HomeMy WebLinkAbout220 PALMER ST - Building PermitsCITY OF COSTA MESA *
BI/ILDING DIYISION
77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • w�rN.ci.costa-mesa.ca.us
FOR INSPECTIONS CALL: (714) 754-5626
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PERMIT NUMBER: B09-00011
PERMIT TYPE B_ROOF2 STATUS: ISSUED
APN: 42533206 DATE ISSUED: 01I22I2009
ISSUED BY: BJK
JOB ADDRESS: 220 PALMER'ST CM ' � Suite/Urnt:' `
Vicinity: REROOF RESIDENCE ONLY ��: =• -' -- - ' z % '
Squares: 2600 . � -� Valuation. �>� ,- -$7;377.00
SCOPE OF WORK: REROOF, RESIDENCE AND ATTACHED GARAGE:
7 STORY: T/0 WOOD SHAKE (BOOSF), REPAIWREPLACE SHTG AS NEEDED, FELT PER MFGR'S SPECS, APPLY-
30-YEAR COMP SHINGLES. 2-STORYi OVERLAY EXISTING 20 YR COMP ROOF (1800SF), FELT PER MFGR'.
SPECS, APPLY 30-YR COMP-SHINGCES.�PITCH 3:12 " . ' � ! -. .. ' ' , �
OWNER' BINNING,ROSALYNL�T�R, _ Address: '108VIAANTIBES�#C� ty---
PHONE: .;; ' ;,;.` . ;` :-...�`....�.. � City/State/Zip: NEWPORT.BEACH CA � ,':,..,. �+.`.
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APPLICANT: NIELSEN;�JACKI - Address: 29222 RANCHO VIEJO RD ` t'��
PHONE: 949-542-7265 �, - . _ , �. „' City/State/Zip:'SAN JUAN CAPIS7RAN0, CA=f � '�"�"
CONTRACTOR. CRANK BROTHERS CONSTRUCTION INC �' ` . License No. �� 458773
Address: 29222 RANCHO�VIEJO'RDUnit:- • � . : SUITE 127 . , . � PHONE:.�:" �� 949-542-7265
CitylSlate/Zip: SAN JUAN CAPISTRANO,`CA- � � , _ � � � � �� g2675 . CELL: -� �
ARCHITECT: - License No, ., . � �_PHONE:�
ENGINEER: ".;, � -� License�No. : � � ,,, PHONE:
FEE SUMMARY
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Reroof PlanCheck: $0�00�_-;�,` . - � --
Reroof Permit Fee: $153.25 ��` � -� � , . .
Reinspection Fee: $0.00 `� . � �� -
Bldg Std Admin Fund $�.00 � ' - � . . _ �. - � -
Un(t:
Unit: :SUITE 127
NOTICE: The work authonzed by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related
r�gulations. (Ord. No. 92-28, § 1, 12-21-92) '
�XPIRATION: 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.
UE . INSPEC710N TYPE
1616 Fixed System Final Fire Prevention
1266 Pool Spa Final
Zb0 Finai Re-Roof
201 Final Block/Retaining Wall
z02 Final Factory Fire Place
203 Final Sign
204 Final Demolition
DAiE INIITALS
�
COOEt INSPEC110NTYPE
206 Final My�hanical -
208 Final Plumbing
210 Final Electrical
Z72 Final Fire Prevention
220 Final Planning Approval
222 Final Site
250 Final BuildinglOccupancy
DATE - INTOIRLS
�
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WORKERS' COMPENSATON DECLARATION.
I hereby a�fm u�er penatty of pe�ury one of the owing declarations:
❑ I have and wi�l main[ain a certificate of consent to self-lusure (or worke'rs'
compensation, as provided tor by section 3700 of the Labor Code. for the
peRormance of the work for which this permit is issuetl.
❑ 1 have anC will maintain vqrkers' compensation insurance, as requiretl 6y
section 3700 of the Labor Code, fa ihe peAormance o( the woAc fa which this
pertnit is issued. My worker5' compensation Insurance cartier antl policy
numberare: �� � / �
/1w�� 1�
` (ThissepmrieMnalEemmpetetl/Ihepem�4kvaNetlafine�uMrtd�llars(Et00)wless)
P�.�� a3�3 a7 ���
❑ I certify [hat in the peAormance of the work for which this pertnit is
issuetl, I shall no[ employ any person in any manner so as to become subject
lo the vrorkef5' COmpenSalion laws o( Califomia, and agree that i( 1 shoUltl
become subject to the workers' wmpensation provisions of Section 3700 of
t e Labor otle, I shall forth ':omply with these provisions.
