HomeMy WebLinkAbout3232 IDAHO PL - Building Permits,
CITY OF COSTA MESA
�,O�pMF$p ' BUILDING DIV/SION
a
i ., .., � 77 FAIR DRIVE, COSTA MESA, CA 92626 • p74) 754-5273 • Faz (714) 754-4856 • www.ci.costa-mesa.ca.us
�, ` � FOR INSPECTIONS CALL: (7'14) 754-5626
°'�°'� PERMIT NUMBER: BC10-00521
PERMIT TYPE: B COMBO STATUS: ISSUED
Sub Type: RES_ALT DATE ISSUED: 12/16I2010
ISSUED BY: RMD
�oe a��Ress: 3232 IDAHO PL CM
APN: 13908408 Zoning: , ,
Vicinity:
Const Type: V-B
S�. FT: 220
Suite/Unit:
Primary Occ:
Valuation: $45,000.00
SCOPE OF WORK: 220 SQ FT SINGLE STORY ADDITION TO AN EXISTING RESIDENCE. EXTEND TWO EXISTING BEDROOMS.
REMODEL 1 BATH. WINDOW REPLACEMENT. INSTALL INSULATION. REMOVE SIDING AT FRONT OF RESIDENCE AND APPLY
STUCCO. 48 SQ FT SOLID ROOF COVER OVER EXISTING OPEN BEAM AREA IN THE BACK OF THE RESIDENCE. PLUMBING
TO
INCLUDE: RELOCATE WATER HEATER. ADD LAUNDRY SINK IN GARAGE, 1 GAS OUTLET FOR FAU RELOCATE, 1 SHOWER, 1
KITCHEN SINK, 3 WASH BASINS, 2 TOILETS, 1 WATER REPIPE, 1 WATER SERVICE LINE FROM METER TO RESIDENCE.
ELEC TO INCLUDE: 18 LIGHT FIXT, 20 OUTLETS, 15 SWITCHES. MECH TO INCLUDE: CHANGE OUT FAU AND
RELOCATE TO ATTIC. CHANGE OUT A/C - SAME LOCATION. WINDOW REPLACEMENT. NO ADDITIONAL BEDROOMS OR
BATHS.
OWNER: TALLMAN, DONALD H TR
Phone: 714-566-7804
APPLICANT: GUSSIN, AL
Phone: 714-538-1007
Address: 3232 IDAHO PL
City/State/Zip: COSTA MESA, CA
Address:
City/State/zZip:
CONrRACTOR: WEST CARRIAGE CONSTRUCTION INC License No. 627346
Phone: 714-538-1007 Address: 18512 1/2 SANTIAGO BLUnit:
Cell: . City/State: VILLA PARK, CA
ARCHITECT:
ENGINEER:
COMBINATION PERMIT FEE SUMMARY
Building Plan Check:
Building Fees:
Eleclrical Fees:
Mechanical Fees:
Plumbing Fees:
SMIP Residential:
SMIP Commercial:
Bldg Std Admin Fund
TOTAL FEES:
License No.
License No.
$385.94
$593.75
$103.60
$80.15
$162.10
$4.50
$0.00
$2.00
$1,332.04
Unit:
Unit: :
ZipCode 92861
PHONE:
PHONE:
"Refer ro fee recei ts for all fees aitl for ro ect
HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3N8/2010 - PER CMMC Sec. 13-279
Montlay thru Fritlay-7:00 am thru 7:00 pm. Saturtlays-9:00 am thru 6:00 pm. Prohibited all hou�s - Sundays and the following Fede�al holidays:
regulations. (Ord. No. 92-28, § 1, 12-27-92)
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 wdes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and fnal approval wiil resWt in the expiretion of this permit.
CODE/. INSPEGiIONTYPE DAiE INPTIALS CODEN INSPECTIONTYPE �ATE INPTIpLS
1616 Fixed System Final Fire Prevention 206 Final Mechanical X`i' S��� p,��L
1266 Pool Spa Final 208 Final Plumbing x N- 5- I I ry�_ �j
200 Final Re-Roof 210 Flnal Elecirical X H-�'-p ��
201
202
203
Final Block/Retaining wall
Final Factory Fire Place
Final Sign
204 Final Demolition
212 Final Fire Prevention
220 FinalPlanningApproval
222 Final Site ��p
250 FinalBuiiding/Occupancy � �"�J`I� �ll
�
WORKERS' COMPENSATION DECLARATION:
I hereby aKrm under penalry of pprjury one of the following declara�ions:
❑ I have and vnll maintain a cehificate o( consent to self-Insure for vrorkers'
compensation, as provided for py seciion 3700 of the Labor Cotle, for Ihe
peAormance of lhe work for which lhis permit is issued. �
❑ I have antl will mainlain workers' compensation insurance, as required 6y
sectbn 3700 of the Labor Code, for the pedormance of [he wvrk for which this
pertnii is issued. My workers' Compensation Insurance carrier and policy
num6er are: �
Cariier ST ilir�d�
(This seciqn need nof be cnmqple�ted A(he permR is vaWed at one hvndied dollars (5100) or less )
Policy,'Number: /�(�//��
❑ I certify �ha� in �he performance of the work (ot which [his permit is
issuetl, I shall not employ any person in any manner so as to become subject
to the workers' compensation laWs of Califomia, and agree Ihat if I should
becom jec,{ to the vrorkers' Compensa[ion provisions of Seclion 3700 of
Ihe bor (?, hall fj I with comply wi[h Ihese provision .
. /L �� o
pl can� ignawre �Daly
WARNI � AILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
(5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 37pfi OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aNirm that 1 am licensed under provisions of Chapter 9(wmmencing
with Section 7000) of Division 3 of the Business and Professions Code, and
my license is in (ull (orce and eftect. /�
u�r -- Z?3�/6 [qass#' /,J
7i Zo/�
ee iactor's SianaWre LOale;_
CONS UCTION LENDING AGENCY:
❑ I hereby aRirm that there is a construction lending agency for the
pedormance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender's Address:
$ignaWre Date
OW NER-BUILDER DECLARATIONS:
I hereby affrm that untler penalty of perjury that I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5,
Business antl Pro(essions Code: Any ciry or county which requires a permit to
constmct, alter, improve, demplish, or repair any strucWre, prior to its
issuance, also requires ihe applicant for such permit to fle a signetl statement
that he or she is licensed pursuant to Ihe pmvisions of the Contraclors
License Law (Chapter 9(commencing with Section 7000) o( Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and
Ihe basis for Ihe alleged exemp�ioa Any viola�ion of Section 7031.5 by any
applicant for a permit subjects th� applicant lo a civil penalty o( not more than
five hundre0 tlollars (5500).):
❑ I, as owner of the property, or my employees with wages as their sole
compensation, WILL DO THE WORK, and the strucWre is not intended or
oRered for sale (Sec. 7044, Business and Professions Code: The Contractors
License Law does not apply to an owner of property who builds or improves
thereon, and who does such vrork himself or herself or through his or her ovm
employees, provided that such improvements are not intended or oRered for
sale. If, however, the building or improvement is sold within one year of
completion, the owneo-builder will have the burden of proving that he or she
did not build or improve for purpose of sale.).
❑ I, as owner o( [he property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to consWct Ihe pmject (Sec. 7044, Business antl
Professions Code: The contractors License Law dces not apply to an owner of
pmpeAy who builds or improves thereon, and who coNracts tor such project with
a contracta(s) license pursuant to the Contractas License Laws.).
❑ I am exempt under sec.
Business and Professions Code for this reason:
305)-46(3/0])
Owner ID veri(ied by driver's license. ❑ Yes ❑ No
Driver's License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or tleetl):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certAy that no excavation Me (5) or more (eet in depth into wfiich a
person is required to descentl, will be made in connection with vrork authorized
by Ihis pertnit, and that no building sWcture, scaffdding, falsev.ork, a demolition
or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 32, Grp
2, An 2, Sec. 341, Ttle 8, Califomia Administrative Cotle).
❑ As owner-builder, I will not employ anyone ro tlo work which vrould
require a permit from the Division o( Industrial Safety, as noted above, unless
such person has a permit to do such work from the division.
ApP���nl's SignaWre
Division o( IndusUial Safety Permit Number: _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
t. Will the applicant or present or fuWre buildinq occupant need ro file and
certify a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of lhe Califomia Health and Safety Code requires, with some
excep�ions, tha[ a Business Plan be fled with Ihe Costa Mesa Fire
Department by every business which has at any one [ime during a reportetl
year a quantity o( hazardous matenals equal to or greater than a weight of
500 pounds. or a volume of 55 gallons, or 200 cubic feet of compressed gas
a[ standard tempereture antl pressure).
