HomeMy WebLinkAbout3217 NEW YORK AVE - Building Permits�C�O'�p M�'r9
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PERMIT TYPE:
Sub Type:
JOB ADDRESS:
APN: 13910221
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CITY OF COSTA MESA
� �• BUILDING DIVISION
77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax p14) 754-4856 • www.ci.costa-me�a.ca.us
FOR INSPECTIONS CALL: (714) 754-5626 `
PERMIT NUMBER: BC11-00021
Vicinity:
Const Type: V-B
B_COMBO
RES_ALT
�3217'NEW,`Y9QRK,;AV�GM�
oning: , ,
SQ. FT: 0
STATUS: ISSUED
DATE ISSUED: 01/13/2011
ISSUED BY: KJB
Suite/Unit:
Primary Occ:
Valualion: $20,000.00
SCOPE OF WORK: REMODEL 2 INTERIOR BATHROOMS. DEMO 1 INTERIOR NON-BEARING WALL. RELOCATE SHOWER INTO
EXISTING CLOSET AREA. ELECTRICAL TO INCLUDE: 5 LIGHTS, 3 OUTLETS. PLUMBING TO INCLUDE: 1 BATH TUB, 1
SHOWER, 2 WASH BASINS. ,
OWNER: BISSONETTE DAVID
Phone:
APPLICANT: BARqZSU, DAVE
Phone: 949-559•8082
Address: 3217 NEW YORK AV
City/Slate/Zip:. COSTA MESA, CA
� Address: 5071 PARIS WY � �
City/State/zZip: IRVINE, CA - .
CON7RACTOR: bAVE BARAZSU CONSTRUCTION License No. 649835
Phone: 949•569-8082 . Address: 5071 PARIS WYUnit: �
Cell: � - City/State: IRVINE, CA � "
ARCHITECT:
ENGINEER:
COMBINATION PERMIT FEE SUMMARY
Building Plan Check:
Building Fees:
Electrical Fees:
Mechanical Fees: �
Plumbing Fees:
SMIP Residential:
SMIP Commercial:
Bldg Std Admin Fund
TOTAL FEES:
License No.
Litense No.
$208.81
$321.25
$32.30
$0.00
$62.70
$2.00
$0.00
$1.00
$628.06
Unit:
Unit :
ZipCode 92604
PHONE:
PHONE:
. HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279
,Monaay tnr� Friaay • �:oo am thru 7:00 pm. Saturdays-e:oo am thru s:o0 pm. Prohibited all hours - Sundays and the following Federal holidays:
r[ j.
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Catifomia statutes and related
� regulations. (Ord. NU. 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 inspectioqs and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permil.
COOE1. INSPELPONTYPE DATE INII11AL5 COOE;1 INSPECTIONTVPE ORTE INTTIALS �
1616 Fixed System Final Fire Prevention 206 Final Mechanical �-� �t �IJ i1� �% hl�L
�1�L � F bu
1266 Pool Spa Final 208 Final Plumbing �
200 Final Re-Roof 210 Final Elecirical
2oi Fina� BIocWRetaining Wall 212 Final Fire Prevention
202 Final Factory fire Place 220 Final Planning Approval
�203 Final Sign p22 Final Site ��,�� �� ,
204 Final Demoli�ion 250 Final Building/Occupancy �\� � m P ,
M
WORKERS' COMPENSATION DECLARATION:
I hereby affrm untler penalty o( perjury one of the following declarelions:
❑ I have and will maintain a Certifcale o( con5en[ [0 5elf-Insure for workers'
compensation, as provided for by section 3700 of the Labor Code, for the
erformance o( the work fc!which tlijs permit is issued.
I have and will maintain workers' compensation insu2nce, as required by
s tbn 3700 of [he Labor Code, fw the peAortnance of Ihe work for which this
permit is issued. My wo� compensal�ura e wrner and policy
number are: ��
Cartier. \X--
(i�isser]ionneetlrrolbemmdel� d���uedatgpe neredtlollars(S100Jorless)
/\ _'/
Policy Number. �l %
i
❑ I certi(y that in Ihe peAormance of the vrork (or which this permit is
issuetl, I shall not employ any person in any manner so as to become su6ject
[o the workers' compensation laws of Califomia, and agree tha[ i( I should
become subject to lhe vrorkers' cor�ge a'on provisions o( Section 3700 of
the Labor Code, sly�ll f� iwi omply � t se provis' ns.
n 0 I �% (
�! Abplicanl's. gnal e Dal
/
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE
IS UNLAWFUL AND SHALL SU&IECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
(3100,000), IN ADDITION TO THE COST OF COMPENSATION, 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 pmvisions of Chapter 9(commencing
with Section 7000) of 'y+sion 3 of the Business and Professions Cotle, antl
my license is i fu f IdSa �c�
�C
Lic. # U Class #
� 13
nva r's Si " ure Date
CONSyRUCTION LEN 1�t(G AGENCY:
❑ I hereby affrm that lhere is a constmctbn lending agency for the
peRortnance of the v.ork for which this permit is issued. (Sec. 30W, Civil Code�.
Lender's Name:
Lender's Address:
Dale
OWNER-BUILDER DECLARATIONS:
I hereDy affirtn Ihat under penally o( pBrjury that I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5,
Business antl Professions Code: Any city or coun[y which requires a permit to
construct, alter, improve, demolish, Or repair any stmcture, prior to its
issuance, also requires [he applicant for such permi[ to fle a signed statement
Ihat he or she is licensed pursuant to the provisions of [he CoNractors
License Law (Chapter 9(commencing with Section 7000) of Division 3 0( the
Business and Professions Code) or that he or she is exempt therefrom and
the basis for Ihe alleged exemption. Any violation of Section 7031.5 by any
applicant tor a permit subjects the appliwnt to a civil penalty of not more than
(ve hundred dollars (5500).):
❑ I, as owner of the property, or my employees with wages as their sole
compensation, WILL DO TME WORK, and ihe sWcture is not intended or
o%ered for sale (Sec. 7044, Business and Professions Code: The Contractors
License Law does not apply to an ovmer of propeny who builtls or improves
Ihereon, and who does such work himself or herself or through his or her ovm
employees, provided ihat such improvements are not intended or otfered tor
sale. If, however, the building or improvement is sold within one year of
complelion, lhe ovmer-builder vrill have lhe burden of proving tha[ he or she
tlid not build or improve for purpose of sale.).