�-- Z OS
Md� ��S�gnaWre 0 le
NING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS - UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE CAST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirtn that I am licensed under provisions of Chap[er 9(commencing
wilh Seclion 7000) of Division 3 of ihe Business and Professions Code, and
my license is in WII torce and eRect.
�s �� ��, c-3�
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C NSTRUCTION LENDING AGENCY:
❑ I hereby aff"mn that there is a consWction lending agency fw the
pertormance of ihe v.oAc for vfiich tlris permit is'ssuetl. (Sec. 3097, Civil Code).
Lender s Name:
LenCer s Address:
Signalure Da�e
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury lhat I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for lhe tollowing reason (Sec. 7031.5,
Business and Professions Code: Any city or county whiGh requires a pertnit to
wnstruct, alter, improve, demolish, or repair any siructure, pnor t0 i[5
issuance, also requires the applicant for such permit lo fle a signed statement
lhat he or she is licensetl pursuan[ to the provisions of the Conhac[ors
LitenSe Law (Chapter 9(commencing with Section 7000) of Division 3 of Ihe
Business anC Professions Code) or that he or she is exempt therefrom and
the basis tor the alleged exemption. Any violalion of Section 7037.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more [han
fve hundred dollars ($500).):
❑ I, as owner of the property, or my employees vnlh wages as their sole
compensation, WILL DO THE WORK, and the slructure is not intended or
oflereG for sale (Sec. 7044, Business and Professions Code: The Contracrors
License Law dces not apply to an ovmer of property who builds or improves
thereon, and who dces such work himself or hersel( or Ihrough his or her own
employees, provided that such improvements are not intendetl or offereC for
sale. If, however, lhe 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 ovmer of the•property, am�EXCLUSIVELY CONTRACTING WITH
110ENSED CONTRACTORS to construcl the project (Sec. 7044. Business and
Professbns Code: The con[2ctors License Law dces not appty lo an ovmer of
propeny wno builds or improves thereon, and who conlracts for such project with
a cont2Ctor(s) license pursuant to the Contractors License Laws.)..
❑ I am exempt under sec.
Business and Professions Cotle for this reason:
SignaWre ` Oa�e
3051<6 (3I0])
f _.�
Owner ID verified by driv�. ..:ense. ❑ Yes ❑ No
Drivers Litense No. Expires:
Verification o( Ownership by (rype of Cocument, i.e. - property tax bill or deed�:
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: �' -
❑ I hereby certify that no excavation frve (5) or more feet in tlepth inlo which a
person is require0 to descentl, will be made in connection vrith work aulhorized
by Ihis pertnit, and that no builtling sWCNre, sc�(dding, falsework, a tlemolil'qn
or dismantling thereo(, will be more �han Ihihy-sa (36) feet high. (Chap. 32, Grp
2, M 2, Sec. 341, Ttle 8, Califomia Administ2tive Cotle).
❑ As owner-builder, I will not employ anyone to do vrork which would
require a permit from Ihe Division o/ InOustrial Sa(ety, as noted above, unless
such person has a permi[ to tlo such work trom the division.
A00�����'s SgnaWre
Division of Industrial Safery Permit Number. _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will Ihe applican[ or presenl or future building occupant need to 61e and
certify a Business Plan for emergency response to release or threatenetl
release o( a hazardous ma[erial? ❑ Yes ❑ No
(Section 25505 of the Califomia Heal[h and Safety Code requires, wilh some
exceptions, Ihat a Business Plan be fletl vrith the Costa Mesa Fire
Department by every business which has at any one time dunng a reportetl
year a quantity ot hazardous materials equal to or grealer ihan a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas
at slandard temperature and pressure).