2. Does or will the applicant or present or future building occupant neetl to fle
a registration tortn for awtely hazardous materials? ❑ Ves ❑ No
(Section 25533 of lhe Califomia Health and Safety Code, with some
exceptions, requires regislration with Ihe Costa Mesa Fire Departmenl 6y
each business which at any one time has on hand a quantity of acutely
hazartlous materials equal to or greater Ihan a weight o( 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas al standartl
temperamre antl pressure).
3. Does or will the applicant or presen� or future building occupan� need to
prepare an RMPP (Risk Management and Prevention Program (or acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of the Califomia Health and Safety Cotle provitles that the
Costa Mesa Fire Department may require the preparation, certification and
filing with the Fire DepaAmen[ of an RMPP by businesses which are required
to regis[er awtely hazardous materials with the Fire Department.
4. If an RMPP is presently requiretl, has Sec[ion 25534 of the Califomia
Health and Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or future builtling occupant require (or
the work which is the subject of this application a permit for such construction
or modifcation from the South Coast Air Quality Management District or from
any other air polWtion control disUict or agency? ❑ Yes ❑ No
(Sectbn 658502 of the Califomia Govemment Code requires that the requested
infortnation be fumished on applications fa noo-residential building permits).
6. Will any part of lhe facility to 6e constructed untler this permit be wi�hin
1000 feet (rom the outer bountlaries of a school? ❑ Yes ❑ No
Qf'yes", �he facility must meet ihe requirement o( Sections 25534 and 42303
o( the Califomia Health and Safery Code).
7. If a permit (rom the South Coast Air Quality Management District or other
air polWtion control districl or agency is required for the work which is the
subjec[ of �his application, have all of the disclosures prescribed by Califomia
Health and Safety Code Section 42303 heen made? ❑ Yes ❑ No
8. Qf'yes", atlach certificate of compliance from the appropriate air polWtion
control officer).
CERTIFICATE OP COMPLIANCE: I certify that under penalry of perjury the
information given above is correcl. I agree to compty with all state laws and
city ordinances regarding Hazardous Marenals and Emissions.
. $ignalufE Dale
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certity under penalry o( perjury that I have read this application and state that
the information given is correcL I agree to comply with all state laws and city
ordinances relating to building consiruc[ion, and authorize representatives of
the City of Cosla Mesa to enter upon the above-described property for
inspection purposes. I agree not ro occupy or allow occupancy of any building
authorized by this permit until �nal inspec6on.
t o! Le wner(s) oa�e
� j2.�.� Lo/a
CorAUl�onzetlAp011can1 Tele 'y
�i AVV���anl to flll In all spaces exceo� tnose within heavy boraer lines antl sl9n all appropriate tleelarotlons.
'� CITV OF COSTA'MESA - -` ' - PERMIT NO. TRACT NO. ' LOT NO. BLO . .
CONSTRUCTION PERMIT. � - D D
Project AddreSs 2� Z L TVPE OF CONSTRUCTION ' NEW ADD ALTERA710rv REPAIR
AppliCent'SMailingAddfEu 'l S�H6 ❑CONVERSION ❑OEMOLISH ❑OTHER Ap�
�OA.A✓�J fri TALLY� 4✓ PhoneS7`�'%Ro DESCRIPTION OF WORK
Owner's Name % S Main Building:
Addre55 -3L3L /J�A.�� nL� . , TVPEOFPERMIT , GRADING FOUNDATION STRUCTURAL T FfOnt. �
Arch/Eng. - License No. 'O TENANT ❑ ELECTRICAL O PLUMBING ❑ MECHANICAL B . '
Rear
Addr¢ss '� - ❑ �OTHER � A
Cdntrector's Nam� � hone PROJECT DESCRIPTION 54. F7.� �oCCuaANC�' C Right "
' � K Left
AddrCa�mailing) CONSTRUCTIONTVPE VALUATION$ $
ZONE GRADINGCU.YOS. ACRES Pln Ref.# �
City LicPnse No. � . 9�
LICENSE� CONTRACTOR DECLARATION . ' Remarks: ' � �
Parking Req./Provided
I hereby alfirm that I' am IiCenSeC untler provi5ion5 of•Cbarter 9(commenting � '
wlth section �000) ot Divislon 9 of the Business antl Protesslons Cotle, a�tl � - � � � ' Use of Building:
my Ilcense�is In (ull (orce antl effe�t. '
License Class LI<ense No.' � � . PLUMBING FEES Planning Notes: �
Date ' Signature ' . Bar Sink ' � Showers � �
WORKERS'COMPENSATION DECLARATION. '
I he�eby affl�m tM1at I have a ce�U/��a[e o( con5¢nt to seli-insure or a certiflcate gpckflow Preventer ' Service Sink '
� ' Workers' Compensation Inw��n<e;'or a certifletl copy thereof (Section - - -
00, Lab. C'.) � � � BeckflOw Irrigation Sewe� Ca '
oliCy NO. ' Company , ' P
BCertl(letl topy is hereby tumishetl. Bathtubs Sewer Connection
Certliietl copy is filetl with [he ��ty Builtling Division. � , . ' %�utOmetic WaSh¢�
Date Applitant � Clerifiers . $olar Collectors ConStrUCtion Pole
E%EMPTION FROM WORKERS' COMPENSATION-DECLARATION -- � DishuYdsher '
(T�issection neetl not be completetl if the permit is for one huntlretl (SI00) or Solar Piping � - -- � CoOking Unit�
iess)'. , . � �� Drinkin Fountains �
I certfly�that In the Oerto�manca Of tltG wo�k fo�;which thit pe�m�t is'Issuetl, I 9 • Solar Tank � � Dishwasher
shall not employ any person In any m er so'as to e om e yp �ett to the ' � - . .
workar�_ ens ti n law9ot Calito�. // I/ �j/� � Floor Diains� � Swimming Pool w/Spa � Dryers ❑Gas� C
Dato �T-51 nature %���/ ��+�dJ . ,
NOTICE: 1f, after making tM1is tleclaration, you ou become sub�ect to the � Floor Sinks . � ' Ufinal � � Fan.
Workers' Compensation proviSloPs ot [he labor Code, you mus[ fort�wkh ' - ,
comply wlth such • prbvi5ions OL lhis �permlt Shall be' tleemetl �evok2tl. � (�i35 S2rviCE � -011tlBts ' � �
CONSTRUCTION•LENDING AGENCV- .. • WaterCloset _ ��F.A.U.
I hereby affirm tbat
ot tna work ro
Lentler's Name�
LEntler'S Atltlress
OWNER BUILDER
a
�
Sale. If, noweve�, the
pktlon„tne owner wi
P�r ve torlhe purpo5e
9�' I, as owner o( the
tracmrs to <onstruct t
The Conlractor's �Lic
bulltls or improves tl
tractor(s) Iicense purs
❑ :I am'exempt uritle
Date
the
fo� the
<Ity ol '
d�Piotessions Cotle)•oi that he%she is�exempt '''
ie allegetl exemption. Any,vlolation of Section
' a Permit Subject5 the aOPIICant [O 2 Civil ,
untlretl tlollars (5500). . • I
{ybr my employees.witti wa9es as thelr sole :
k, dntl fhe structu�e i5 no[ intentletl O� Otferetl
iess antl Profe55ionaP Gotle: The Contractor's
an owner of a property who builCs or Improves . �
mfk himselt/her5elf or Nrou9 h nls or her o�+n '
In�Prov¢ment5 are not intentletl or offerea for
or �mprovement Is soltl within one year o( com- �
ia Purtlen Of proving he/she tliG not builtl orim- 1
am exclusively con[racting with Iicensetl con-
�(5ection �044, eusiness antl Professlons Cotle: '
does� not appty Io�an owner of property who-!�
ltl �"/ho contlacts for SUCh ploj¢Ct5 wlth a COn-
io Contr±ctor'S License Law). .
. B. & p. C. for this reason
_ OwneY
hava rea�
Drivers' License or 55 � � ��
CMFOB65-46rev.�7/83` White
G
Kitchen Sink � - .
Lavatories �G � , �
P—TraP . ' . ' '
Roof Drains� �
Reinspec[ion;Fee.=. I '$25��
Boiler •
DucP• Under Ground . � �
Ducc-Structwal ' ,
Duct-Ventilating ! '
Exhaust System ❑ Multiple ��
Firepl/Fact..Blt ICBO'# �
Heating System & Ducting
❑6100,000 BTU 0100,OOOBTI
� ' I , I Reinspection Fee
Applicanh, Plnk - Accounting; Goltlenroe •'ASSesSor -
$25
Water Heater
Water Service
.. � .
� Isue Fee - �
IANICAL
Hood or Type I ❑ .
