HomeMy WebLinkAbout3261 IDAHO LN - Building Permitsa
(714) 754-5273 • Fax (714) 754-4856 • wv+w.ci.costa-mesa��DING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
JobAddress: 3261 IDAHO LN
Suile:
Viciniry:
Primary Occ: R-3 Dwellingsl Cong Res <70 Type of Construction: V-N
Parcel Number: 13906511 Zoning:
Applicant: GROB, DENNIS
Address: 10481RIVINE AV
SUITE 570
NEWPORTBEACH
owner: NORVILLE, GEORGE L
Address 3261 IDAHO LN
COSTA MESA, CA
Contractor: TOTAL QUALITY CONSTRUCTION
Address: �10481RIVINEAV
SUITE 570
NEWPORTBEACH
Zip: 92660
Arch :
Address:
2ip:
Phone:
License:
Phone: 714-866-7623 ISSUED BY:
Zip: 92660
Phone:
Zip: 92626
Phone: 774-866-7623
License: 812634
Eng:
Address:
Status: ISSUED
Applied: 03/13I2006
Issued: 03/132006
Phone:
License:
SCOPE OF PERMIT
DRYWALL REPAIR IN 2 ROOM OF AN EXISTING SFD. WORK TO ALSO INCLUDE REROOF TO INCLUDE RESIDENCE AND ATTACHED GARAGE:
T/O EXISTING WOOD SHAKE ROOF, SHTG AND FELT PER MFGR SPECS, APPLY 40-YEAR COMP SHINGLES. 20 S�UARES
FEE SUMMARY
Plan Check: $0.00
Permit: $139.25
SMIP Res: $0.61
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $139.86
PLANNING & ZONING
SETBACKS
MAIN STRUCTURE Front 0. 0
ACCESSORY Front 0. 0
PARKING Existina: o
Calc Valuation: se,ioo.00
Claim Valuation: Ss,too.00
Rear 0. 0 Left 0. 0 Right 0• 0
Rear 0. 0 Left 0. 0 Right 0. 0
Reauired: 0 Pr000sed: 0
NOTICE: The work authorized by this permit shall comply with all applicable hantlicap access requirements untlar California statutes antl related
regulations. (Ord. No. 92-28, § 1, 1241-92) -
EXPIRATION: This permit shall automatirally expire and become void it work is not commenced wi�hin 180 days, or if work is suspended or abandoned
for a period of 1 BO days.
INSPEC710NS: In order tor Ihe work authonzed under this permit to be considered legal, such work must comply with all applicable codes, and all
raqulred Inspeetions end final approval must be obtained. Failure to obtain inspections and tinal approval will result in ihe expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
WORKERS'COMPENSATON DECLARATON:
I hereby aHirtn untler Denalry ol perjury one of the tollowing dedarations:
❑ I have entl wi�l maintaln e certificate of consent ta selFlnsure lor workers' compensation, as provitled for by sectlon 3700 of the Lebor Cotle, for the pertortnance oi the
work lar whiCh lhis permit i5 issuetl.
❑ I heve and will maintain workers' compensation insuranca, as required by section 3700 of the Lebor Coda, for the pedormance ol the work tor whicti ihis pertnit is issued.
My workers' Gompensation Insurance wrrier antl policy number are:
Carrier.
(Thls se
Policy Number.
�'�.! ceniy that in tha peAo a af the work or hich this permit is issuaq I shell not employ eny person In eny manner so as to becoma subject m the workere'
`1V�CompensatloP laws ot Ca 1 i, a d e II I I IA become sub�ect to lhe workers' compansetio� p�ovisions ot Section 3700 0� the Labor Code, 1 shell tortMvith
com�Iy �wi�th Ihese provisi � "? L
A ;Ilr.a�patu .�'. (' �OBie� �—I.)–Q l7
WARNINa: FAILURE i0 SECUR W NERS' OOMPENSATIIXJ COVEMGE IS UNUW FUL AND SHALL SUBJECT AN EMPIOYER TO CiiIMINAL PENALT1E5l✓MD CML FlNES UP TO IXJE MUNDRED
TMOUSAND DOl1ARE (5/00,000�, IN ADqTION TO THE CQST OF LOMPEfJ$ATIpN, DAN.4GES AS PROVIOED FOR IN SECTION J]OB OF TME LABOR COOE, IMEREST, AND ATTOHNEI"S FEES.