2. Does or will Ihe applican[ or preseM or fuNre building cecupant need to file
a regisiration (orm tor acutely hazardous materials9 ❑ Yes ❑ No
�Section 25533 ot the Califomia Health and Sa(ety Code, with some
excep[ions, requires regist2[ion with Ihe Costa Mesa Pire Department by
each business v+hich al any one time has on hantl a quantity o( acutely
hazardous malerials equal to or greater than a weighl 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 applicant or presenl or future building occupam need ro
prepare an RMPP (Risk Management antl Prevention Pmgram for acutely
hazardous ma[erials)? ❑ Yes ❑ No
(Section 25534 of the Califomia Health antl Safery Code pmvitles that the
Cosia Mesa Fire Depatlment may require ttle preparation, certification and
filing with t�e Fire Departmenl of an RMPP by businesses which are required
to register acutely hazartlous matenals with the Fire Department.
4. It an RMPP is presently required, has Section 25534 of the Califomia
Health antl Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or fuWre builtling occupant require for
lhe work which is the subjecl o( this application a pertni[ for such cons[ruction
or motli(cation (rom Ne South Coast Air Quality Management Disirict or from
any o[her air pollution control disMct or agency? ❑ Yes ❑ No
(Secibn 658502 of the Califwnia Govemment Code requires ihat Ihe requestetl
in(ormation be (umi5hed on applicatbns fa non-residential building pertnits).
6. Will any patl of lhe facility to be consWcted untler Ihis pertnit De vrithin
1000 feet from the ouler bountlanes oF a school? ❑ Ves ❑ No
Qt "yes", the facility must meet the requirement of Sections 25534 and 42303
of the Califomia Health and Safety Cotle).
7. If a peimit from the South Coast Air Qualily Management DisMct or other
air polWtion control tlisMct or agency is required for the work which is the
subjec[ of this appliwtion, have all of the disclosures prescnbed by California
Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
S. (If'yes', attaih certifcate ot�compliance from the appropriate air pollulion
control oKcer). ' � � � � . • . . �.
CERTIFICATE OF COMPLIANCE: I.certify.that undenpenalry of perjury the
information given above is correcL Lagree to comply with all state laws and
ciry ordinances regarding Hazardous Matedals and Emissions. '� ''�
_ .. , . � , ,_ . . i
Date '
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalty of perjury that I have read Ihis application and state that
the infortnation given is correcL I agree to comply with all state laws antl ciry
ortlinances relating to building construclion, and authorize representatives of
the City of Costa Mesa to enter upon the above4escribed property for
inspection purposes. I agree not to occupy or allow occupancy of any building
authonzed by this pertnit until final inspection. ,. • , � �
. �., .. -
�,�,_ � � �
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OWNER HORN� TOM
JOB ADDRESS 220 Pa
LOT
GAS
ROUGH PLUMBING
PROP. SWR. LINE n HOUSE CON.
MISCELLANEOU'�
ROUGH HENTING
TEMPORRRV SE
UN�ERGROUNO I
ROUGH WIRING
TRENCHES �
FLOOR SVSTEM
BONO 2EAM �
SHEATHING
IR CONOITIONING
POWER
fORMS U STEEL REINF.
STEEL REINFOFCE I-I
FFAME ANO FLASHING
IATMING - IN �; (
PLASTER.BROWN COAT
ELECTRIC, FINAI
BUIL�ING,'FINFL
T
7RACT
DATE 5-7-7k
FIRE ZONE
SUBCONTRACTOR
NG PERMIT N0.
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, 3836�
COSTA MESA BUILDING-SAFETY DEPARTMENT
p.0. BOX 1200 COSTA MESA, CALIFORNIA 92626
APPLICATIOT�1 FOR BU{LDING PERMIT
For Applicant to Fill in Complerely qE iv o�av D E RECEIV D DATE ISSUED
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ADDRESS / �/
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OWNBR �y� A.P. NO. 'C
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y� LI0. NO. C'/� /'� �0� ��LIC. NO � MAIN BVILDING ACCESSORY BUIIDING
� O (FROM C/L STREET)
SIZE NO.OFBIDGS. L
OF LOT NOW ON LOT RONT FT. F
USE OF
EXI5TING BLDG. '1- FT.
I� SIZE OF NO F
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COVEP�NG COVERING REAR FT. FT.
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d i� MAIN BLDGS. ACCESS. BLDGS.
