HomeMy WebLinkAbout288 PALMER ST - Building Permits�wEcrnooeess: zgg pALMER ST '
�owxee•sxnMi: VERGPNIA WAISLER :
�ooeess: SAME . • •
ANCN/ENGINEEH: t - • ,
' 110UPE53: . ' ' � .
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, � BEG.NO.: .
. . . , . ' . � UNR:' "
_ PEflMI1TEE:CC COLE�PLMG. 6 HTG-.'� � � (719)�645-1�161
:'�ODBESS:.' 2z8O NEWPORT BL ' ' � ' �
CM : , -. CA 92627 � � .�
LICENSEO CONTMCTOB OECUMTION: I �ereEy affirm that I am licensetl untler provisions of C�aD�er 9(cammencin0 ��� �c[ion
7000) of Oivision 3 of Ihe Businew ana Protessions COAe, and my license is in full force an0 eflect. ; ' . .
ciTruc.: p 748 srnTeuc.:37558 cur.' /^/ -
Date: � � SiAnature: ����6..�1 '
WOBNEBS' COMPENSRTION UECUM7ION: I Aere6y attirm that I �ave a certitica[a of wnsen[ lo self-insura or a cetlificatebf Workers'
Compensation Insurance, or a cenified copy tAereoi (Section 3800, La6. C). � � � '
roucrxo.:001608-89' �cr.oaTe: O1/O1/90 '
coMvnxx: STATE FUND �
❑ CCrtifieO copy/is hereby �umiSheA..�� Cenified copy is filed witn the ciry BuilOinp Division. -
Date: ( �/IY .! FS9 ppPlitanL �f._d�� . . .
E%EA1PfI0N FlIOM YlOXI(ENS' COMPEN5ITIOX UECIAMTION: (This secuan necd not Ge completeC if Ne permit is lor one AunOreO �5100) ar less�.
I cerlM �hat in ihe Dehormance of ihe vrork for wAicA ihis permit is isSueA, I sAail not emDloy any person in any manner so as to Eecome
' subject ro the Workers' Campenution Laws oi Calilomia. ' ' ' . ' ' '
Date: - t SignaWre: - �
NOTICE: If, atler makinA Ihis tleclaration, you shoWd �ecome subleR ta Ihe�Workers' Compensatian provisions ot,ihe Labor
Cotle, you must fotlhwit� wmpty vn(h such O�ovisions ar t�is permit s�all be tleemed revoked. •
CONSTRUCTION LENUING �CENLY: I Aere6y aflirm tAat tAere is a construction IenOing aAency for Ihe pedormance af Ihe work for
wAicA this permit is issueA (Section 3097, Civ. C). . , , ' -
� LENOEB: � . ' .
' . RDORE85: . . . , . . . . . .. .
OWNEB BUILOEB UECLAMTI�N: I AereOy aifirm that I am exem0� �mm the Coniractors' State License Law for ihe followin0 �ason
(Section 7031.5 Business antl Pmfessional CoOe: Pny ciry of counry which requires a permit ro conslmci,'alter, impmve, tlemolish, or
. repair any stmcture, Drior to its issuance, atso 2quires t�e apDlicant for such�permit to file a signeE statement that he/s�e is Iicense0
pursuant �o the D�ovislons of IAe Contractors' State License Law �Chapter 9(commencinp wi�� Seclion 7000) of Oivision 3 al I�e Business
� an0 Pmiessions CoJe) or t�at he/she is erempt thereimm anC the basis far ��e alleqea exemption. Any tiolation of Section 7031.5 by
any applicant for a permit su0lects the aDUlicant to a cNil penalry ot no[ more than five hunUreC Uollars (f500�. � �
� I, u owner � ol the properry or my emyloyees with wapes as. their sole; compensatlou, will do Ihe work,' antl Ne
❑ stmqure is not intendeE or ottered for sala (Section 7044. Busineu and Pmfassional COUe: 'The Contracrors' State License Law
aces not apply to an owner ot a D�oDerty who Ouiltls ar imOroves t�ereon, an0 who tloes such work himself/herseli or throuph
� ' his or her awn emDloyees, Drovitled that such imprdvements are not intentle0 or offeretl for sale. Ii, �owever ihe EuilAinp or
improvement is sold wit�in one year of completion, ihe owner.vnll,have the OUNen oi pmving he/s�e tliE not build or impmve
�lor tAe Puryose oi satel.� � , , . ' � ' . :
° t. '
,I, u owner ai the Droperiy, am eMclusively cont2ctinA'Mth licensetl contractors to consimct Ihe Droject (Section 7044, Business
❑ "an0 Pmfessions Code: Tha Can[racrors' State Li<ense Law does not aDPly ro an owner af Droperry w�o bmltls or im0�oves IAerean
antl wAo caniracis for such Drajects wIN a cantractor(s) license pursuant ta t�e Contractors' State License Law). I am aware
, that Dmoi ol Iheir Worker's CamDensatian iniurance s�oultl be provitle0 ro me: , ' ,
� I am exempt unAer Section: � B..B P. C. , , , � ��
tor this reuon: ' .