LICENSE� CONTRACTORS DEClARA710N:
I hereby aHirm t�a� I am Ilcensed un er r�i�isions ol Chapter 9(commencing wilh Seclion 70W) of Division 3 of ihe Businp� antl Prolessions Code, and my license is In full
lorce end eflect.� i,c� –N,1� �T .. Cless L`
Ca�traR6fsSfqnai0re�s a 1M� D�g;1 `j–��–�
a�n . v
CONSTRUC710N 4ENDING AGENCY:
❑ I hereby aNirm Ihat ihere is e consWction lending egency for the pertormance of ihe work for which ihis pormit is issued. (Sec. 3097, Civil Code).
Lentler's Neme: Lender's Adtlress:
Signeture: Date:
OWNER-BUILDER DECLARATIONS:
I hereby eMirtn that untler penalry ol perjury that I am EXEMPT FROM 7ME CONTRACTORS LICENSE LAW lor ihe following reason (Sec. 7031.5, Business anC Professions
Code: Any ciry or counry whic� requires e pertnit to consWct, alter, improve, tlomolish, or repair eny strucWra. Drior to its iuuance, elso requires the applicam tor such permit
to file a signed statament that ha or she is licensed pursuaN to tha pmvisions ol the Contractors License Law (Chapter 9(commencing witb Section 7000) ol DMsion 3 01 t�e
Business antl ProfBulons Code) or that �e or sha is exempt therefmm and t�e basls br Ihe ellegea examplion. Any violation ot Section 7031.5 by any applicant tor a pertnit
subjects the epplicant to e civil penalty ot not more than five hundred tlollars ($500).):
❑ I, as owner oi �he property, or my employees wilh weges as �heir sole compensatlon, WILL DO 7HE WORK, entl the struc�ure Is not intentled or oNered tor sale (Sec.
7044, Busine5s and P�olessions Code: The Contractors License Law does not apply to an owner of property who builtls or improves thereon, antl who does such work
himself or herself or Nrough his or her own employees, providetl that such impmvemenis are not iniended or oflered tor sale. If, however, the building or imprwemeni is
sold within one year oi completion, �he owner-builder will have the burden al proving that he or she tlitl not builtl or improve for purpose ol sale.�.
❑ I, as owner of the pmpetly, em EXCLUSIVELV CONTRACTING WITH LICENSED CONTqACTORS to constmct the project (SecJ044, Business antl Pwtessions
Cotle: The con��actors License Ww does not appty to an owner of pmpeny who Duiltls or impmves ihereon, and who contracis for Suth prqeci with a contractor(s)
license pursuRnt to lhe Coniractors License Wws.).
❑ I am exemp[ Under sec. Business antl Pmlessions Cotle lor this reaso�:
Signature: Date:
Owner ID verified by drivefs licensa. Yes ❑ No Oriver'S License No.
Verifitetion of Own��Ship by (typa of tl me I, i.e. - properry taz blll or deetl):
DIVISION OF INDUSTRIAL SAFETY PERMIT CER7IPICA710N:
Expires:
❑ I hereby certity Ihat no excavation live (5) or more feet in dapih inm which e person is required to descen4 wiil be matla in connection with work authoAzed by this
pertni6 and that no builtling structure, scaflolding, lalsework, or demolition or Cismantling thereof, will be more ihan thirty-six (36) leet high. (Chap. 32, Grp 2, An 2, Sec.
341, Tltle 8, Celifornla Atlministrative Cotle).
❑ As owner-builder, I will not employ enyrone to tlo wark whic� would require a permil imm ihe Division ol Industrial Salery, es noted abova, unleu such person hes e
permit to do such work Irom ihe division.
Signeturo: �ate:
Division of Intlusirial Safety Pertnit Numher:
CEHTFlCATE OF COMPLJANCE AND AUTHORQATON OF ENTRY: I certify under penalcy af parjury that I hevo read this application antl state ihat the inlormation given Is
correct. I agrea to comply with all state laws end ciry ordinances relating m building consWction, and eulhodze representatives ol the City of Costa Mesa to enter upon the
abova-descnbed property br inspection puryoses. I egree not lo occupy or ellow occupancy ot any builtling aulhonzed by this permil until finel inspection.