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Q /� Q _ VAR.#E DATE
O �� �/r"f�� i/�R`� C.U.P.iW APPROVE�
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VI heratlV ecknowlatlge that I have reatl this application antl stete f �
� that the above infarmation is correct and apree to comply wiih �
� all lawz regulaNng buildin8 construction, and I shell not employ �, a
F any pe�son in violation of the workman's compensation laws of � / v
� y ffi¢ Stete ot Californla. m
z I herebV cartity ffiai 1 am O�operly licensetl as a contracror untler SQ. FT. o
. the Sta�e ot Calitornia Business antl Protessions Cotle, Divisicn 3, THE AMOUNT SHOWN UNDER VALUATION•IS FOR '
Chapte� 9, antl that such licensas ere in tull force and eftect, or I THE PURPp$E OF ESTABLISHING�A PERMIT-FEE ONLV: �
am exempt trom Me provisions of the State ot Calitornla Business VALUATION ¢
antl Prafessions Cotle, Division 3, Chapter 9. ' r
PERM�T FEE $ O"'Q ]
Signatura of �� � m
Permittee �� $�/,L� PLqN CHECK y �� F
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Author�zed nt { . �/ LL
TOTAL FEE $ c/ (l—l/
� OWN ER
�JOB ADDRESS
GENERAL C01
'C� t �.117-1
I� cCTIONS
GAS
W AT
PAUL AND
P�mer
2N� TOM
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LOT TR
Sii
ROUGH PLUMBING
PROP. SWR. LINE Q HOUSE CON. �
SPftINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONOITIONING
TEMPORARY SERVICE OR POLE
UNOERGROUND � POWER �
ROUGH WIRING
TRENCHES ❑ FORMS � STEEL REINF.
FLOOR SVSTEM
BON� BEAM � STEEL REINFORCE �
SHEATH�NG
FRNME AND FLASHING
LATMING - IN �
PLP[TER,BROWN COFT
"ORAL,FINAL
H� .NG, VENT., REFR
PLUMB�NG, FINAL AN�
ELECTRIC, FINAL
Bt11L01NG, FINAL
DATE 4-22-74 .
BUILDING PERMIT N0. 3794'
SUBCONTRACTOR
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For Applicant to Fil/ in Completely
BUILDING
ADDRESS
OWNEF �
MAIL
ADDRESS G�
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BRANCH ( "�
A�DRESS Z �
ARCHITECT
OR EN�
AD�RESS
CONTRACTOF
ADORE55
CITY
STATE
LIC. NO. �
SIZE
OF LOT
VSE OF
EXISTING BLDG.
S12E OF
NEW BLDG.
EXTERIOR WAW
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f3-8-7i1��;,,:00 439;: ;:��*,zl$.50
:ATION FOR BUILDING PERMIT
BY DATE RECE V� DATE ISSUED
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A.P. NO. I � � — f
BUILDING //i.
ADDRESS GV
OWNER
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FIRE .
S' / Y( .�a � � .Q ZONE
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A�/i`T /_J-G/ �Q
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�p 7 LIC. NO.
� NO. OF BL�GS.
k i3 i— I NOW ON LOT
'C � J �.4 Li C_ �P
O.OF
7 ROOMS STORIE:
ROOF
� COVERING G`
AND WOfiK TO BE PERFORMED
NE ^ NO.OF �
�y P�� ,
VARDS APPROVED
DISTANCE BET.
LOT
DATE
BLOCK
USE OF NEW
BUILDING �ru ,
VARDSAP VEO
ACCESSORV BUILDING
DATE
&
I hereby acknowletlge ffiat I have reatl this apPlication antl state '�L V1��NT�
that the above information is correct entl agree to comply with
all laws regulating builtlin8 construction, and I shall not employ � -5�.�
any person in violation of the workman's compensation laws of -
Me State of California. �
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I hereby certity that I am properly licensetl as a conttactor under� SQ. FT. o
tha State ot Califomia Business antl Professions Cotle, Divisicn 3,- T E AMOUNT SHOWN UNDER VALUATION IS FOR �
Chapter 9, antl that such licenses are in full force and effeci, or I� THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLV: m
am ezempt from the Orovisions ot the State ot Calitornia Business �
antl Professions Cnoe, Division 3, Chapter 9. VALUATION �
PERMIT FEE $ �
. / �
Signature of ���///�/� m
Permittee $[; L�l+/� PLAN CMECK $ E
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Authorizetl ABent TOTAL FEE $
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?,PR 22-74�.,�.00 (3i6 c:::-�.- , �
COSTA MESA BUILDING-SAFETY DEPARTMENT .