Canopy � Type I I ❑ '
�0.100,000 E
Sys[em Repai
m
❑ 100,000 Bl
luue Fee
Device Boxes
�Utl¢t5 '
3027 1/24/84 20.5p TL
Zone
Park.Fees $
i , .
ELECTRICAL �
Transtormer ❑ 15�50 KV
❑ 50+KW
` ' . Meter �up m 100 amps
Meter ❑over 100 amas �•.
� .Sub Panel
_ Motors OI
� �• �Garhage Disposal ,
� ;� �'9" Generator �0.5 KW �5-15 KW
$�3 •f �'Reinspection Fee '
FEES': '
,PGBLIC SERVICES REQUIREMEN�
l
, .I 2oning APProved By
� /^ APPliwtion APProved BY
$ 3
Inc.Solar t
' � Microwave
' Pole Light
Fiange ,
Trash
luue Fee
�
2
O
N
I
N
G
R
E
�
U
I
R
E
M
E
��
��
��,
���
%'�-� � � � � �SUMMARY OF FEES ' '
.i ' BUILDING�PERMIT $ SMIP $ �_
' PLAN CHECK • $ � PERMIT � i
, PLUMBING � $ � 17J�1t �>� �ISSUANCE � $ , .
PLAN CHECK $ ENERGY P.C. $
. ELECTRICAL ' $ Q. GRADING � $
PLANCHECK $ .3. %S MICflOFILM $ ��' �'�/
; MECHANICAL , $ � 'TOTAL FEE $ ��
PLAN CHECK � $ � �
CONSTRUCTION ANDPLANNING ' POOL� ,A �
APPROVALS Permit # Date Inspector AppROVALS Permit # Date Inspector
, 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement � 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings . 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, � Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, � Undrgcnd.
10. Structural Floor System . �61. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. 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 Elearical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
79. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit#
21. Ducts, in Struc[ure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping OGas ❑Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd. Storage Tank O Gas ❑ Oil
�5. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & 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. Plaster Brown Coat � 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes: � _�y r �T K�
34. Final Heatin9 & Air Conditioning �
35. Final Gas Pipe-Test
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final
41. Solar pomestic-Final '
42. Backflow Preventer .
��43. Bar.kflow Irrigation �
�44. �Landscape �Irrigation System
-45. Sound Attenuation �
�46. Handicap Regulations .
�47. FINAL STRUCTURE & BUILDING
48. Special Requirements,Completed �
49. Electric Release to Edison �
50�. Gas Release to Southern California Gas Co �
51. CERTIFICATE OF OCCUPANCY
No. Date
�
AOp�icant to fill in all spaces except those within heavY bo�tler lines antl si9n all apPropriate tleclarations.
CITV OF COSTA MESA CO�y$ R CTI�OI)I PERMIT
Project Address f F '� � � /i�',{� /. '
ApplicanYs Mailin Ad ress � � 1�
Owner'sName ������) -�� hone � ��
Address � % �� •
Arch/Eng: License No.
Address
Convactor's Name � �� � ( fione � � ,
Address (m �I" gl / � �� '
City License No � ` �' �
LICENSED CONTRACTOft DECLARATION �
1 M1ereby affirm that I am licensetl untler provisions of Charter 9(commencing
with section 7000) �of Divislon 3 of the Business antl Professions Code, antl
my license is in full o�e antl effect.
. Licens Q aFz ` ' i ns o
Date �1' Signature
WORK 5' COMPENSATION DECLARATION .
I hereby atfirm that I have a certiticate oi consent to seli-insure or a certificate
of Workers' Compensation Insurance, or a certifietl copy thereof (Section
3800� lab. C�,�� �/7' .��/' ^ �
'icy No. �t' � Company_�.�� �L��
Lertifietl copy ¢ hereby fumishetl. / .
�J Certi i tl op i iletl with the city �� I' � i��n�/� L
Date Applicant L ��
EXEMP I N ROM WORKEf15' COMPENSATION DECLARATION
(This'section neetl not be completetl if the permit is ta� ane huntlretl ($100) or
less). �
I certity that in the performance of the wo�k'for whicM1 tM1is permk is issuetl, I
shall mt employ any person in any manner so as to become subject to the
Workers' Compensation Laws ot Calitornia. �
Date � Signature
NOTICE: If, afte� making this tleclaration, you.shOultl become subject to the
Workers' Compensation provisions of the Labo� Cotle, you must fortM1with
comply with such provisions ov� this pe�mit shall be tleemed revoketl.
CONSTRUCTION LENDING�AGENCV ,��
I hereCy affirm that there is a construction lentling agency for the pettormance
of the work tor which this permit is issuetl (Section 309]:-Civ. CJ
Lentler's Name
.Lentler's Adtlress ' �
OWNER 6UIL�ER DECIARATION � �
1 hereby attirm that I am exempt trom the ContractoYs License Law tor the
foilowinq rea5on (Section ]031.5 Business antl Professional Cotle: Any city or
counry which requirez a permit to construct,'altev, imp�ove, demolish or repai�
any structure, prior to its issuance, also requires the applicant for such permit
to-fiie a signetl siatement that he/she is Iicensetl pursuant to the provisions'of
the ConVacior's License Law (CFtapter 9(mmmencing with Section.7000) of
�Division 3 of the Business�antl-Pro(essions Cotle) or that he/she is�exempt-
theretrom antl the basis for the alle9etl�exemption. Any violation of Section
�]031.5 by any applicant for a permit subjects the applicant to a civil
'�rldlty ot not more than�tive huntl�etl tlollars ($500).
I, as' owner of ,the property or my employees with wages as their sole
npensation, will tlo the work, antl the structure is not intentled o� offeretl
.,.r sale (Section ]044, Business and Professional Cotle: The Contractor's
' License Law tloes not apply to an owner ot a'praperty who builtls o� improves
; the�eon, antl who tloes such work himself/herself or through his or her own
employees, provitletl that such improvements are not intentletl or offeretl tor
Sale.df;�M1oweveq tYle builtlinq ol Improvemeni is soltl wi[hin one year of com-
pletion, tM1e owner will have the burtlen of provin9 he/she tlitl not build or im-
prove tor the pu�pose ot sale). -'
� 0' I, as owner of the property, am exclusively mntractin9 `�+'ith IicenSetl con-
tractors to construct the projecf (Section ]044, Business antl Protessions COCe:
The�Cont�acto�'s-License Law tloes not apply�to:an owner of property who
builtls or improves thereon, antl who: mntracts for such projects with a con-
� tractor(s) iicense pursuant to the contractor's �icense Law). I am aware that
' proof ot tbeir Wo�ke�'s Compensa[ion insurance shoultl be providetl to me.
�� I 5m exempt untler Section • B. & P. C.-Por this reason
� Dafe Owner
m
co
above
TYPE OFCONSTRUCTION LJ NEW U ADD LJ ALTERATION Pd REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHER � A P # ,
DESCRIPTION OF WORK/USE OF B�DG. .
� S Main Buildi
TYPE OF PERMIT '❑ GRADWG OUNDATION ❑ STRUCTURAL ' T Front
❑ TENANT ❑ ELECTRICAI PLUMBING ❑ MECHANICAL B Rear
❑ OTHER %�
PROJECT DESCRIPTION •5t3. FT. � oCCUaANCV C�Right�
K Left
CONSTRVCTIONTVPE VALUATION$ $ �
ZONE - GRADING CU. VpS. ACRES p�ng. Ref. # '
pemarks: , . A �' �� , ' Planning Notes:
Sink
Preventer
Irrigation
Clarifiers'
Drinking Fountains
FloorDrains '
Floor Sinks
Gas Service Outlets
Interceptors
Kitchen Sink � _.
Lavamries '
P-Trap
Roof Drains - '
Reinspection Fee
$15
Boiler
Duct-UnderGround �
Duct - Struciurel
Duct - Ventilating
Exhaust System ❑ Multiple ❑
Firepl/Fact.,Blt. ICBO #
Heating System & Ducting�
❑ 0-100,000 BTU O 7 00,000 BT
I Drivers"Licen/�� orFSt ��. �
CMF 0865-46, rev. 30/84 White - Builtling; Canary - Applitant; Pink � Accounting; GoltlenrOtl - qssessor
Showers
Service Sink � �
Sewer Cap . .
Sewer Connection
Solar Coilectors
Solar Piping
Solar Tank �
Swimminq Pool w/Spa
Urinal
Water Closec
Water Heater
Wa[er Service
Auto-Wash
Issue Fee
Hood or ' TYPe I ❑
Canopy TYPe I I ❑
Refrigeration System
❑0-100,OOOBTU ❑700,000
System,Repair/Alteration �
Fire Dampers . '
� Registers . -
luue Fee
fEES
$ 3
$ 3
Zone ' �J�OO T�.