�
Date: Owner:
I Ao hereby cenity ihat I am aware ol and understand ihe requirements oi Califomia Health and Salery COAe Sections 2550.5, 25533, antl
25534 and that 1 or any fuNre buil0ing occuDant wiNwill not (circle one) neetl ta compty with saitl state co0es and the reQuirements for a
permit /or conswction or moEification irom the Nr Dualiry Management Distnct. Residential constmction appliwtions are exempt (rom
ihese provisions. � . � � , �
Daie'� ' ADPlicant
I �ereby certity tAat I have reatl ihis application anA state thai ihe ahove informa[ion is correct I aAree to compty wuh all ciry antl counry
orainances anA state lavrs relatinp to builtling consvuction anA hereUy authonze represe W� s oi this ciry to enter upan ihe a�ove-mentioneU
pmperry for inspecti n purposes. ^
Oa�e: � Signature: O.J+6-d�
oriver's �icense or Sociai Securiry x: . �'�
1841A8 White-Builtlingj Green—CoEe Enlorcement; Canary=Applicanp Pink—Revanue; GolEenrotl—Asseswr '
-, r_ITY OF COSTA MSSA — BUILDING PERMIT PERM NO:� P�. 044946_
� ' ., . . ,
PERMIT NO: P 044946_ ,PLAN CHECK.NO: N GOVT�: N_SUPP,,: N
CONSTRUCTION-TYPE; PERMST-TYPE.e''PLU— , i 'P,URPOSE;: �AI+T
JOII .DESCRIPTION 1; NEW WATER� SERVICE - ��� ' SQ FT� '
CLAIM VALUE:' ' � , 300,00. ' CALC-VALUE: • '� ; � ', GROUP' OCC:', R=3 - �/
COMMENTS: SERVICE HOUSE TO STREET �',i .
' iE 3f 3F 1k iE iE if if iE �F if iE iE fF jk ik iE 3f iE if iE it if iE iE 3f 3E it iE iE * iE'iE IE iE if iE iE iE 1E ik if iFiF iE k if i! fk 1E i! if iE iE iElk iE iE iE iEik 1k 3f iE df iE iE iF'�E iE if iF �f,iE 9E iE+� iE�iE.
., ' Z O N I N G R E Q�U I;R E M E N T S '� ' •-
S E"T B A C K S ,- ` -
. , • : , . i,. , .
------------ MAIN BUILDING ---=--=---' :-------- ACCESSORY�HUILDING ------�—=
FRNT: FT . IN REAR: FT IN • fiRNT: , FT , IN RF.AR: : FT ; ;IN '
LEFT; FT : IN�RGHT: FT IN ' LEFT: FT: IN RGHT: 'FT �' IN'
� , i
PARKING REQ: PROV:. PARCEL: 42516201 ZNE: REF NO; ..