❑ 1, as owner of the property, am EXCLUSIVELY CON7RAC71NG WI7H
LICENSED CONTRACTORS to construct �he project (Sec. 7044, Business and
Professbns Code: The contraclors License �aw dces not apply to an owner of
property who huilds or impmves thereon, and who contracls tor such project with
a contractor�s) license pursuant to the Contractas License Laws.).
❑ I am exempt under sec.
Business and Professions Code for Ihis reason:
, I 305]-66 (3I0))
�
Owner ID verifietl by driver's license. ❑ Yes ❑ No
Driver's License No. - Expires:
Verification of Ownership by (i�pe of tlocument, i.e. - pmpeny tax bill or deed):
DIVISION Of INDUSTRIAL SAFEN PERMIT CERTIFICATION:
❑ I hereby certdy Ihat no excavation five (5) or more fee[ in tleplh into which a
person is required [o descentl, will be made in connectbn with wvrk authorized
by ihis pertnit, and that no building sWCWre, scaf(dding, falsework, or demolition
or dismantling Ihereof, vnll be more �han Ihiriy-six (36) feet high (Chap. 32, Grp
2, Art 2, Sec. 341, Title 8, Califomia Administ2tive Code).
❑ As owner-builtler, I will not employ anyone to do work which would
require a permit from the Division of Industrial Safety, as notetl above, unless
SUCh per5on has a pertnil [o tlo SUCh work lrom the division.
Appliwnfs SignaWre
Division of IndusMal Safey Permit Number _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant neetl to file and
certity a Business Plan (or emergency response to release or threatenetl
release of a hazardous matenal? ❑ Yes ❑ No
(Section 25505 of the California Health antl Safery Code requires, vnth some
exceptions, lhat a Business Plan be filed vdth the Costa Mesa Fire
Department by every business which has at any one time during a reponed
year a quantity of hazardous materials equal �o or greater than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas
at stantlard tempereture antl pressure).
2. Does or vrill the applicant or present or future builtling occupant need to fle
a registration form for atutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the Cali(omia Health and Safety Cotle, with some
exceptions, requires regislralion with the Costa Mesa Fire Department by
each business which at any one time has on hand a quantity of acutely
hazardous ma�enals equal �o or greater Ihan a weight of 500 pountls, or a
volume of 55 gallons, or 200 cubic feet of wmpressetl gas at standard
temperature and pressure).
3. Does or will the applican[ or present or future building occupant neetl to
prepare an RMPP (Risk Management antl Prevention Pmgram (or acutely
hazardous matenals)? ❑ Yes ❑ No
(Section 25534 of the Califomia Health antl Safety Cotle pmvides that the
Costa Mesa Fire Department may require the preparation, certifica[ion and
fling with the Fire Department of an RMPP by businesses which are required
[o register acutely hazardous materials with (he Fire Department.
4. I( an RMPP is O�esenHy require4 has Section 25534 of the Cali(ornia
Heal[h antl Safety Cotle been fuliy complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or fuNre building occupant require for
Ihe work which is lhe subject of this appliwtion a permit for such conslruction
or modifwtion from [he South Coast Air �uality Managemen[ District or from
any other air pollution control tlisirict or agency? ❑ Ves ❑ No
(Sectbn 658502 of the Califomia Govemment Code requires that Ihe requested
intortnalion be fumis�ed on applications fa rwn-residential builtling pertnits).
6. Will any part of the faciliry to be constructed untler Ihis permit be within
1000 feet from Ihe outer boundanes of a school? ❑ Yes ❑ No
Qf yes", the (acilily must meet the requirement of Sections 25534 and 42303
o( the Califomia Health and Safery Code).
7. If a permit from the Soufh Coasl Air Qualiry Management Districl or other
air polWtion conirol district or agency is required for the vrork which is the
subject of this applicatioq have all o/ the disclosures prescribed by Califomia
Heallh and Safety Code Section 42303 been made? ❑ Ves ❑ No
8. Qf'yes", attach certificate of compliance trom ihe appropriate air pollution
control officer�.
CERTIFlCATE OF COMPLIANCE: I ceAify that under penalry of perjury Ihe
infortnation given above is correct I agree to comply with all state laws and
city ordinances regarding Hazardous Materials and Emissions.
SignaWre Dale
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalry 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 ro building conswction, and authorize representatives of
the Ciry of Costa Mesa to emer upon the above-described property for
inspection purposes. I agree not ro occupy or allow occupancy of any building
authonzed by Ihis permit until fnai inspection.
S t fIRa2 0 eqs) Da
' � �3
Anelor Aumon a np ¢aN oale
CITY OF COSTA MESA
��'tp MFsq BU/LD►NG D/V/SION
Ft�� 77 FAIR DRIVE. COSTA MESA. CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
� FOR INSPECTIONS CALL: (714) 754-5626
��'°�^`°°'' PERMIT NUMBER: M11-00008
PERMIT TYPE MECH
APN: 13910221
JOB ADDRESS: 3217 NEW YORK AV CM
V'rcinity: GARAGE "
SQ. FT: 0
STATUS: ISSUED
DATE ISSUED: 01/O6/2011
ISSUED BY: RMD
Suite/Unit:
SCOPE OF WORK: RELOCATE EXISTING FAU TO GARAGE WITH NEW MECH GAS PIPING.