Accessory Building:
ELECTRICAL � '
Automatic Washer Trensformer-�� 15-50 KW
Construction Pole Sub. , � 50 + KW
Cooking Unit
Dishwasher , � �
Dryers ❑Gas ❑Electric
Fan '
F.A,U.
Fixtures
Device Boxes
O ut lets
Switches
Garbage Disposal
Generator �0-5 KW �5-15 KW
Meter LJup to 100amps
Meter ❑over 700,amps '
Sub Panel
Motors DO-1 HP 01 %- 8
Ina Solar 09-15 HP 016-15+
Pale Light �
Range
Sign
Standing Sections
Trash Compactor
I Reinspection Fee .� $15 � � Issue
DEVELOPMENTSERVICESREQUIREMEN7S:
Zaning APProved BY �
Building Approved By
Application Issued BV � � �+ �
FEES
$
Z
O
N
I
N
G
R
E
Q
M
T
S
� , SUMMARV OP FEES � .. - � -
BUILDING PERMIT $ - SMIP � $��
PLAN CHECK � : $ - ��*-� PERMIT
PLUMBING � $ �_y;� � ISSUANCE . $ -�
PLAN�CHECK 25% $ � , ENERGV P:C. $ �
ELECTRICAL '. $_ GRADING� � $- -
PLAN CHECK •50% $ � MICROFILM� $ ,
MECHANICAL $ � L,�% '�
TOTAL FEE ; $ ��
PLAN CHECK 25% $ . ,
=,
CONSTRUCTION AND PLANNING � � POOL & SPA -
APPROVALS Permit# Date Inspector qppROVALS Permit# Date _Inspector
1.� Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. , 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms -"'
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding �- i
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test ''
6. Electrical UFER Grnd. 57. APPROVAL TO COVER�=GUNITE�
7. Footings ' �, '. 58. Electrical Conduit-Undrgrnd. �
8. Foundation - 59. Gas Pipe, � Undrgrnd., Test �
u.�
9. Water Pipe-Undrgmd. 60. Backwash Lines, P-Trap, O�Undrgrnd. _
r
10. Siructural Floor System 67. APPROVAL TO DECK ��
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. 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
76. Rough Electric Wiring ' 67. Fencing & Access Approval
17. Rough Wiring Sign 6S. APPROVED FOR PLASTERING
18: Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
79. 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 0 Gas ❑ Oil
23. Gas Pipe-Rough & Test 72, Underground Flush
24. Roof Framing 73. Undergrnd. Storage Tank O Gas ❑ Oil
25. Roof Sheathing 74. Overhead Hydro �
26. T-Bar Ceiling'(Structural) & 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. Plaster Brown Coat 79. FINAL INSPECTION -
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes:
34. Final Heating & Air Conditioning
35. Final Gas Pipe-Test -
36. Hootl or Canopy .
37. Final Factory Fireplace ,
� 38: Final Plumbing (2-dS'Vi L�IG(J '
39. Water Service-Final ' . '
40. Gas Service-Final • ,
41. Solar pomestic-Final
� 42. Backflow Preventer ' .
43. Backflow Irrigation
44. landscape Irrigation System -
� 45. Sound Attenuation �
46. Handicap Regulations -
47. FINALSTRUCTURE&BUILDING .
48. Special Requirements Completed '
49. Electric Release to Edison �
50. Gas Release to Southern California Gas Co � .
51. CERTIFICATE OF OCCUPANCY
No. Date
Applicant to fill in all soaces axcept tM1osa w� neavy DorEer Iinas anE sign all appropriale
J�11'V OF COSTA MESA
ONSTRUCTION PEEMIT
�yP oject Add ess ;Z ; 7 I 1 Llc) �/j��
�Applicant'sMailingAddress�I ��'�'1-1� 'J
Owner's Nartre u�n t�.� TAV- �� � Phone.']ZE(^-7��1
Addreu 3212 1 DHHo PLta� c C►� � 4 ZceZ(o
Arch/Eng. License No.
Address
Contractor's Nam � �� � A Phone
Address (mailing) - �
Ciry License No. '
LICENSED CONTRACTOR DECIARAT�ON '
I hereby affirm tha[ 1 am licensetl untler provisions of Charter 9(commencing
with section 7000) of Division 3 of�'the Businass antl Professions Cotle, antl
my Iicense is in fuH iorce antl et�ect. -
LlcenSe Clzss � License No.
Date Si9nature
WORKERS' COMPENSNTION DECLARqT10N
1 hereoy affirm l�at I have a certiticate bt consent to seH-insure or a ccrtificate
ot Workers' Compensation Inzurance, or a c¢rUtiea copy thereot (Sectlon
3800, Lab. C.) "
Pollcy No. .Coerypany
Certifietl copy is hereDy tumishetlf.
Certlfletl copy IS (iletl with tha cityB4iltlin9 DIvlSion.
Oate APPlicant '
EXEMPTION FqOM WORKERS' COMP�NSATION DECLARATION
(Tnis section neetl not be completetl if th¢.permit is for one huntlretl (5300) or
I¢zz). -
I ce�ti}y that In the performance of the W k fOr which t�l e�m�t IS ISsuetl I
5hall not emD�oY any person in any md r so t o e ect to t{�a
Worke�,s-' �/o-m�pe}� S�a,tl_on Laws o( CalifO �. �-
�ate �1J./S�Signature
NOTICE! If,'af4er making this tleclara[ion, you hou tl become sub�ecl to the
Workers' Compansatlon provisions o( the Labor Cotle, you must forthwith
comply with such Orovisions or this permit snall be tleemetl revoketl.
CONSTRUCTION LENDING AGENCY
I hereby aftl�m that t�ere i5 a construction lentling a9eOCy tor the pe��o�mance
of [ne work fo hic this p rmit is issuetl (SecH� pn� 309] Civ. C.)
L.entler's Namn ����'^'� � �H�bY6ES ciYiB�T V✓ta/-�
Lentl¢r'S Atltlre« -C/ixiTA i%+�lf IY,(iywJGN /7d�
OWNER BUILDER�DECLARATION
I hereby af(irm that I am exempt from the ConlractorY Llcense Law for the
following reason (Seclion 7031.5 Business and Protessional Cotle: Any city or
munN wM1ich reaulres a oermit to construcr. alter_ imorove_ tlemol6h or reoair
'e�rom antl ihe basis tor me ane9ea exemption. Any violatlon oi Secvon
'1.5 by any applicant fo� a permi{ subjec[s the applicant to a clvil
alty of nol more than five huntlretl t1011ars ($500).
1, as owner of the property or my employees wlth wagas as Ihelr sole
ipen5a[iOn, will tlo the work, dntl [hp� structure is nol IntentleG or OH¢r¢tl
sale (Section 7044, Business antl hrote55ional Cotle: The Contractor's
;nse Law tloes no[ appry to an owner of a propertY �+ho builtls or improves
reon, and who tloes such work �Imsel(/herself or tnrou9h his or ner own
�loy¢es, pwvidetl that zuch ImOroverryents a�e nOt Inten�etl or offOretl for
. If, however, [he builtling or improvement is soltl wlthin ona year of tom- �
�.ioq the owner will have'the burtlan of proving he/she tlitl not bulltl or im- ,
ve for the purpose of sale), �
I, as'owner of the property, am exclusively contractinq with Iicensetl con-
:torsto construct the project (Section 7044, Business an0 Protosslons Cotle:
: Conlractor'S License Law does not apply to an owner of.Oroper[y who
bWltls or improvet thereon, an� who cOntracts (or such pro7ect5 with a con-
iractor(s) license pursuant to the Contra¢tor's Licenx L.aw).
❑ I am exempt untlar Section�-/ ' 8. b P. A(qr 1h15 reason
//
Date `�+9"i'T�r Owne _ _ _,
I Signature i�-'!r.T
� Drivers' Lirense or 55 �
\ CMF 0865-46 �ev. 7/83
, I
tate that tho above
tl'county ortlinances
�by authorize re0�e-
loned property for
Date 4 Z- ��
TYPE OF CONSTRUCTION LJ NE
❑ CONVERSION ❑ DEMOLISH
DESCRIPTION OF WORK �E�
7VFE OF PERMIT LJ GaadING LJ F
❑ TENANT ❑ ELECTRICAL ❑pPL
❑ �OTHEi3 �T 7�
PROJECT DESCRIPTION 5�. F SL..2
CpNSTRUCTIONTVPE _
ZONE GRADING
Remarks: r"'�
P. C
Bar Sink
Backflow Preventer
Backflow IrrigatiOn
Drinking Fountains
Floor Dreins
Floor Sinks
Gas Service Outlets
Interceptors
Kitchen Sink
Roof Drains
Reinspection Fee $25
Duct- UnderGround
Duct-Structural '
Duct - Ventilating
Exhaust System ❑ Multiple ❑
Firepl/Pact. BIL ICBO # J/�%$
Fleating System & Ducting
❑0.100,000 BTU 0100,0006T
peinspeccion Fee � $25
W hite - Builtling; Canary - APplicant: Plnk - A<counting; Goldenrotl - Assessor
ADD LJ ALTERATION LJ REPAIR
JATION �STRUCTURAL
NG ❑ME,}IANICAL
ie.