PLANNING NOTES> ; " � . ' i �
_ � . : .. . � ' _ � . . � �._. .
iE iE 9f iE iE ik iE 3f iF if iE )f iE iF iE if jF iE iE iE df k iE ik if it 3k iE iE 3t iE iE IF 1E!! �E 1E iE 9f �)E if 1E 1E 1E if 3f iF it jE if k iF iE iE iE iE iE iF ikif it iE f(� iF iE ik iE iE ik iE ik if iE if 3E iF iE IE k
, D,E V E L O P M E N T S E R V I C E S,:e; R E Q U I R.E M E N. T�S
ZONING APPROVED BY �"" DATE: �
.. . _ : . . .. . . .. . - . ' " '
BUILDING APPROVED BY : ' ' � DATE: ,
APPLICATION ISSUED BY: � � �DATE: 4
�E 3f iE if 1f 3E if iE iE if iE iE if iE iE if'3h iF 1E ih 3E iE k iF iE iF if 3! iF 3t 3t iE�iF�iF 3E
it*x�**ititx+t�'itx�*��*******��r**ititit*itit**�*�*i E*+�+r**�+�+�*�r***�*+t�r+titx��x��*�at+t*�***x��*�
LEGALIZATION:N ` F.E'E ` S M M A R Y �"".`STRUCTURAL SEGMENT;N
i $LDG PMT PLUMHING ELEC�TRI MECHANIC �FIRE� .SMIP/RE5 GRADING
PERMIT , ; - ' 2.00'- � i �
258=. � �SMIP/NON—RES .
PLAN . , . � . . .,
ISSUE FEE' 3.00 , ,
DUILDING—DIV—> 'PERMIT ISSUE PLAN—CIiECK TOTAL PAID DUE
TOTALS----> 2.00 3.00 0:00 5.00 5.00 .00
REVENUE DIVISION TOTALS--> COLLECTED: 5.00 OVER/SHORT: .00
BLDG PMT PLUMDING.ELECTRIC MECHANIC FIRE SMIP/.TOT GRADING,PL`AN—CHECK
.. S.OU � .
ik �k iE 3E iE 1E iE iF 1f iF iE iE �F iE 1F iF iE iF iF �IE 3E ik i! iE iE �E iE 3F iF iE iF iE iE iE iE iElE ik iE iE iE iE k iE iE it ik if iE iE if ik ik ik iE 1k if� 1E 1E it iE if iE �E if if iE 1E iF 3F �E if iE iE if iE jE iF 3f
. I.N D I V I,-D U A L� F E E, B R E A K D O W N ,
• � ' - � � . , ' � � � �
'TYPE QTY . U E S�C R I P T I O N � UNIT.COST iTOTAL COST.
PLU 1, WATER SERVICE 2.00 � 2.00
� � ' END OF FEES , ; •
�
�.
7
• �
� .�� AU�wi.''�.�_"��'t��`f�'��, '. 9'.D:i� � .'.��,1�
Lr�T�: I�..'L4139 TZiC: ;.:Y, , �
fiJ ,�: ��:
_, „ ,s .-
�CONSTRUCTION ANO PIANNING • : _ POOL & SPA . � . -
t. APPROVALS Permit # Date Inspector p�ppROVALS Permit.# Date Inspector �
1. Temporary Electrical Se"rvice or Pole: �� � 52. -Pool & Equipment Location � "
2.-�Soil Pipe-Undrgrndn-� c. ': � �r' �~� , - 53. Steel Reinforcement • � �•�
-�'3.�Electrical ConduiC'Utility-Undrgmd�� � . � • 54. Forms ' � � ' � .
--� . . -�
"t4. Electrical Conduit=Undr9rnd. �;,= . 55. Electrical Bonding �
�: 5'. Steel Reintorcement � x �' � 56. Rough Plumbing & Pressure'Test
y -
��,6. Electrical UFE�R,Grnd. ,,,;L. 57.�APPROVAL TO COVER�GUNITE ` ",� �
•7.�'. Footings �•- � - 58. Eiectrical Conduit-Undrgmd. . r.