P.O.'BOX;200 COSTAMESA,CALIFORNIA92626
� AP LI TION FOR BUILDING PERMIT
Fo� Applicant to Fill in Completely R � OATE FECEIVED
BUILDING I DATE ISSUED
ADDRESS �y �
� J� PERMITNO.
OWNER 4L�.(, ( �t A.P. NO.
MA�� ' BUILDING ^, I -J
ADDfiESS ADDRE55 �.���py���
TEL. TRACT lOT BLOCK
CIT V NO.
CONSTRUCTION N W ADD A T P
LENDER
BRANCH
oWN� �..�.r, .T
ADDRE55 �� VA�U$ ���
ARCHITECT TEL.
OR ENGINEER NO.
FIRE S
AD�RESS � 20NE 'TYPE GflOUP
APPROVED
CONTRACTOR ' BV DATE
ADDRESS
TEL. Z�NE NO.OF USE OF NEW
CITV NO.
PI.AN$ BUILDING
STATE CITY �'ARDSAPPROVED VARDSAPPROVED
LIC. NO. LIC. NO. MAIN BUILDING ACCESSORY BUILDING
SIZE NO.OF BLDGS. (FROM C/L STREET)
OF LOT NOW ONLOT FRONT FT. FT.
VSE OF -
EXISTING BIDG. S FT. FT.
SIZE OP NO. OF
NEWBLDG. � FOOMS STORIES L.SIDE ' FT. FT.
EXTERIOIi WALL ROOF ,
COVERING COVE(iING REAR ' FT. FT.
USE OF BUILDING AND WORK TO BE PERFORMED DI5TANCE BET. BET. MAIN &
- ' MAIN BLIX3S. ACCESS. BIDGS.
VA0. � DATE
� C.U.P.# APPROVED
APPROVED
I hereby acknowledge ihat I have reatl this application and state
�hai ffie above infotmation is correct antl agree to comply with .
all laws regulating builtling construction, and I shall not amploy ` .
any person'in violation,of the workman's compensation laws of .
the State ot Calitornia. �
I hereby certity [hat I am properly licensetl as a contractor untler � SQ. FT.
[he State oi California Business entl Protessions Code, Divisicn 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR
Chapter 9, and that such licenses are in tull torce and effect, or I- THE PUFP�E OF ESTABLISHING A PERMIT FEE ONLV:
am exempt trom ffie provisions of the State ot California Business VALUATION i��(y
antl Professions Coue, Division 3, Chapter 9. - _ , PERMIT FEE $ J ��
SiBnature of
Permittee � PLAN CHECK $
Authorizetl Age^t ' TOTAL FEE $ ��" �
�OWNER BALALIS� PAUL AND HORN� TOM
�JOB ADDRESS a er St� AdR __
GENERAL CONTRACTOR Charles Pigneri
�A' .117-1 2-0 LOT TRACT
� IR .CTIONS Si not�
501 L
GAS
W ATER �
ROUGH PLUMBING � Q
PROP. SWR. LINE � -'�HOUSE CON. � ��
SPFINKLING SVSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONOITIONING
TEMPORARV SERVICE OR POLE
UNDERGROUN� POWER 2
ROUGH WIRING
TRENCHES � FORMS � STEEL REINF. �f Z�
FLOOR SVSTEM
BON� BEAM � STEEL REINFORCE
SHEATHING ��' �
FRAME ANO FLASHI
LATHING — IN. � OOT �-
PLASTER.gROWN COAT
ST URAL, FINAL
HE.. ..G. VENT., REFRIG. AND A.
PLUMBING, FINAL ANO GAS TEST
ELECTRIC, FINFL
BUILOING. FINAL
F INAL
FIRE
DATE �+-22-74
SUBCONTRAC70R
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-' COSTA MESA BUILDIN GSAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For Applicant to Fill in Completely
BUILDING �/% �+
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ADDRESS �,
CONTRACTOR
ADDRES
CITV �
STATE r/ �
LI0. NO. rC
SizE �
OF l OT [
USE OF
E%ISTING BLOG.
SIZE OF
NEW BLDG. �!
EXTERIOR WA41
✓�ez�'�'�.�t�G� NE��'
CITV
OU' 7� LIC. NO.
`�C �� � INOWONLO�
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I hereby acknowletlge ffiat I have reatl this application antl state-
thai the above information is correct antl aeree to comply with
all laws regulating builtling construction, antl I shall not employ�
any person in violation of the workman's mmpensatian laws of.
the State of California.