OWNER: BISSONETTE DAVID Address: 1938 KILLDEER CIR Unit:
PHONE: City/State/Zip: COSTA MESA, CA
APPLICANT: DE JONG, EDWARD Address: Unit: -
PHONE: 949-597-1420 . Ciry/State/zZip: �
CONTRACTOR: DE JONG AIR CONDITIONING AND HEATING
Address: 23498 SANDSTONEUnit:
City/State: MISSION VIEJO, CA �ZipCode: � 92692
MECHANICAL PERMIT FEE SUMMARY
MECH ITEM FE�; $44.45
PLAN CHECK FEE: $0.00
INVESTIGATION FEE: $0.00
REINSPECTION FEE: $0.00
TOTAL FEES: $44.45
License No. 625188
PHONE: 949-597-14'10
CELL:
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 expiralion of this permit.
GODEp. INSPEGTIONTYPE DATE INTITIALS COOEi INSPELiIONTYPE DATE INTITIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical 3��9'h �%1��
1266 PoolSpa Final 208 Final Plumbing
200 Final Re-Ropt 270 Final Elecirical
201 Final Block/P,etaining Wail 212 Final Fire Prevenlion
202 Final Factory Fire Place 220 Final Planning Appmval
203 Final Sign 222 Final Site
204 Final Demolifion 250 Final Building/Occupancy
A - �
WORKERS' COMPENSATION DECLARATION:
I hereby aKrm untler penalty o( perjury one of Ihe following declarations:
❑ I have and vrill maintain a certifcate o( consent to sel(-Insure for workers'
compensation, as providetl for by section 3700 of the Labor Code, for the
peAormance of the vrork (or which Ihis permit is issued.
� I have antl will maintain workers' compensation insurance, as required 6y
sectbn 3700 of the Labor Code, fa the pertormance of the work (or which this
permit is issued. My workers' compensation Insurance carrier and policy
number are:
Cariiec
(inis sectun need rol Ee mmqefed d(he perrM is valuetl at one hundred dollars (St00) oi less )
Policy'Number:
❑ I certify that in Ihe peAormance of [he vrork /or which this permit is
issuetl, I shall not employ any person in any manner so as lo become su6ject
to lhe workers' compensation laws of California, and agree tha[ i� I shoultl
become subject to the workers' co pensation provisions of Section 3700 0(
the or Code, I shall forthwith c pty wilh Ihese provisions �
y--�--� �-�- li
qPd- r��z,�:...,..�.,. Dale�
WARNING: FAILURE TO S URE WORKERS' COMPENSATION COVER4GE
IS UNLAWFUL AND SHALL SU&IECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEV'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aNirm that I am licensetl under provisions of Chapter 9(commencing
with Seclion 7000) o( Divi5i0n 3 of the Business and Professions Code, and
my license }i in full force and eHect.
u�''b 2s /8� ����u G' - 20
� �� �' — l�
Contrador'i5ign r — (�ate+"
CONSTRUCTION LENDI G AGENCY:
❑ I hereby aKrtn thal there is a construcfron lending agency (or the
peAormance of the work fa wfiich this permit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender s Atldress:
Sig�lure �ate
OWNER-BUILDER DECLARATIONS:
I hEfOby afflfrtl lhel Untlef penalty of perjury [hat I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5,
Business and Professions Code: Any ci�y or county which requires a permit to
consWct, aller, improve, demolish, or repair any stmcwre, prior to its
issuance, also requires the applicant for such permit to file a signed statement
thal he or she is licensed pursuant Io the provisions of Ihe Contracmrs
LiCense Law (Chaptef 9(cOmmenCing wilh Section 7000) of Division 3 of Ihe
Business and Professions Cotle) or that he or she is exempt therefrom and
the basis for the alleged exemption. Any viola[ion of Section 7031.5 by any
applicant (or a permit subjects the applicant to a civil penalty of not more than
five hundred dollars (5500).):
❑ 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
o(fered for sale (Sec. 7044, Business and Protessions Code: The Contractors
License Law does not apply to an ovmer of property who builds or improves
[hereon, and who does such work himself or herself or through his or her own
employees, provided ihat such improvements are not intended or oHered tor
sale. If, however, the building or improvement is sold within one year of
completioq the owner-builder will have Ihe burtlen of proving that he or she
did not build or improve for purpose ot sale.).
❑ I, as ovmer of the property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to consWc[ the prqect (Sec. 7044, Business antl
Professrons Code: The cont2ctors License Law dces 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 untler sec.
Business and Protessions Code for this reason:
Slgnalure oa�e
305]-<6(3I01)
1I
Ovmer ID verifed by tlnver's license. ❑ Yes ❑ No
Driver's License No. Expires:
Venfication of Ovmership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certdy thal no excavalion five (5) or more (eet in depth into wfiich a
person is requiretl to tlescentl. will be made in conneclion vrilh work authorizetl
6y this pertnit, and thai no building s[ructure, scaffolding, (alsewnrk, or demolition
or 4ismanHing thereof, will he more than thihy-six (36) feet high. (Chap. 3.2, Gry
2, Art 2, Sec. 341, Title 8, Califomia Adminisiralive Code).
❑ As owner-builder, I will not employ anyone lo tlo vrork which would
require a permit (rom the Division o( IntlusUial Safety, as noted above, unless
such person has a permit [o tlo such work from the division.