` ;8. Foundation - , � � � 59.'Gas Bipe, O Undrgrnd:, Teit ' '
y:.
9. Water Pipe-Undrgrnd. • ' � 60. Backwash Lines, P�Trap, O Unilrgrnd.
10. Structural Floor'System .� .- I 61..�APPROVALTO DECK - ' _
'1
11. Property Sewer Line�& HouseiConriection �, � - 62.'Backwash & Receptor�-Final � �'
12. Sewer Cap � -'�', j s� '•� � . 63.-Heater & VenbFinal �
13. Roof Drains _. - � 64. Plumbing System - Final .'
74: Rough Plumbing � . 65. Electrical-Final � '
15. Rough Electrical�Conduit � 66. Solar System-Final
16. Rough Electric�Wiring � � 67. Fencing & Access ApProval
^77. Rough Wiring Sign ' 68. APPROVED FOR PLASTERING •
18. fiough Electrical-T Bar Ceiling � � 69. POOL/SPA SYSTEMS FINAL
19._Rough Heating &.Air CondiiioRing � 4 �. -,�.�. �,. _ ....,FIRE DEPT. REQUIREMENT
�_ : • ..: , y '. •. � .. ,- _i -t '- n� D � '�: �:
20=Rough Facto;ry Fiieplace �r , = o--• �= :!: �APPROVALS:=+=Permit # - �
- - - . �� � �-,�,r
21"'Ducts,in�Struauie�` .... �""�' % = _ ��''•� � ^ -'-y � '�
,. �: - ; _70. Underground� Hydro x
22-Ducts, Ventilatin� � ' ' - '7 V - � '
g• �l tir k'77, producT'Piping � Gas ❑-Oil
23. Ga4,Pipe-,Rough &,Test "�� '• �� � � ,�„* ^ �7z, Undeiground Flueh' ' "'
n� .� ^i-• � i i _ s Y. _
24. Roof F aming ;r„ ��J � �r: ' `-� ` � � -73r-Undergmd.Storage_Tank�OGas,OOil
25.�Roof Sheathing � �: `: � ; � C � �:;�F; � ^74. �Overhead Hydro'�_„ `'
26;�T�Bar Ceiling (Structural) &'Monocoat - ,. • r �� 75 _'Dry Chemical .-�. T � � „
27rFrame and Flashing� _ �%: � " �" `" '�'�'� ^ 76. Dry Standpipe `'�'"- `
.. - x �, c-� r ^
,_28.Wthin &Sidin � .. ��r.- _ .. . . .: -- �-� -,':-� .: ^ .. .
. 9� 8-� - L: r � .w •• 77r, FIXED SYSTEM� EINAL�� = �
29. Insulation '� �� ; ' '� ��+�^ " 78:;FIRE PREV. FINAL � ' " '
-� !l . � k " 6 ,� . '� T
jF .5'
~30. Drywall.Nailing -, .. =� - � �i;; ::; _- � HEALTH-DEPT. REQUIREMENT
^31. Plaster B'rown CostN = �'�' " � � �: �'79. FINAL INSPECTIO�N j V
�32�-Electrical Power'Meter F.inal �� CJ � -�� fi � `�
i , �,.e��: S0:-FOOD CERTIFICATE ISSUED�
= 33: �Final Electric,. �. `' �i. r.� � i �iis � Notes: �, �� - ��
�'34:_Final Heating & Air�ConHitioning' 1 ' '��� � " � ' �" " - -' �
1 �,. ' #
�1 � - i �k� � �'r. v �� ...-.
35.'�Final Gas Pipe-Test� ;,�� •• "�-+ � ;; i" ?; :%� ' � ^ +'' ,
� l. =., : �,
"36�Hontl or CanoPY '' - - •»� e. �'� � � j f �f�r� g ;� e F.
r j � a. "7 . :'i
^37.�Final Factorv Fireplace-: ti^ ?� ; � � � *" ` � "•
i � � c1� ' A.
