ACNNOWL8O0H TXAT I XAV[ R6AD TXIB ApPLIWTION AN� ST�T6 THA) THQ AHOYC 18 CORAECT AND AORE[ TO COM. PLY WITH M1LL CITY OROINANCHB AryD 9TAT8 LAWS RBGULATINO BUILO�NO CONSTRUCTION. � ` � AUTHORIZEDAGENT'� VAR. # TXB �MOUNT eHO�N PURPOBH OP HBTJI VALUATION $ly,sY�� DATE �� A UNOER VALUAT�ON 19 FOR THE IBH�NO A PERMIT F[6 ONIY. ? (/D PERMITFEE $ J s� PLAN CHECK S � / TOTAL FEE S / Y �