ApplicanYs Signamre Date
Division o( Intlusirial Safety Permit Numher: _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or fuNre building occupant need to file antl
certify a Business Plan for emergency response lo release or Ihreatened
release o( a hazardous material? ❑ Yes ❑ No
(Section 25505 of the Califomia Health and Safery Code requires, with some
exceptions, [hat a Business Plan be filed vrith the Costa Mesa Fire
Department by every husiness which has at any one time during a reported
year a quantity of hazar0ous matenals equal to or greater than a weight of
500 pountls, or a volume of 55 gallons, or 200 cubic feet of compressetl gas
at standard temperature and pressure).
2. Does or will the applicant or present or fuWre builtling occupant neetl ro file
a regisiration form for acufely hazartlous materials? ❑ Ves ❑ No
(Sec[ion 25533 of the Califomia Health and Safety Cotle, with some
exceptions, requires registration with the Costa Mesa Fire Department by
each business which at any one time has on hantl a quantity of acutely
hazardous matenals equal to or greater than a vreight of 500 pounds, or a
volume o( 55 gallons, or 200 cubic feet of compressetl gas at stantlard
temperature and pressure�.
3. Does or will the applicam or present or future building occupant need to
prepare an RMPP (Risk Management and Prevention Pmgram for acu�ely
hazardous matenals�? ❑ Yes ❑ No
(Section 25534 of the Calitornia Health antl Sa(ery Code provides that the
Costa Mesa Fire Department may require the preparation, certification and
filing with the Fire Department o( an RMPP by businesses which are requiretl
[o register awtely hazardous matenals with the Fire Department.
4. If an RMPP is presently required, has Section 25534 0( the Cali(ornia
Healih and Safety Code been tully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or future building occupant require (or
lhe wOrk which is lhe subject of this application a permit for such construction
or motlification from the Soulh Coasl Air Quality ManagemeN DiS�riCt Or Imm
any other air pollu[ion con[rol di5[nc� or agency? ❑ Yes ❑ No
(Section 658502 0( the Califomia Govemment Cotle requires that the requested
in(ormation De fumished on applications for noo-residenlial building permits).
6. Will any part ot the facility to be constmcted under this permit be within
1000 teet from the outer boundaries of a school? ❑ Yes ❑ No
(I( yes", the (aciliry must meet the requirement of Sections 25534 and 42303
of the Califomia Health and Salety Cotle).
7. If a permit from the South Coast Air Quality Management Dislrict or other
air pollu[ion control district or agency is required for the work whiCh is [he
subject of this application, have all of the disclosures prescribed by Califomia
Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
8. (If'yes", attach certifiwte of compliance (rom the appropriate air pollution
control oKcer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury Ihe
information given above is correct. 1 agree to comply with all state lavrs and
city ordinances regarding Hazardous Materials and Emissions.
SignaWre
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalry of perjury that I have read this application antl state that
the information given is correcL I agree [o comply with all slate laws antl ciry
ordinances relating ro building construction, and authonze representatives o!
the City of Costa Mesa to enter upon Ihe ahove-descnbed property (or
inspection purposes. I agree not to occupy or allow occupancy of any building
authorizetl by �his permil until Mal inspection.
Signalure ol Legal Owner(s� Date
AnGd.Au��onz¢4 APCfcanl �dle=
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14=�n`�
LANNING
APPROVAL
City of Costa Mesa Planning Div.
Subject to Building Division Regs.
� Revision must be approved.
Required Prior to Buildinq Final:
OYES i7JFl0 ing Inspection
OYES �O T affid Park Fees
gy. ate:l �o I � I
fl�U does plofi" �i1CYo0�h ��+�
�eau�ru� de(�n .
f�����=ss ;
�jZI� N��n/ `/G�Zk �YilF'
CoSTa Mc:✓� t c.� .�f2 h�L�
(714) 754-5273 • Fa�c (714) 754-4856 • www.ci.costa-mesa.ca.us
BUILDING PERMIT
Job Address:
Suite:
Vicinity:
3277 NEW YORK AV
RESIDENCE 8 ATTACHED GARAGE
Parcel Number: 13910221
Applicant WOLSKY, BRIAN
Address: 17662 METZLER LN
HUNTINGTON BEACH, CA
owner: LAWTON, CHRISTOPHER
Address 3217 NEW YORK AVE -
COSTA MESA, CA
Contractor: TOM BYER ROOFING
Address: 17662 METZIER LN
Arch :
Address:
Zip:
HUNTINGTON BEACH, CA
Zip: 92647 .
Phone:
License:
Zoning:
Phone: (714)847-9332
Zip: 92647 �
Phone:
Zip: 92626
Phone: (714)847-9332
- �License:�' S75002� �
' . Eng:
� . Address:`
77 hAIM UHIVt, GUS IA MtSA, GA 92626
ISSUED BY:
Status: ISSUED
Applied: 04/27/2001
Issued: 04/27/2001
Phone:
License:
� ' -' - �`. SCOPE OF PERMIT -, :`�_� �
REROOF21 SQUARES OF PITCHED ROOF & 3SQUARESOF FLAT'AREA: T/O EXISTING, REPAIR SHTG AS NEEDED, 2, �
LAYERS OF 15# FELT, APPLY 20-YEAR COMP SHINGLES TO PITCHED ROOF. FLAT ROOF: T/OiAPPLY B.U.R. WITH � �
CAP. - " 1 . . r; _ , - ,.
, ' , , __ . -/ % -
i; ,� - _
�. _ _ .
_ � — _ � FEE SUMMARY ;; _ : _ , r' �:' ,
PIan�Check:'� . $0.00 /� ! � Calc Valuation: �' � � $3,�zs.00
� Permit: '�' $9725 � ' Claim Valuation:� �, � � �� $3,�2s.00
SMIP-Res . �, $0.50 �— ' °�- ���; � ' � �� i� �;
SMIP Com �- � � '� � � %
�'$0,00 � - Pi`f� : ' � .' l
� �Other � ��$0.00 � „i r'> �" '�w � s%�l �.. � � /�,'� �
�
Inspection � $0 00� >� ' �` � , , �� ` i� �
� �� _�, ;
,. , :�v� � fi'�� ,� � "�.� ti'� ' '.`> ' .