!-� ! .J . L�1 1: ' .�i H X .�^. .
_ 38. Final Plumbing .F �_ r Y; � �
u39. Water Service-Finalc :. ' c -' � � -K r ^ � _ %; -
_40. Gas Service-Final ;<;*� a;;+? < �� t'1 � � �+' * :�^� �^� �• .
� n t� �- � t M. .. F- ��: f d
,-41. Solar pomesticFinal � -:� �i > t-• -io �� i :; �
42^Backflow Preventer" . `�' "�' l ' � r`" ^ ="-' � G r-i
� 1 'l1-ir: i' F- LL �' :•J �i(� .
43. Backflow Irrigation: �: �� �'x - f '� �� � - ;� � "�
- - ��: � -
^t rt" CJ G^ L C;' :-i -� r A: l: ,^ nJ CJ .: : J r' :t: �_
;44._ Landsca"pe lirigation System,�._, � �;: �� ��* �; -; - - �. S "
45r:8ound .Attenuation ;� .. ' � •'t :�.< �: �+ =" c.� : r" 4 .
V � �.Ln
' '46,' Handicap Regulations � �� y; � � '` � :� � "� c :
;-47`FINAL STROCTURE & BUILDING x-• i �.�'� ,y: � y Y i. _
aa=F�N:4L PLANNING � -' �� �� 1 � 1�' i` - �`'
w � �1: � i. J CJ '�
�''49:�Electric Release to�Edison ` i - � ~- "
U . � � �Z'i: � .i.
"�50.`�Gas�Release to $outhem California Gas Co � • ��"` •` - `' V ' � ��`; " '
o '� c K T S ��:= fi ..
' �51. CERTIFICATE OF`OCCUPANCY ' '� � '� ' - ' ^' �' � "
No. Date
C�TY OF COSTA MESA
PARK FEES
Fee Payment Receipt
N°
3'7 9
Project Address
A.P. Number
Building Pe�mit
Owner's Name
Mailin9 Address _
FEE:
iingle Family'
2-Bedrooms or Less
3-Bedrooms
4-Bedrooms
5•Bedrooms +
Multiple Family "�'
Bachelor or Studio
1-Bedroom
2-Bedroom
3-Bedrooms +
Number of Units
@
@
@
_ @
$ 702.70
983.13
1,260.33
1,476.32
386.81 =
467.38 =
718.80 =
1,135.66 �' ���
Total Fee�L�r���
Pianning Department ro Date 8V G— - /
ApplicanYs $ignature �
� c __
� Gty Ortlinaq�e 72-44 '• CitY Ortllnance 72-55 •'* Gty Resolutlon ]]-89
CMF 0174-32 Rev. �/77 White—Plannlnq; Canary—%anning; Plnk—Finance; OoltlenroC—ADP��cant
cosGam�sa
7":i3 IS 'iG CEnTZFY t:.at Snsulctlo:. h¢s b�en ir. atalled ln ' �
ccn;c:�aance o;ith tSo current enorgy ragulatlon�� Callfox�ttls
•' AcL�inietmtive Code, Title 25, State of Callfornla. Sn the {. �•ti
buildin� located att .
ac+cre�e 28B �q1MCC� Lot /{ Tract �
Clty C.bS'44 �e�o�_
CEILZNGSi Mfgr. �tP�Yp�V�'(�'J�un�1 aXTERICR 7JALLSt i�'f�r. T�'dyy)IUm �c�U
� „ 5��2,i
Thlclmees 5 �2 Thicknese
R Value _ � R 'Jalue � �
FiGGnS: M.`gr.
Thlcknese
R Value _
PARTY hlfgr.
WpI,LS
T. lcknese
R Value _
GE2�cRAI. CONTRACTOR
HY
DAiE
FOUNDAT.ION I+.fgr.
NAi.L9
Thickneae
R Value
FLGOR/CaILI�1G Mfgr.