_ VALUATION $
V DS. A(
Showers
Service Sink
Sewer Cap -
Sewer Connection
Solar Collecrors
Solar Piping
Solar Tank
Swimming Pool w/Spa
Urinal
Water Clout
Water Heater
Water Service
Isue Fee
Hoodor Typel �
Canopy Type II ❑
Refrigeration System •
❑aioo,000eTu ❑ioo,aoo
System RepaidAlteration
Issue Fee
FEES
$ 3
$ 3
A.P.;� I' —De
S Main Building:
TFront 2� ,
A Rear i
C Right �
SLeft C
Ping. Ret. #�
Parking Req./Provided
WseofBuilding: �,
Planning Notes: _
7cJ6' ���i���l:
-- O ' 2one � I
Accessory Building:
--- I Park.Fees
� C�_Jl/�
n � La �
2
O
N
1
C�
E
_ n
U
I
R
E
E
ELECTRICAL
Transformer ❑ 75
Construction PoleSuh. � 50
Cooking Unit Meter ❑up to 100 amps�
Dishwasher Meter ❑over100amps� �
Dryers ❑Gas ❑Electric � �Sub Panel ��.i
Fan '��'y Motors �0-1 HP 011K,'-8 �
/ F.A.U. � ' Inc.Solar �9-15 HP �16-15+
� Fixtures • : ; Microwave � �
- Device Boxes � . � Pole Light
Outle[s �
pSwihhes � ` •
Garbage Disposal ' �
�! Generator �0�5 KW �5-15 KW
. I Reinspection Fee � .
PUBLIC SERVICES REQUIREMEN
Zoning APProved BY_��
APPlicztian APProvad By
' BUILDING PERMiT
• .PIAN CHECK ,
� �PIUMBING
PIAN.CHECKr
, ELECTRICAL�•
- P,IAN CHECK-
� MECHANICAL�
PLAN CHECK
FEES
, Standing Sections .
Trash Compsctor
i luue Fee $ 3
,>
.,..._ iP�zG .
" SU MARV OF FEES �7
$- %93,0o SMIP $ `•LO
$.—� "�— PERMIT
g� !. (!(> �SSUANCE $
$ —p� , 00- ENEFGV P.C. $
g' o,Tc7 GRADING $
$- � MICROFILM $
$' � TOTAL FEE $ 2Z , ZO
$, �
.. . POOL & SPA ., Y . •
'CG�JSTRUCTION AND PLANNING � � �
� APPROVALS Permit# Date Inspector - AppROVALS Permit# Date Inspector
�
1. Temporary Electrical Serviceor Pole� . 52. Pool & Equipment Location '
�
12. Soil Pipe-Undrgmd. 53. Steel Reinforcement � �
3. Electrical Conduit Utility-Undrgrnd. 54: Forms 7
4. Eler,trical Conduit�Undrgrnd. . 55. Electrical Bonding � �
5. Steel Reinforcement • � 56. Rough Plumbing & Pressure Test
�6. ElectricalUFERGmd.�j j�� /I 57. APPROVALTOCOVER-GUNITE �
7. Footings �- 5 �� � 58. Electrical ConduirUndrgrnd. j�
8. Foundation p� pS - 59. Gas Pipe, O�Undrgrnd., Test %
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, O Undrgmd. I
10. Svuctural Floor System 61. APPROVAL TO DECK . �
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final �
�
12. Sewer Cap 63. Heater & Vent-Final • i
13. Roof Drains 64. Plumbing System -.Final � '
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit � 66. Solar System�Final
16. Rough Electric Wiring /Z � 67. Fencing & Access Approval
'17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
.18. Rough Elearical-T. Bar Ceiling � 69. POOL/SPA SYSTEMS FINAL -
.19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit #
�
21. Ducts,'.in Structure � � , 70. Underground HYdro ,
22. Ducts,.Ventilating ;" 71. ProductPiping�Gas ❑Oil �-'
,. �
23. Gas Pipe-Rough & est � 5. I-JD, � 72. Underground Flush
24. Roof �raming ' • , . � , 73. Undergrnd.StorageTank OGas ❑Oil '
25. Roof;Sheathing' , " D� � L� 7q, pverhead Hydro � '•
26. T-Ba� Ceiling ($tructural) & Monocoat 75. Dry Chemical �.
27. Frame�and Flashing �s �_ �„ 76. Dry Standpipe .
28. Lathing & Siding � ' . � „�� 77. FIXED SYSTEM FINAL
29. Insuletion , � �_ �Q, 78. FIRE PREV. FINAL
30. Drywall Nailing ��. � �' �_ HEALTH DEPT. REQUIREMENT
31. Plastee;�rown Coat.'.- ' ' ,�S /� � 79. FINAL INSPECTION
32. Electrical Power Meter-Final' �� Sb. FOOD CERTIFICATE ISSUED +
33. Final Electric :' , � , . � � Notes: � "
34. Final Heating &�Air Conditioning / � �p '
-O
35. Final Gas Pipe-Test, � � 2�1C�Qii �
36. Hood or Canopy.
37. Final Factory Fireplace ��/ �7y. �
38. Final Plum6ing .. ��_�6 , �.
� g' [
39. Water Service-Final ' A �
a i-F-
40. Gas Service-Finalj L� ��j-I�j F'�trt.��� Oi.6G br{ (3q2S�hK ���%"�"��
41. Solar pomestic-Final . _ � (�,g yy,,�� �� ,� �p
42. Backflow Preventer 8 �. . '' '�
43. Backflow Irrigation "r ' '� % �` � '�
r
44. Landscape Irrigation System �
45. Sound Attenuation � �
46. Haridicap Regulations � � �
47. FINALSTRUCTURE&BUILDING � � :
48. Special Requirements Completed � • � , � •
' 49. Electric Release to Edison - 'ri
50. Gas Release to Southern California Gas Co ' ' ' �
51. CERTIFICATE OF OCCUPANCY • ` t
No. Date � � �
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 proposed
property improvement. ❑ Yes I8 No
2. I(have/have not) �AvE signed an application for a building permit for the
proposed work.
3. I have contracted with the following person (firm) to provide the proposed construction:
Name � V� �si� EN HnRN
Address B�RZ �u SS7 /-, ius i£� Au£ City �v�%H/NS?E/L
� Phone (���) �S 8- 2.2 2 4 Contractor's Lic. No. �i 3� � 7 �
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 contracted (hired) the following persons to provide
the work inqicated:
Name Address Phone � Type of Work
I hereby affirm that I have received a copy of the information set forth in Section 19830 of the
State of California Health and Safety Code and have completed the above information to the best of my
personal knowiedge,' compliance with this State law. /
Signed: ���� -�7'"�+cE�/rHl�—� Date: l G u! b
/
Name: �auRt-l� N• �LLMAtiI
(Printed or Typed)
C.D.L. #or S.S. #
CMF 3042�46 7545273
CityofCostaMesa INSULATION CERTIFICATION� suildingSafetyDivision
3L3'� IOA'H1a P�— Coa-rn f-�.ESA c�RA-f.���
Number and Street City County
z s'
Subdivision
� Z
Lot Number
DESCRIPTION OF INSTALLATION
ROOF
Material f/�.t/� 6��9 SS Brand Name �W��s
Thickness (inches) � Thermal Resistance (R Value) �' ��
EXTERIOR WALL
Material Fi�Z��GASS Brand Name �L'-���J
� //
Thickness (inches) 3� Thermal Resistance (R Value)
CEILING
Batt or Blanket Type
Thickness (inches)
Loose Fill Type
Minimum Thickness (inches)
Area Covered (ft2)
FLOOR,ELEVATED
Material
Thickness (inchesl
FLOOR,SLAB
Material
Thickness (inches)
Width �inches�_
FOUNDATION WALL
Material
Thickness (inches)
Brand Name
Thermal Resistance (R Value)
Brand Name
Number of bags Weight per bag
Thermal Resistance (R Value)
Brand Name
Thermal Resistance (R Val
Brand Name
Thermal Resistance (R Value)
8rand Name
Thermal Resistance (R Value)
DECLARATION
I hereby certify that the above insulation was installed in the building at the above location in conformance with
the current regulations setting Energy Conservation Standards for new residential buildings (located in Title 24
of the California Administrative Codel.