Totel: S97 75'��� ' =. < � � '� � � i �
�� ��� <; � /> ������ � �� e � - ;� '�"�' - � 90 �'l'��/) ��/� � i�, �/
`; �\ , ��i� ; - � � . ' PLANNING & ZONING� 1��� ``' ,� i
l
SETBACKS �'� �;ti�/j.� J ,� . �� 7� `� /�%' l/
MAIN STRUCTURE Front �0�0 �.., '�l�` Rear 0. 0_ Lek 0 0 z S��� RigM �� O�O; j �
� � _ _ �'; ; � � .r_ � , :,-.}• � i/i .
i, /�
ACCESSORY Front 0. 0 = ;'_�.,, �Rear 0- 0 ' ' - : Lek � � 0- �0 � �ll�"�� Right� �0- 0
�
�.�=�.��-�.._ �� %�.'�,A�..--i! _� �-� ,�.��,�,
PARKING Existinq: o ��Reauiretl:-- pr _ proposedJjp�! �%
- .. , . _ ic., _ -
NOTES:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 9248, § 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 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
required inspections and tinal approval must ba obtained. Failure to obtain inspections and final approval will result in the expiration of ihis permit.
'� FOR INSPECTIONS CALL: (714) 7545626
244fi-4fi (N00)
WORKERS'COMPENSAnON OECLARAn((iI� �
I hereby Bttirm untler penalty oi perjury one of the following dedereilons:'
❑ I have end will maintain a certiticate ol consent to selt-Insure for workere' compensation, es provided tor by section 3700 ot the Labor Code, lor Ihe pertortnance of the
work for wNc� Ihis pertnit is issuetl.
I have and will maintain workers' compensetion insurence, as requiretl by section 3700 oi the Lebor Cotle, for ihe pertortnance ot the work for which ihis permit is issued.
.workers' compensation Insurance cerrier and policy number are:
Carrier: Policy iJumber:
(Triis secfion need nof be cromplefed il the permit is valued af one hundred dollers ($100) or Ie55J
❑ I certify Ihat in the peAormance of the work for which this permit is issued, I shall not employ any person in any manner so as to becro e suCject to the workers'
compensation laws of Calitomia, antl agree that it I shoultl ome-subject to Ihe workers' wmpensa[ion pmvisions oi Sec n 370 f the Wbor Code, I shall torthwith
comply with Ihese r ' 4
Applicent Signeture: Date: / Z� Q�
WARNIN(3: FNWRE TO SECUR WON� B NSATION COVEMGE IS UNLAWFUL M1D SHALL SUBIECT rW EMPLOVER TO CRIMINAL PENALTIES AND GVIL FlNES UP TOONE HUNDRED
TKKASANDDOLLARE(5100,000),IN COSTOFCOMPENSATION,DAM4GESASPROVIDEDFORINSECTIIXJ3/O6pFTHELABORCODE,IMEREST,ANDATTORNEY'SFEES.
LICENSED CON7RACTORS DECLARATION:
I hereby eHirm t�at I am licensed under provisions of Chapter 9(commencing with Section 7000) of Division 3 of the Business antl Pryfassio� Code, end my license is in full
force end eHect. Llc. a � Clau k �
Contracmrs SigneWre�—� Date: � �7 �[ �/
CONSTRUCTION LENDING AGENCY:
❑ I hereby aHirtn that there is a construction lending agency for Ihe pedormance of ihe work for which this pertnit is is5ued. (Sec. 3097, Civil Cotle).
Lenders Nama: Lentler's Atltlress:
Signature:
Date:
OWNER-BUILDER DECLARATIONS:
I hereby ettirtn that under penalry ot per�ury ihat I am E%EMP7 FROM 7HE CON7RACTORS LICENSE LAW for Ihe following reason (Sec. 7037.5, Business and Protessions
Code: My ciry or counry which requires e permit to construct, alter, impmve, tlemolish, or re0air eny sWcture, prior to its issuance, also requires the applicant tor such permit
to tile a sl8netl statement ihat he or she is Iicensed pursuam to the proNsians ot ihe Contracrors License Lew (Chapter 9(commencing with Section 7000) of Divlsion 3 ot the
Business and Professions Code) or lhat he or she is exempt therefrom and the 6asis for the alleged azempiion. Any violation of Section 7031.5 by eny epplicant 1or a permit
subjecis Ue epplicant to a civil panalry oi nat more than five hundred dollers ($500).):
❑ I, as owner ot t�e properry, or my amployees with wages as their sola compensation, WILL DO THE WORK, and Ihe sirucWre Is not intentletl or oHeratl tor sale (Sec.
7044, Busineu and Professions Code: The Coniractors License Law does not appry to an owner of propeny who builds or improves thereon, end who does such work
himself or �ereelt ar through his or her awn employees, pravided Ihat such improvemenis ere not intended or oHered lor sale. If, however, ihe building ar improvement is
sold within ona year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose ot sale.).
❑ I, es owner of the properry, am E%CLUSIVELV CONTRACTING WITH LICENSED CONTRACTORS to construct the prolect (Sec. 7044, Business antl Professions
Cotle: The conirec�ors License Law tloes not apply to an ownar ol property who builds or improves thereon, and who contrects tor such prolect with e contrector(s)
license pursuant to ihe Contractors License Laws.).
❑ I am exemp� under sec. Business antl Professions Code for this reason:
Slgnature: Date:
Owner ID venfieC by tlriveYs license. ❑ Ves ❑ No Drivefs License N0.