I hereby ceriify that I am properly licensetl as a contractor untler�
tne State of Calitornie Business antl Professions Code, Divisicn 3,�
Chaptar 9, and ffia[ zuch licenses are in tull force and ettect, or I
am exempt trom the provisions ot the $tate ot CalifOmia Business
antl Professions Cr��e, Division 3, Chaptar 9. , `
Signature of Q�� `�'�
Permittee �� �yr`%%y
Authorizetl Agent .
PRtU .��
�Es-s-,��.;.,.co ��3�,Y ,�:<,t��s,,
TION FOR BUILDING PERMIT
A.P. NO. I� I
BUILDING �J
AODRESS L
TRACT
OWNER /� �, �
s UN1r
FIRE
ZONE /
APPROVED
av
r
ZON NO.OF
PLANS
YARDSAPPROVED
MAIN BUILDING
(FROM GL STREETyij
FT
VAR #
C.U.P. #
APPROVED
THEAMOUNT
THE PURPOSE C
VALUATION
VSE OF NEW
BUILDIN ^G /
vAROS Ai
eET. MAIN &
ACCESS. BLD
DATE
APPROVED
ED
T, � �
0
UNDER VALUATION IS FOR � j
LISHIIVG A PERMIT FEE ONLY: ¢
m
RMIT FEE S �
� 7
m
AN CHECK $ O - E
`a
LL
TOTAL FEE
� �� _. �
3�94 .
Z .
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Z
ZQ
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d m
J �
J N
Q1 J
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COSTA MESA BUILDING-SAFETY DEPARTMENT
P n_ HnX 1200 COSTA MESA. CALIFONNIA 92626
PAIC
;p�t Z:-?L��nz 0i� 8i7_ �^�':*16t�.50
P ICATION FOR BUIIDING PERMIT
For Applicant to Fill in Completely
R C V D BV DATE RECEIVED DATE ISSUED
BUILDING , u
ADDRESS V�E
�}�' P I O
OWNER Q�.,AL� J T A.P.NO.
BUILDING /J AQ
MAIL ADDRESS `L LM
ADORESS
TEL. TFACT LOT BLOCK
CITV NO.
CONSfRUCTION EW ADD A T F li P
LENDER
BRANCH
OWNER (.
ADDRESS /� V LUE
ARCHITECT TEL. S 1' $�y�
OR ENGINEEfl N
FIRE
ADDRESS ZONE TVPE GROUP
APPROVED
CONTRACTOR BV ' DATE
ADDRESS
� TEL. ZONE NO.OF VSE OF NEW
CITY � NO. ' PLAh6 BUILDING �
STATE CITV �'ARDSAPPROVED VAFOSAPPROVED
LIQ NO. IIC. NO. MAIN BUILDING ACCESSORV BUILDING
SIZE NO.OF BLDGS. (FROM GL STREET)
OF LOT NOW ON LOT FRONT FT. FT.
USE OF
E%ISTING BLOG. 5 E FT. FT.'
SIZE OF NO. OF '
NEWBLDG. ROOMS STORIES L.SIDE FT. FT.
EXTERIOR WALL ROOF
COVERING COVERING ' REAR FT. FT.
USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN &
MAIN BLDGS. ACCESS. BLDGS.
VAR. # DATE
C.U.P.� APPFOVED
APPROVED
I hereby acknowledge that I have reatl this epplication antl state '
ffiat the above intormation is correct and agree to comply with
all laws regulating builtlinB construction, and I shall not employ �
any person in violation ot the workman's compensation laws of ,
the Stare of Calitornia. ' •
1 hereby certify ffiat I am properly licensed as a coniracmr untler � SQ. FT.
ffie State ot Califomie Business antl Professions Cotle, Divisicn 3„ THE AMOVNTSHOWN UNDER VAIUATION IS FOF
Cnapter 9, antl thai such licenses are in full force antl effect, or I- THE PURPOSE OF ESTA845HING A PEFMIT FEE ONLV:
am eaempt from ffie provisiOns of ffie S[ate of Califomia Business VALUATION �
and Protessioos Cnc�e, Division 3, Chapter 9. PERMIT FEE $
Signature ot
Permittee $ --� PLAN CHECK $
Authorizetl Agent /�
TOTAL FEE 5 (r�J