Z/,c:G,P.�.J�/��.,...) ,E,J7.EQ ��QiSi�S
/� Generel Contractor (Builder)
L�-C l C/ LJrI.Z'�C
7 nature and Title
5�� /�
Su6 Contractor (lnsulation Applicator)
Signature and Title
CMF 1306-06
-v3Go7o
License Number
,�-l3 -��
Date
License Number
Date
�
I
��r.
AVO�i�ant lo fill in all
GTY OF COSTA MESA a�tnns ryp.�
CONSTRUCTION PERMIT F-� 5 X
Addres �3Z3 Z t.T�A.Na P�
Arch/Eng. License No.
Address
-lfui�f)E2 Phone
witbin heavy bartler lines anC sign ali appropriate Eeclantian
_ TRACT NO. LOT NO. � BLOG!NO.
Address
LICENSED CONTRACTOR DECLARATION
I nereGy affirm that I am Ilcensed untler provislons of Charter 9(com-
mencin9 wlm section 1000)� of �ivision 3 of tha Businass antl �
Protassions Cotle, antl my Iicense Is in full force antl effect. �I
License Class � License No. �
Ddte $ignature ,
�WORKERS'COMPENSATION DECLARATION �
I h¢reDy atfi�m tha[ I have a CGrtlfiGate of ConSent [O selt-InSure Or d
c¢rU(IWte ot Worke�s' CompenSatiOn InsurdnCG, Or a certifletl coPyll
thtreof (Section 3800, Lab. C.). ..
Pollcy No. Gompany
❑ Certifletl copy is her¢by turni5hed.
� 'ertlfietl copy iz filetl witn tbe Gry Builtling Divlslon.
NPTION FROM WORKERS' COMPENSATION DECLARATION
; section neetl not be comple[etl if the permit I5 tor one huntlretl
�ai00) or less).
certi(y that in the performance of th¢ work tor which thii p¢rmit is
IszueG, I sltall no( emO��Y any perso In any nner so s to become
subjact to the Workers' Compen5ati Ldws {}�/ �ni /
Date �Z'� 7-i�! Signature ���^ w%N�^—
NOTICE: If afte� making this tleCla�aUon, you Shoultl bOtOm¢ SUDject
to [ha WOrk¢�5' Compensation p�ovl51on5 Of the l2bOr Cotle, you mu5t
tOrlhwith comply with zuch provi5lons or this permit thall b¢ tleeme0
revoketl. . . .
CONSTRUCTION LENDING AGENCV
I he�eby a(ti�m that there i5 a const�uctiOn 1¢ntlin9 agGnGy fo� tlte Oe�-
formance of the work for whlch this permit is issuetl (Sec[lon 3097
Civ. C.1. " ' ' _ ' '.. . ... . ... .
Lender's Name
Lentler's Atltlress
OWNER BUILDER-OECL'ARATION' " '-' ' - '
I nereby affirm that I am exempt from tha Contractor's Llcense Law tor
the following reason -(Section ]031.5 Business antl Professlons Cotle:
Anv citv or countv which r¢Ouires a De�mit to COns[ruct, aller,
quires the applicant for such perml[ to flle a slgnGtl Sla[emen[ i�at ne
'is Iicensetl pursuant to the provi51on5 Of the Con[ractor's LlcenSe Law
(Chapter 9(commencing with Section 7000) of Division 3 of the
BuSin¢55 and Professions Cotle) or [ha[ ne Is exempt thcrefroT'antl the
basls lor the alle9etl exemption. Any violation of Sectlon 7031.5 by
dny appliCant fo�-a pe�mit subjeCts'th¢ applicant [o a clvil penalty
o1�(iot more than five huntlretl tlollars (g500).
, as owne� o/ the property, o� my employee5 with w5ges as thel�
compen5ation, will tlo the work, antl the 5t�ucturC is nol Intentletl
,tferetl for sale. (Section ]044, Buziness antl Professions Cotle: The
ContraGtor'S License Ldw tloe5 nOl apply to dn OwnCr Of a property
who bulltl5 or improves the�eon, antl wlto tloes such work him5elf or
through his own employees, provitlCtl thal such improv¢m¢nts are no[
intentletl or offeretl for sale. It, M1oweveq the Duilainq or improvemen[�
Is soltl within one year of complelion, lhe owner will �ave tne burtlen
of 0/oving he tlitl not bui10 or impiove for lh¢ purpos¢ 01 sale).
❑ 1, as owner of the �proPerty, am exclusively conlydcting with
IiCenS¢Q cOnt�actors to conslruGl the project (Section 7040, BuSinezS
antl Professions Cotle: The Contractor•s License Law does not applY to �
an owne� of property who builtl5 or Imp�ov¢5 thereon, antl who con-
tracts from such pro�ecfs wittt a contrdGtOr(5) IiC¢5n0tl pur5uant to
the Contractor's License l.aw).
❑ I am exempt untler Section � 8. & P. C. for this
reason - -
�Oate Owner
I I hereby certity that I have reatl this aOPlication antl state that the above
I iniormation is mrrect. I agree to Comply wlth all City dntl county
Iortlinances and state laws relating [o construction, an0 hereby authorize
represen[atives of this city [o enler upOn lhe above m¢n[ionetl
property, t�inspe ti , se;q� L
�Y
TVPE OF CONSTRUCTION
❑ NEW O ADD ❑ ALTERATION
❑ REPAIR ❑ CONVERSION ❑DEMOLISH
❑ OTHER
OESCRIPTION OF WORK
TYPE OF PERMIT -
❑GRADING ❑ FOUNDATION ❑�STRVCTVRAL
❑ TENANT ❑ ELECTRICAL �PI.VMBING ❑MECHAI
❑ OTHER
PROJECT DESCHIPTION � . . . .
SQ.FT. . . . .
OCCVPANCV_CONSTRVCTIONTYPE
VALVATION ZONE
GRADING CU. VDS. - ACRES
R
PLUMBING
TOIlETS • -
LAVATORIES '
KIT: SINKS �
SERVICESINKS '
FLOOR SINKS �
DRINKING FOUNTAINS'
INTERCEPTORS �
SWIMMING POOL' "
WATER SERVICE
GASSERVICE �
WATER HEATERS -
SEWER CONNECTIONS
PLAN CHECK
SHOWERS ' '
URINAL$
CCARIFIERS
PTRAP '
ALTERATION '
OUTLETS
BTU OUTPVT"- '
SOCAR TANK " " " COLLECTORS
SOLAR PIPING SVS. - � �
ISSUE FEE ' � � -
MECHANICAL PLAN CHECK
HEATING SVSTEM 0-300,000 BTU_
ANDOUCTING 300,000+_BTU_
REFRIGERATION 0-300,000 BTU_
SVSTEM -� 100,000 * BTU_
BOILERS BTV
SVSTEM REPAIR,ALTERATION
EXHAUST SVSTEM MULTIPLE
Signature ""�'�'f� i� M"2-"i Date � -�7�gz—
Drivers' Litenze or 55 �� ' -I� � �SSUE FEE
CMF 0865-46 Wnite-Builtling; Canary-Applicanl: Pink�Accountinq; Goldenrotl-Assessor
��2� �2��)/d2
ZONING REGULATIONS
A.P. �
ZONE
REAR VARD (TO P/L)
PKG.SPACE REq.
STREET WIDTH
ZONING APPROVEO BY
SPECIAL CONDITIONS:
'ELECTRICAL
REF. �
PROVIOED
PARK FEE $
PLAN CHECK
GENERATOR 0-1 KW_1-10 KW =
TRANSFORMER
APPLIANGE 30-50 KW_50 * KW _
MOTORS � - - 0�1-HP_1-30 HP'_
(INC. SOLAR) � 30-50 HP_50 + HP _
FI%TURES' OUTLETS SWITCHE!
GAS TUBE SIGNS ' � -
POLE LIGHTS - ' ' ' ' '
PANELS
SERVICE -
MAIN SUB
. • -- AMP
;io b0
ISSUEFEE "' ' �_
APPLICATION APPROV ED BV� - ' DATE
SUMMARV OP FEES � ,
BVILDING � -
PERMIT $ �SMIG $
PLAN CHECK S�_ � P SUAINCE E
PLUMBING S •
.. ' GRADING E
PLANCHECK .E . . -
ELEGTRICAL S b-
PLANCHECK E MICROFILM E '
MECHANICAL'E TOTAL FEE y
PLANCHECK �§ � ' ' LESSAD- _
, VANCEPC S- "
, FINALFEE f ��O
CONSTRUCTION AND PLqNNING • . POOL & SPA �� � • . � .