Verification oi Ownere�ip by (rype of documem, i.e. - properry tex bill or dead):
DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION:
Expires:
❑ I hereby certity that no excavetion five (5) or more �ee� in depth into which a person is required to descend, will be metle in connection with work authonzed by ihis
pertnit, and t�at no building sirucNre, scaflolding, talsework, or tlemolition or tlismantling thareof, will be more ihan thiny-six (36) leet hiqh. (Chap. 32, Gry 2, Art 2, Sec.
341, Title 8, Califomia Administrative Code).
❑ As owner-builder, I will rwt employ anyone to do work w�ich woultl require a permit Iwm the Division of Industnal Sefery, as notetl above, unless such person has a
permit to do such work from ihe division.
Signature: Date:
Division oi Industnal Satery Permit Number:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF EMAY: I certify under penalty of perjury that I have read ihis application and state tha� ihe informetion given is
correct. I agree to comply with all state laws entl ciry ortlinances relating to building consiruction, and authorize representatives ol the City ot Costa Mesa to enter upon the
above-described property tor inspection purposes. I agree not to occupy or ellow occupancy of any building euthorized by ihis permil until final inspection.
CQOE I, INSPECTIONTYVE
7616 Fizetl Sys�em Final Fire Prevention
1266 Pool Spa Final
200 Finel R8-Roof
207 Final Block/Retaining Wall
202 Final Factory Fire Place
203 Final Sign
204 Final Demolition
P�I4 1[1IIIleLfl
s r_�� � —^
ate
% �' o /
Date
CO�E 11 INSPEGTION TYPE
206 Final Mechanical
208 Finel Plumbing
270 Final ElecMcal
272 Final Fire Prevention
220 Final Planning Approval
222 Final Site
250 Finel Building/Occupency
QAIE INTR1��5
' ci7voF�cOSTAMESn CONST�R,/UCTIONPERMIT
P:�ject Address � � � ' 'Il]CK ' '
i
Applicant's MailingJ�Address � � � e� ���' ` �
� Owner'sName. �^e-On t�Jh Phone�S�-�-'
Address '���� �QW ��l !
Areh/Eng. i�License No.
Address �
1
Contractor'sNa «i- 2 �L one.Sy/-��
Addresslma"I� gl � � �hp%• �e��erciM �.IV �1�\
City �License No. Q��9 � i' �
LICENSED CONTRACTOR DECLARATION . .
1 herEby affirm Nat I arti licenzetl untlei p�ovisions oi Cba�ter 9(commencing
with'section 7000) of Division 3 of the BusinessantlProf ' antl
a-;y license is imfu�l torce ana effect. ' ,
��e ' ' ' � ' License N
7- � c'gnar ... ����/—'Y�q� ���
COMPENSATION DECLARATION �/ � !`� �
I hereby attirm that I have a ce�tificate o� consent to self-insure or a certificate
� of Workers' Compensation Insurance, or a certifietl Copy thereof (SeCtion
3800, Lab. C.)� '/ G '
� Poucr No. PL{/IT�I`I� 1� ComPanY Zen���
1 � CertiT co y is heveby fu�nishetl. . ' i
�1 c letl with the city Builtl� q Oivizlon_
���°��APPlicant �� � ' .
EX FROM WORKERS' COMPENSATION DECLARHTION
(This section neeC not be completetl if the permit is for one huntlretl ($100) or
IC55).
I certity that in the pertormance oi the work,for whicn this perm�t is issuetl, 1
shali not employ any person in any manner so as to become subject to the
Workers' Compensation Laws of California. �
Date Siqnature ' �
NOTICE: If, af[er making this tleclaration, you shoultl bewme subject to the
Worke�s' Compensation pravisions ot the Labo� Cotle, you must forthwith �
comply with such' O�ovisions or' thi5� permit snall be tleemetl �evoketl.
CONSTRUCTION LENDING AGENCV ' ' �
I hereby affirm tM1at there-is a wnstruction lentlin9 agency for Ihe performance
of tne work for which this permit. is issuetl (Section 309] Civ. C.)
Lentler's Name
_Lentle�'s,Atltlress ' � � ,
OWNER BUILDER DECLARATION � ' �
I hereby affirm that 1 am exempt from'the Contractor's License �aw for the
:-'ollowinq reason (Section 7031.5 BuSin¢ss antl Professional CotleF Any city�or
l.;bunty which requirez a pe�mit to construGt, alfe�, improve, tlemolish o� r¢pair
'+ny 5[rutture, prio� to its issuance, also requi�es the applicant for Such p¢rmit
��'t0 tile a signetl statement that he/she is licensetl pur5uant to th¢ provisions�of
the Contractor'S Licenze lWw (Chapter 9_(commencin9 with Sectlon 7000) of
-Division-3-ot the BuSiness antl-Profe55ions-Cotle)•or-that M1e/she is exempt
' the�efrom, antl'the basis.for the alleqetl exemption. Any violation of Section
7031.5'"by any applicant tor a permif subjects tM1e appllcant to�a civil
� penaltybf noi more tban five huntlretl tlollars ($500�. •, . : , •
❑ I, as owner of the' property or my employees witM1 wa9e5 as [h¢i� sole
�<ompensation, will tlo-the work, antl the structure is not intentled or�offeretl
for`saie (Sectiom Zo44, Business an0 Professional Cotle: The Gontractor's
License��aw tloe5not'3pply to an owner of a property who builtls or improves
� thereon. antl who tloes such work himself/herself or through hiz or her own
� employees, provitletl that such improvements are not intentletl o� oHeretl for
�sale:'It; M1oweve�; tM1e builtling or improvement Is soltl wi[hin one year of com-
_ pleiion,-the ownei will-have the bu�tlenbt provinq he/she tlitl not bulltl or i�n-
. prove fo� the,pu�pose of sale). .. , � .