A99Ei�.'HL I�8
Thickneee
R Value
LICENSEM
�"INSULATION CONTRACTOR Gillco Inaulation Contractors,Inc. #347857
27882 Camino Capietrano #B-1 �
{� \Lag a Niguel, alQif. 92677
3y .�J. d. h. L1ATfi �D ��,
�':i5 IS TC CEnTirY t:.at Sr.suletio:: iias t,oen ir at:.11ed in
co..cr�ance urlth tya current ei:or�y regulatlons� Californta
�AcL^�inistrative Code, Title 25, State of California, in Lhe
buildin� located att
ar'.cresa �.Q g Po,�mer Lot # Tract � � �,
City C.05"fo rneSa
CEILINGS: Mfgr. P��,�yY�(3��„�� F:XTERIGR7JALLSe i�'.f�r. I�P UIW�g�py�J
'i'hlclmees ���oZ�� Thickneea 3��.1�
R Yslue _L � h 7alua ��
Fi,GGRS: MfEr.
T_hlcknese
R Value
PARTY Flfgr.
WpI,I,S
T :Sckneee
R Value _
GEIIERAL CONTRACTO�
� 3Y —
INSULATION CONTRACTOR
FOUNDAT.iON [dfgr.
+�Ai.L9
Thicknese
R Value
FLGOR/CLZLIDiG Mfgr.
A99Ei�u3LIF.8
Thickneee
R Value
LICENSEM
DAiE
ion
2 882 Camino Capietrano #B
` La una Niguel, C lif. 92677
By Otl 0 DATE ���
'#34Y857
No.117-184-25 LOT
PECTIONS
ER �F,% '�{._
GN'PLUMBING
P. $WR. LINE Q XOUSE CON.
INKLING SVSTEM
CELLANEOUS
GN NEATING AND �IR CONOITIONING
IPORARV SERVICE OR POLE '
ERGROUND � POWER �
GM WIRING
NCMES ORMS STEEL PEINF.
OR SYSTEM
D BEAM � STEEL PEINFOHCE �
ATMING
ME �ND FL�SMING �
HING - IN OUT � � �%)
STER, BROWN COAT
UCTURAL, FINAL
TING, VENT., REFRIG. AND �.C., FINAL
MBING. FINAL ANO GAS TEST n
DATE
SUBCONTRACTOR
ia:��►rr.��a
,.. ��'..
. 7 .. �<� - 453!�U �� �.
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA. CALIFORNIA 92626
For Applicant to Fill in Comp�etely — Use Ink Only
BUILDING n
AD�RESS L� ��
OWNEfi (�j `,Q
MAIL 4 I��n�, /�
ADDRESS i�( l�
/� ,/�,� TEL. �•
CITV (!'14-/� 1 V\l�t� NO. 5,�( .
BRANCH �
ARCHITECT a TEL.
OR ENGINEER
ADORESS � � A�{a�7�
CONTRACTOR ��L� Q r�J[,
L
3907 I/�5/78 1�6 TL
FOR STRUCTURAL PERMIT
9A_J RETv� !/ i�/��'!
A.P.NO. // � .^."oC� Y9
BUI�DING � i� �' � .
ADDRESS � 4 f �'
/ � \
- TRAC� i ' LOT � BLOCK
W A � P ` �
!� � �
. /� �°. � /
/I y.....
OWDf R�,^� b:e d.
� C, ' ' "� LUE
e. �
USE�•• � • ' ��•� � ul� $
FIRE�g`��"_-`0.�GZQ . .
ZONE . O YPE / GROUP ���///
APPROV � �//�'/
eV �, , .� DATE /
TEL. ZO NO�.O� USE OF NEW
CITV � � NO. �?O�
PL°Q075 ' BUILDING
rE. STATE CITY - �'ARDSAPPROVED VARD PPRO ED
� �IC. NO. LIC. NO. � MAIN BUILDING ACCES V VIIDING
Lc� 512E Y pa NO.OFBLDGS. g, (FPOMC/ E¢T)
0+ OF LOT �� /� � Y'O � O-( NOW ON LOT �J • FRONT FT. F.