APPROVALS Permit# Date Inspector p�ppROVALS Permit# ' - Date �.Inspector
1. Temporary Electrical Service or Pole 43. Pool & Equipment Loration - '
2. Soil ipe-Undrgrn • 44. Steel Reinforcement
3. Elearical Conduit Utility-Undrgrn 45. Forms
4. Electrical Conduit-Undrgrn 46. Electrical Bonding �
. tee ein orce 47. Rough Plumbin Si Pressure Test � '
6. Elec[rical UFER Grn 48. APPROVAL TO COVER-GUNITE
7._ Footings � � 49. Electrical Conduit-Undr rn
8.- Foundation 50. Gas Pipe, ❑ Undr m, Test ��
9. Water Pipe-Undrgrn . 51. Backwash Lines P-Tra ❑ ndr rn �
10. Structural Floor System 52. APPROVAL TO DECK � �
it. Property Sewer Line &.House Connection . 53. Backwash & Rece tor-Final � �
12. Street Sewer Connection '' -' � 54. Heater & Vent-Final
13. Rough.Plumbing
14. Rough Eiectric-Conduit - �56. Electrical-Final
15. Rough Electric-Wiring � -57. Solar System-Final - �
16. Rbugh Heating & Air'Conditioning - - _ � encing & Access Approval •
17. Ducts in Structure� '�' ' APPROVED FOR PLASTERING .
18. Ducts,-Ventilating � _ . '. . _ �
19. Gas Pipe-Rough &Test ' - - 60. POOUSPA SYSTEMS FINAL ' � " ' � �
� 20. - Roof Fiaming - - - ' - - - . .- - - ` ,. . . ,. �� . . � � .
21. Roof Sheathin - - � � � �- � i� - � �
22. Frame and Flashing - - �• - NOTES: ' . •
23. Insulation-� ' ~ .... . ..,:;�- ..,_-' '-- .. .. ..
24. Lathing &�Siding - '-' . - � - -�- - . . ' - . - . .. . _ . .
25. Drywall Nailing - � - � � - -
26. � Plaster Brown Coat � ' � � - -
- 27. Electrical Power Meter-Final ' ` � � �
28. -Final Electric - - - � � ' � ' • �
29. Final Heating & Air Conditiqning - ' ' �
� 30. Final Gas Pipe-Test - � �
31. Final Plumbing . -
32. Water Service-Final �-
-33.- Gas Service-Final � - ' �
34. Solar pome3tic-Final �
35. Landsca e S rinklin S stem • � � � �
36. Sound Attenuation _ . ' -
37. Handicap Regulations "' - - - - ' ' � �
38. FINAL STRUCTURE & BUILDING
39. Special Requirements Completed � -
40. Electric Release to Edison -"
41. Gas Release to Southern California Gas Co.
42. CERTIFICATE OF OCCUPANCY �
� •
No Date
,. AVP��cant to flll in all iCaces
CITY OF COSTA MESA /%/� _���5—� PERN1IT NO. —
CONSTRUCTION PERMIT
Project Address Z - � ' TVPE OF CONSTRUCTION NE
Appli[ent'S Melling Addleu . S/�« �j( ��� � /{ � CONVERSION ❑ DEMOLISH
Owner'S Name �� A'`'m � �'y�.AhoneV7�1 DESCRIPTION OF WORK
Address �Z� L- �.(�"/�" L �
Arch/Eng. Licenu No.
Address
CoMractor's NamP l� � �`-� �� Phone
Address Imailing) � .
City License No. � �
LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am Ilcensetl undar provl5ions ot Charter 9(<ommon<ing
with sectlon ]000) ot Divlslon 3 ot tne Buslness antl Professions Cotle, antl
my Ilcense Is in full torce an� affece.
LJcense Class Licanse No.
Date Si9nature
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a tertltltate o( consent to sel/-insure or a cartifica[e
of Workers' Compensation Insuranca, or a cartlfietl coDY thereof (Sectlon
3800, Leb. C.) �
�olicy No. Company
eCertifletl copy Is �ereby fumishetl.
CerUtietl <opy Is flled with the clty Bulltling Dlvislon.
Oate Applicant
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(This Section n08tl n0t b0 completetl If the permit is fOr One hunCretl (E300) or
Iess). '
I certify that in the performance of lhe work for which this permk is izsuetl I
shall not employ any parson In any ma9�/ er so as t e ma 7ecl to t�e
WOfke! Com� a t 0 LdwS 07 Cdllfo��}` n Ly
Date �'�`f'—��Slgnature �T �"^-�' � ,�^��l�
NOTICE: If,iatter making this tlaclaratlon, you snou a ecome sub7ec[ to the
Workers' Compansdtlon prOvizlons af the l.abor Cotle, you mu5t forthwith
comply wl[h Such p�ovlSlont o� th15 08rmI[ Shdll be tl0¢metl �evaketl:
CONSTRUCTION IENDING AGENCV
I hereby af(irm t�at thara I5 a tonsytrucrt�tlton lentling age(�nc�yr fyopr t�h�a perfCor'mance
of tne work fgyyvhl�a�IN]zerChfS�LOYtlEx � C/K'�9f UN 0�l✓
Londer'S Name ��r�
l.entlers Atltlress SA'NiQ tiA
OWNERBUILDER DECLARATION
I hereGy affirm that I am exempt from the Contractor.'s License Law for the
following reason (Sectlon 7031.5 Buslneis antl Professlonal Cotla: Any city or
county whlch requlres a permlt to tonstru<t, alter Improve, tlemollsn or repalr
any structure, prlor to Its Issuance, also roqulres t�e apP�lcan[ for such permit
to flla a 5ignetl ztatement t�at ne/she Is Iicensatl pursuant to tha provlilons of
the Contractor's LitanSe Law (Chapter 9(commencing wltn Sectlon 7000) of
Division 3 of the Business antl Professlons Cotle) or t�at he/she Is exempt
tnerafrom antl the basiz tor the allegetl axemptlon. Any violation ot Section
7033.5 by any applicant for;a permlt subJects the applicant to a civll
�enalty of not more than five huntlretl tlollars ($500).
I, at owner of the property ar my employees wlth wages as thelr sole
�nse Law aoas not appry [o an ownar or a proparty wno ouiias or �mprovas
'eon, antl who tloes such work,himself/herself or through his or her own
tl0y ees, provitletl that such improvementz aro not Intontlotl or offeratl 1or
1/, however, the bullCing or Improvament Is soltl wlthln one year of com-
�ion, t�e owner will have the burtlen of proving ha/she tlitl not builtl or im-
re for tha purposa of sale).
I, as owner of the Oroperty, am excluslvely contracting with Ilcensetl con-
tors td construct the project (Sectlon 7044, Buslness antl Professlons Cotle:
Contractor's License law does not apply to an owner ot property who
tls or improvas thareon, antl who contracts for su<h pro7acts wlth a con�
tor(5) Ilcense pur5uant to the Contractor's Llcense Law).
I am exempt unEer Section B. & P. C. for this reason
anG si9n all appro0��ate tleclaratians.
J ADD, LJ ALTERATION LJ REPAIR
OTHER -
TVPE OF PERMIT ' LI GRADING LI FOUNDATION LI �STRUCTURAL
❑ TENANT ❑ ELECTRICAL ❑ PLUMBIfVG� ❑ MECHANICAL
❑ �OTHER ' ' �
PRQIECT DESCRIPTION Sa.FT. oCCUPANCv_
CONSTRUCTIONTVPE VALUATION$ '
20NE GRADINC.CU.VDS. ACRES_
Remarks:
3ar Sink
3ackflow Preventer
3ackflow Irrigation
3athtubs '
�lerifiers
�IShW35h2! �
Jrinking Fountains
Floor Drains
Floor Sinks
uas Service Outlets
Interceprors
Kitchen Sink
Lavatories
P—Trep
Roof Drains -.
Rainspection Fee $25
Boiler
Dutt = Untler Ground
Ouct - Structural
Duct - Ventilating
Exhaust System ❑ Multiple ❑
Fiiepl/Facc BIL ICBO #
Date Owner � Heating System & D�u,/cting
I hereby certlfy that �I have reatl thls applicatlon antl state that tha abova ❑6100,000 BTU tN100,0006T
information I5 corract. I agrea to comply with all clty antl county ortlinances
antl state laws ralating to bulltling construction, an0 heroby authorize repre-
sentatives of t i7 clty to ente n t e bove-mentlonetl proDerty for
inspectlon Ou Ses.