❑ I, as owne� ot'the property, am exclusively mntrattlnq with liceniea con-
��tractors.to construct the project (Section ]044, Business antl Professions Cotle:
The.Contractor's License Caw tloes:mt apO�Y to'an owner.of property who
� builtls or improves;thereon, antl who contracts for such p�'Ojects with a con-
i. t�actor(51 license pursuant to the' Contractor's Licenie Law). I am awa�e that
• j proof of their'WorkeL'S Compen5ation insurance shoultl be providetl to me:
:�-I am'exempt untler Section �B.'& P. C. tor thii reason -
� . . � � � . . i.
•�Date + Owner � ' � � '
r I M1e�eby certity that I have reatl this application antl state Ihat the above I
� information is wrrect.�l agree!to comply with all city antl county ordinances
.antl-state laws relating�to builtling construction, and hereby authorize reore- .
sentatives of- this, city; to �enter upon tne above-mentionetl - erty .tor '
inipeG[ion'pu pos . n _ �. -
' Signature � � � • Date +
y ,:Drivers' �Litense or 55 � , � - �
�o�icant to fi11 in all zoaces ezcept tnoze within neavY Eoraer lines antl sign all aoVropriate Oeclarations.
PERM T O: �� TRACT NO. � LOT NO. UNIT NO. � ' , �
� i �
� TYPE OFCONSTRUCTION � NEW: ADD ALTERATION REPAIR '�
❑ CONVERSION ❑ DEMOLISH ❑ OTHER � A.p,�b ' ' �
DESCRIPTION OF WORK/USE OF BLDG. � � �~ � S Main Buildin
i . 9 :
TVPE OF PERMIT � 0 GRADING ❑ FOVIVOATION ❑ STRUCTURAL ' T F�Ont� ! �
, O TENANT ❑ ELECTRICAL � O PLUMBING�MECHANICAL � B Reaf
❑ OTHER . ' ' ' ' A
PROJECT DESCRIPTION 54. FT. ' ocCUPANCv C Right;'
CONSTRVCTION:TVPE VALUATIONS � ' S Left �
� ZONE � GRADING CU. VDS. � ACRES� p�ng. Ref. # '
i
+ ' ;14d2 I'2/14/87 +
I , f 1
� Zo
� � ' Accessory Building:
r ' . ' �
Remarks: , , � 1 • . - � Plamm�g Notes: '
.i , .
.. _ �PLUMBING - �� � ` ' ' . •
Sink
Iriigation, � _ �
uanners �
Dishwasher ' �
Drinking Pountains
Floor Drains l ' � � -
Floor Sinks - ' �
Gas Service ' Outlets
Interceptors ; �
Kitchen.Sink , . �
L`avatories I
Drains
Reinspection�Fee, ,
Boiler � �
- Svuctural
i Showers � '
� Service Sink ,
� Sewer Cap�.- I . �
Sewer. Connection
Solar Collectors �
Solar Pipin9 i _
Solar Tank
� Swimming Pool w/Spa
� Urinal
' Water Closet �
Water Heater �
Water Seivice.i.._
Laundry Trays
$15 �; I � . Issue Fee'
_' Firepl/Fact.,BICICBO#
e ting System & Ducting. �
0-100,000 BTU � 100,000 BT
- Reinspection'Fee � `� ,-$75
i
3oltlenrotl - Assessor ' �
Hoodor .Typel ❑ �
CanoPY TYPe 11 ❑ �
Refrigeration System .
❑0-100,000 BTU� 0100,
- ; I
AutomaticWasRer�- '
ConstiuctioryPole Sub.
Cooking Unit ' '
Dishwasher = � " �
Dryers ❑Gas ❑Electric
Fan
FA�II. _ � � '
Fixtuies
Device Boxes
Outlets .
Switches � �-
�
; 7.D0 �TU I
� � '.
�ELECTRICAL ' ,
. Transformer ❑ 15-50 KW
',: � � ❑'50+KW
� Meter ❑up to 100 amps
� Meter. �over:100�amps
SubPanel •�
Motors � 0�1 HP � 1'/: - 8
� , Inc.Sola'r �9-15 HP �16-15+
Generator �0-5 KW �5-15 KW
Pole Light'
Range
Sign "
Standing Sections �
Trash Compacmr
� I ' 1 � . i
Reinspection Fee �$15 � � Issue Fee
j FEES . ���
� _ DEVELOPMENTSERVICESREQUIREMENTS:. ,
' Zoning APProved BY .
� - �Building Approved By . �
Applicatian Issued By
_, i
o��
� �
laue Fee � ' $ 3
_ Z
. O
N
I
- 'N
G
R
E
�
M
T
S
$ 3
i � � � SUMMARV OF'FEES , � � �
-� BUILDING PERMIT $ SMIP . „ $ � - � � �
' t PLAN CHECK ' $' �PEFMIT
PLUMBING : ' �, $ �- ISSUANCE .�� $:�"
''; PLAN CHECK . 25% S� � ENERGV P.C: $.
- ELECTRICAL $" �GRADING � $ - " -
', " PLAN CHECK 50% $ ` -MICROFILM � $ .__�
MECHANICAL : $_ �� TOTALFEE $ ,a� l
" PLAN CHECK ' 25% $ " _ � r
CONSTRUCTION AND�PLANNING POOL & SPA � �
APPROVALS Permit�# Date Inspector ° qpPROVAIS Permit # Date Inspector
1. Temporary Electrical�Service or Pole 52. Pool & Equipment Location '
r
2. Soil Pipe-Undrgrnd. � 53. Steel Reinforcement `��"
e:: ;.