� USE OF � � � %y� /�
EXI5TING BLDG. SI F D // ��/I � F.
� ( �/
FSeparate permits ace requiced for L SIDE FT FT.
Q electric, plumbing and heating work. REAR �Fr /I � �, � n
[.W.� USE OF BUILDING AND WOflK TO BE PERFOFME� OISTANCE BET. BET. MAIN&
�Q MAIN BLDGS. ACCESS. BLDGS. �
^---�^ " ' n � VAR# DATE
"'� lVti 'tJ�—K I.JV QU.P.�W �G APPROVED /-
Q _
� APPROVE
r—
�
a
w
� I heraby acknowlatlpe that I have reatl this appl7cation and stete �+
� that ihe above Information is correct antl agree to comply wlth f &i!li-Ai��A ^�
p+ all laws regulatinB buildin8 construci�on, nnd I shell not employ ��� � �m
z any penon in violation of the workman's compensation laws of m ' t
r`l'� the State of California. �J SQ. FT. � �"�•� N['��
.
3 I hereby certity ffiat I em properly licansetl as a contrector untlet ����
the State of Calitornia 8usiness entl Protessions Cotle, Divislon 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m
Chapter 9, anC thet such licensea ard �� f forca entl effect, or I THE PUPPOSE OF ESTqBLISHING A PERMIT FEE ONLV: �
em exempt from the provisions e S e of Callfornia Buainess Q
VALUATION PERMIT FEE $ �
antl Professlons C de, Divisio e r 9. in
' � PLAN CHECK $ ^�
Signature of � � �
Parmittee $ '��� �� TAX $ !� �/ f
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Authorize ent TOTALPAID $
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COSTA MESA BUILDING-SAFETV DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For Applicant to Fill i� Completely — Us� Ink OAnly
BUILDING n/�/'J ii .�i ilL I /1 ,
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BRANCH
ADDRE55
ARCHITECT TEL.
CONTRACTOR /��,f'j ��Ll��'///
ADDfiESS
TEL.
CITV NO.
STATE CITV
LIC. NO. LIC. MO.
SI2E � I NO.OF BLDGS.
OF LOT NOW ON LOT
USE OF
EXISfING BLDG.
Separate permi[s are required for •
electric, pWmbing and heating work.
VSE OF BUILDING AND WOPK TO BE PERFORMED
u
I hereby acknowletlge thai I nave reatl this application antl state
that the above Information is correct antl agree to comply with
all laws regulating builtlin8 co�sttuction, antl I shall not employ
any person in violation of <he workman's compensation laws ot
tha State ot California.
I hereby certify ffiat I em properly licansed as a contractor untlar
�ne Srece ot Californie Busine9s antl Professions Cotle, Divlsion 3,
Chapter 9, and ffiat such licenses are in full force antl etfect, or I
em exempt from ihe provisions of the State ot California Business
entl Professions Code, Division 3, Chapter 9. ,
Signatura of
Permlttee
Authorizetl Apent �
0820 5/II/7p
0620 5/II/78
0820 OOQ04453 50
APPLICATION FOR STRUCTURAL PERMIT
ECEIVEDBV DATERECENED nnrcissuor
A.P. NO.
BUILOING
OWNE
S � (/j/
FIRE
ZONE
APPROVED �
BV
ZONE NO.OF
PLAfS
VARDSAPPROVE
DISTANCE BET.
MAIN BLOGS.
VAR. #E
C.U.P.�W
APPROVED
TH E AMO V NT SI
THE PURPpSE OF
VALUATION �
$
vv � • S
GROUP •
DATEJ' G
USE OF NEW
BUILDING
VARDS APPROV ED
FT
DATE
APPFOVED
�
243400 TL
243.00CKTD
IA
n
m
i
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m
N
VN UNDER VALUATION IS FOR m
"ABlISHING A PERMIT FEE ONLY: �
PERMIT FEE S a
v�
m
PLAN CHECK y m
0
LL
TAX S �-
V
TOTALPAID E �