519naturo �— Date Z" � —o
Drivers' Licen» or�55 � Heinspection Fee
CMF 0865-46 rev. 12/B3 Whlte - Bulltling; Canary • Appllwnt; Pink - A<counling; Goltlenrotl - Assessor
$25
Showers
$ervite Sink
Sewer Cap
Sewer Connettion
Solar Collectors
Solar Piping
Solar Tank
Swimming Pool wlSpa
Urinal
Water Closet ,
Water Heater
Water Service
Isue Fee
FEES
$ 3
A.P. iW
S Main Buildi
E
T Front
8 Rear
A
C Right
K Left
S'
Ping. Ref. #
Parking Req./Pr�
Use ot Buildin9:
Planning Notes:
Automatic Washer
Construttion Pole Sub.
CoOking Unit
Dishwasher
Dryers ❑Gas �Elec
Fan
F.A.U.
Fixtures
Device Boxes
OuHets
Switches
Garbage Disposal
Genereror 00.5 KW C
4274 2/14/84
Zone
:sory Building:
Park.Fees $
ELECTRICAL ,
Transformer ❑ 15-50 KW
❑ SO+KW
Meter ❑up to 100 amps
Meter ❑over 100 amps �
Sub Panel
Motors �0-1 HP O1 f. - 8
Inc.Solar �9�15 HP �16�15+
Microwave
Pole Light
Range
Standing Sections
5�15 KW Trash Compactor
Reinspection Fee �$25 � Issue Fea
IANICAL FEES �
Hood or T PUBLIC SERVICES REQUIREMENTS:
ypel ❑ Zoning Approved By
Canopy Type I I ❑
� Buildin0 �+PProved By
Refrigeration System
❑0.100,000 BTU Lg�0,000
System Repair/Alteration
laue Fee � �� $ 3
\
I 5.0� T,
Z
O
N
�
N
G
E
�
U
R
E
L
SUMMARV OF FEES .
BUILDING PERMIT $ SMIP $
PLAN CHECK $ PERMIT
PLUMBING $ ISSUANCE $
PLAN CHECK 25% $ ENERGV P.C. $
ELECTRICAL $ GRADING $ �
PLANCHECK 50% $ MICROFILM $
MECHANICAL $ � �� TOTAL FEE $ ��
PLAN CHECK 25% $ .
� �CONSTRUCTION�AND PLANNING � � POOL & SP.. .
�APPROVALS Permit# Date Inspector qppROVALS Permit# Date' Inspector ,.
r
• 1: Temporary Electrical Service or Pole 52. Pool & Equipment Location � . � - .
2:• Soil Pipe-Undrgrnd. " 53. Steel Reinforcement �
3. Electrical Conduit Utiliry-Undrgmd. 54. Forms -
I" 4- Electrical Conduit-Undrgmd. 55. Electrical Bonding
5: Steel Reinforcement � . 56. Rough Plumbing & Pressure Test �
6. Electrical UFER Grnd. _ 57. APPROVAL TO COVER-GUNITE �
7. Footings �'. 58. Electriral Conduit-Undrgrnd.
8. Foundation � 59. Gas Pipe, O Undrgrnd.; Test � �
�
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, � Undrgrnd.
10. $tructural Floor System � 61. APPROVAL TO DECK '
11. Property Sewer Line_& House Connection 62. Backwash & Receptor-Final �
12. Sewf:r Cap 63. Heater & Vent-Final
13. Roof Drains � � 64. Plumbing System - Final -
14. Rou3h 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.+Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL � ;
19. Rou�h �Heating & Air Conditioning FIRE DEPT. REQUIREMENT �
�
20. Rough�FactoryFireplace� � APPROVALS Peimit# � � � �
71. Ducts, in Struc[ure� � . 70.' Underground Hydro '
ucts, Ventilating - � � 71. Product Piping O Gas ❑ Oil
Gas Pipe-Rough & Test _ 72. Underground Flush,
. Roof Framing ' � 73. Undergrnd. Storage Tank O Gas ❑ Oil �,
15. Roof'Sheathing � 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical .
27. Frame and Flashing 76. Dry Standpipe
' 28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation ' � 78. FIREPREV.FINAL
- 30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter;Final • 80. FOOD CERTIFICATE ISSUED
�33. Final Electric Notes:
34. Final Heating & Air Conditioning s�)�y (�� .
35. Final Gas Pipe-Test � . -
36. Hood or Canopy
37. Final Factory Fireplace �
38. Final Plumbing � �
39. Water Service-Final . '
40. Gas Service-Final �
41. Solar pomestic-Final �
42. Backflow Preventer � � _ � ,
43. Backflow Irrigation � �
44. .Landscape Irrigation System
45. Sounil Attenuation� . , , ' _
46. Handicap Regulations � . -
47. FINALSTRUCTURE&BUILDING • - � �
48. Special' Requirements Completed � ' � �' �
49. Electric Release to Edison � � . � - � � .
50. Gas Release to Southern California Gas Co �
I57. CERTIFICATEOF•OCCUPANCY - , � �-�;� � � �
No. � Date
CITY OF COSTA MESA
BUILDING DIVISION
OWNER-BUILDER VERIFICATInN
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 proposed
property improvement. ❑ Yes �i No
2. I(have/have not) �� V� signed an application for a building permit for the
proposed work.
3. I have contr cted with the following person (firm) to provide the proposed construction:
tvame •L�AIi/O 7 �E��i./ffo2�(J
Address 8�8Z wt'S7M�,vSi7=.�2 /�Gt/!�. City ��SrHiNS?ti71.
Phone f%�yl RSg— y`�33 Contractor's Lic. No. ��3 �a� 70
4. I plan to provide portions of ihe work, but I have hired the following person to coordinate,
supervise and provide the malor work:
Name "
Address City
Phone (
Contractor's Lic. No
5 I will provide some of the work but I have contracted (hired) the following persons to provide
the work indicated:
Name
Address
Phone Type of Work
I hereby affirm that I have received a copy of the information set forth in Section 19830 of the
State of California Health and Safety Code and have completed the above information to the best of my
personal knowled�n�pl�ce wi h t' State IawI1`L� ��� / �
< ,/
Signed: . Date: 7 , ��`F
//�/-� i�
Name: �O �C/ �- i� /7 ' / /� LL H/f u
(Printed or Ty'ped)
C.D.L. #or s.s. #�
7545273
CMF 3042-46
�OT 52 -. TRACT 36z5
• �.H.J�-J'$f(
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 9�7 C08TA MEBA. CALIFORNIA
For Applicani io Fill In Completely
TYPE OR PRINT
eUILDING 3�32 �DAHO PLACE
ADDRESS
COSYA MESA CALIFORNIA
oWNER KENKOL COfS TRUCTION CO. �
MAIL �5�j5 P�ACENTIA AVENUE
ADDRE55 '
CITY NEWPORT BEACH Np; 6-3227
ARCHITECf TEL.
� SIZE
. �. , . __,ly._.. . .,.1
�r.: � S- I $-(C c�
�! I1, ., �,,:= „ _ ,
,�,� �� �esT,, .�_�
APPLICATION FOR PERMIT
BUILDING
For Office Use Only
FECEIPT NO. PEflMIT NO.
COSTA MESA. CALIFORNIA
�� � APPROVE�
BY DA
jj55 PLACENTIA AVENUE ZONING
rfEWpORT BEACH zoNe Ho. oF use or
runs ?/ em�o
TEL. 6'-3ZZ7 LE6AL .
NO. DEBCRIPTION '�
( NO. OF BLDG9.
X� OO NOW ON LOT O
A. P. NO.
. YARDS EVES
�G� APPROVED ALLOWI
, BHi9�GK LIN'rnF�R�OM �Q � qEAR YARD �� f «NTHR LINC ST.)
1�� �
I LEFi I RIGHT 5
DESCRIPTION OF WORK
' I X'II ALTERATION I II ADDITION I
BUIL�ING NO. OF /
61ZE � H SF ROOMS V STORIES �
EXTERIOR WALL STU CCO I ROOF WOOD SH I NGLES
COVERING COVERING
USE OF BUILDING AND WORK TO BE PERFORMED
S1NGLE-FAMILY RESIDENCE AND ATTACHE
GARAGE PLAN �-AR
L.SIDE / O
REAR I�
APPROVED��. � ./
BY (S�
�F
� h
� ,!i <J� ✓
a
�
1 HEREBY ACKNOWL&DO8 THAT i XqVE READ TH16 APPLIGTION }�{e AMOUNT BHOWN UNOER VALUATION I6 FOR THE
PND BTATE THAT TXQ ABOVE IS CORRECT AND AGRE6 TO COM-
PURPOSE OF EBT0.0LIBHING A PERMIT FEE ONLY.
FLY WITH ALL CITY OROINANLEB AN� STAT¢ IaWB R6pULATINO
Bu1LDIN6 COnBTRUGT�oN. VALUATION
SIGNATURE OF PERMIT FEE $ �6 ' N
PERMITTE ( / J �j m
I l. I� I A.I i. S I b L�J � PLAN CHECK S /<< s
AUTHORIZED