3. Electrical Conduit Utility-Undrqrnd. 54. Forms ;..�""
4. Electrical Conduit-Undrgrnd. 55. ElectricabBonding .
5. Steel Reinforcement 56. Rough.Plumbing & Pres�L.i@.Test "
6. Electrical UFER Grnd. . 57. APPROVAL TO COVER_GUNITE �
� � ..
� �. _,
7..'Footings � ' 58. Elecirical Conduit-Und�gcnd.:
' 8: �Foundation , �. 59. Gas Pipe, O Undrgrnd.; Test�
�.r;
' 9.;�Water Pipe-Undrgrnd. � . . 60. Backwa5h Lines, P-Trap,(Q�Undrgrnd. ' '
10. Structural Floor System . 61. APPROVAL TO DECK�� ��� �
11. PropertY Sewer Line & House Connection � 62. Backwash & Receptor-Final
72. Sewer Cap � � 63. Heater & Vent-Final
13. Roof Drains� ' 64. Plumbing SYstem - Final � �
14. Rough Plumbing 65. Electrical-Final �
15.� Rough Electrical-Conduit 66. Solar System-Final .
16. Rough Electric Wiring. 67. Fencing & Access Approval
17: Rough,Wiring Sign -- 68. APPROVED FOR PLASTERING �
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL �
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace , APPROVALS Permit #• _ �
21.' Ducts, in Structure ' 70. Underground Hydro
22. Ducts, Ventilating� � 71. Product Piping O Gas ❑ Oil
23. Gas Pipe-Rough & Test 72. Underground Flush ' ' �s �
' 24. Roof Framing 73. Undergrnd.StorageTank �Gas ❑Oil
25. Roof Sheathing , ._ - • - � - ' � 74. Overhead Hydro
26.� T-Bar Ceiling (StructuraQ & 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. Plaeter Brown Coat � 79. FINAL INSPECTION � . `'
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED .,'
� 33. Final Electric Notes: --
34. Final Heating & Air Conditioning �. �Z�j_�7 �'f� �
35.. Final Gas Pipe-Test � - � -
36. Hood or Canopy
37. Final Facto�y Fireplace
' 38.. Final Plumbing j
39. Water Service-Final _. . _ - -- : � -_ ' •
- �40. GasService-Final - _ � � - . "
41. Solar pomestic-Final � . �
42. Backflow Preventer . .
�43. Backflow Irrigation �
��44. .Landscape Irrigation System � � _
45. Sound Attenuation
46. Handicap Regulations .
47. FINAL STRUCTURE & BUIIDING -
48. �Special Requirements Completed - .
i 49..Elec[ric Release to Edison • .
_-50. Gas Release_to Southern Califoinia Gas Co � . _, ..
� � �51. GERTIFICATE OF OCCUPANCY � "
. r' �
NO. ' _ Date �' :
.. .. ' _ ' '_ 1 .
, . �23��
C:OSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 917 C09TA MEBA. CALIFORNIA
For Applieanf fo Fill in Complefiely
' TYPE OR PRINT
COSTA MESA CALIFORNIA
Vermo:rt Anenue Land �o.
Carlson &
■ STATE
NO. OP BLDG9.
��� RE�Etv�D
�` FtNAN�� �EPT.
p��Ty OF COSZA MESA
APPLICATI0�7 FOR PERMIT
BUILDING
` For Oifiee Use Only
PECEIPT NO. � PE:�IT NO.,
.�•�vn
� � �ri�-a
. REC6IVED BYi I�'TE�CEIVEU I O�1TE I650E0
! ��.i,� D-6o .IIIN2 1 196
BUILDING
ADDRESS
COSTA MESA. CALIFORNIA
ZOIdII.'NG
ZO �� / I P ANS `1 /I 9UILDING
�� I
oEs�a���.,,. I,ot 120. Tr. 3(
06TBACK LINB FROM (CeNT¢R LINE 9TJ
cerarew ov arneer 5`l� REAR YARD z� FRONT � FT.
SIOE YARO ILEFT � IRIGHT � �
R. SIDE FT.
DESCRIPTION OF WORK
L.SIDE FT.
NEW I X IIALTERATION I IIADDITION I REAR a / FT.
NO.
BE
APPROVED
I�{SD�`—
�,i_"n a'__
Sinnle £amil residence with
2ttached ar e. P7.an 40CR
1 HERBBY ACKNOWLHDGE THAT I HRVB R6AD THi9 MP4WTION
ANO BTAT¢ THAT TXE ABOV¢ I8 GORRECT AND A6REE TO GOM- TXe AMOUNT BXOWN UNDEp VALUATION 19 pOR THE
PUPPOBE OP EBTRBLIBHING A PERMIT FEE ONLY.
PLY WITH ALL CIT' ORDINANCEB AND BTATE LAWB f160UI.�TING
9uLLDiNo CONBTRUCTI VALUATION
SIGNATURH OF' � � PERMIT FEE $ �S•
PERMITTE
� 15,�45• PLAN CHECK $ �-7�50
AUTH D AGENT �].�52 & olegrove� II1C
TOTAL FEE S 52��0
e
Vermont Ave. Land Co., Inc. DATE
GEIVERAL CONTRACTOR Dike & COle�iuve, 1riC. VALUE $ 1S�OU5
AP. No. LOT 120 TttSCT jb� FIRE ZONE DESCRIPTION OF WORK R2S.W�8tt.Gar.
INSPECTIONS 7_��..�� I DATE I GROUP I R< J TYPE V �LONE R-1
Underground Soil y}�r U.G. Water,�^1 �- PERMITS ISSUED
_. . . . ,.. v'��T� V f=i�iQl SUBCONTRACTOR I . _ _ ___.
OCCUPANCY
Form 210—SM-11-59 5-B P
i