CODE 1. �$v�cnp�YPE
16/8 Fixed Systdm Final Flre Prevention
1266
200
201
202
203
Pool Spa Finel
Flnel Re-Roa�
Finel Block�Ratainfnp We11
Final Factory Fire Place
Final Sign
204 Final Demo��lion
�_1 �III
I/O I . i
., ;
LOOE/ INSPECTIONTYFE
206 Final Mec�enical
20B Finel Plumbing
210 Finel Elocidcal
212 Flnul Ffre Prevanifon
220 Final Planning Approval
222
250
Final Site
Finnl Building/Occupenty
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa��DING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 3261 IDAHO LN
Suite:
Vicinity:
Primary Occ: R3
Parcel Number: 13906511
App�icant: GROB, DENNIS R
Address: 10481RVINE AVE
SUITE 570
NEWPORT BEACH, CA
Owner: GROB, DENNIS R
Address 3261 IDAHO LN
COSTA MESA, CA
Contractor: O W N E R-BU I LDER
Address:
Zip:
Arch :
Address:
Phone:
Type of Construction: V-N
Zoning:
Phone: 714-886-7623
Zip: 92660
Phone: 714-866-7623
Zip: 92626
Phone:
License: 000000
Eng:
Address:
fSSUED BY:
Status: ISSUED
Applied: 04/1 B/2006
Issued: 06/02/2006
Phone:
Zip: License: License:
SCOPE OF PERMIT
ADD 858SF TO SFD. WORK TO INCLUDE: ADDITION OF MASTER BEDROOM WITH WALK-IN CLOSET, MASTER BATHROOM AND GREAT ROOM.
2,882 S.F. BLDG.
400 S.F. DRIVEWAY
2,718 S.F. OPEN SPACE (45%)
Plan Check: $554.94
Permit: $853.75
SMIP Res: $7.93
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $1,416.62
SETBACKS
MAINSTRUCTURE Front 0-0
ACCESSORY Front 0- 0
PARKING Existina: o
FEE SUMMARY
PLANNING 8 ZONING
Rear 20- 0 LeR 0- 0
Rear 0- 0 Lek 0- 0
Reouired: 0 Pr000sed: 0
Calc Valuation:
Claim Valuation:
Right 5-0
Right 0-0
$�s,2�s2o
So.00
NOTICE: The work aUthorized by this permit shall comply with all applicable handicap access requirements under California stat tu es end related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically ezpire and become void it work is not commenced within 780 days, or if work is y��ed or abandoned
I for a period ot 180 days. G-J
� INSPECTIONS: In ord�r for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspeetions and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of Ihis permit.
FOR INSPECTIONS CALL: (714) 7545626
WORKERS'COMPENSAnON DECLARArON: " '
I hereby attirtn under penalry oi perjury ona ot the following declaretions:
❑ I have end will meintain e certificate ot consent to self-Insure for workers' compensation, as proviAed for by section 3700 of Ihe Labor Code, tor iha pertormance of the
work for which Ihis p8rmii i5 issued.
❑ I have entl will meintain workeB' compansaiion insurance, as required by section 3700 oi the Lebor Cotle, lor Ihe peAortnance ol Ihe work for which this pertnit is issuetl.
My workers' compensation Insurence cerner ena policy number are:
Cartier. Policy Numbar.
(This section need not be completed i! the permit is velued et one buntlretl tlollars ($f 00) or Iess.)
'� - 1 tetlily �ha� in �he p dortnanc f th work lor which this permit is issueQ I shall not employ any pereon in any manner so es to become subject to the workers'
,__compensation laws Califomi e gree that ii I shoultl become sub�ect to the workers' compensetion provisions o� Sectlon 3700 ot the Labor Cotle, I shall lorthwith
comply with theso �si n /
Applicant SfBnature:--.+ r Date: l� �_��
WARMNG: FAILURE TO $ CURE WORKERS' COMPENSATION COVERAGE IS UNLFWFUL AND SMP1.L SUBJECT PN EMPLOYER TO CRIMINr1L PENALTIES AND GVIL FlNES UP TO IXJE HUNDRED
TKKISAND OOLLARE (El W.�l. IN ADDfTION TO THE COST OF COMPENSATION, �AMNGES AS PROVIDED WR IN SEGTION 3IO60F THE LABOR CODE, IMEREST, AND ATiORNE1^S FEES.
LICENSED CONTRACTORS DECLARA710N:
I hereby aHirm that I am licensed under provisions ol Chapter 9(commencing with Section 7000) ot Division 3 of the Business and Professions Code, antl my licensa is in tull
torce and ettect Lic. a Class q
Contractofs Signawre: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby aHirm thEl there is a conslruction lenaing agency for the peAormance ot ihe work tor w�ich Ihis pertnit is issuad. (Sec. 3097, Civil Code).
Lendefs Name: Lentler's Adtlress:
Signa�ure: Date:
OWNER-BUILDER DECLARATIONS:
I here6y aHirm that under penalry of perjury Ihat I am E%EMPT FROM 7HE CONTRACTORS LICENSE LAW for the followiog reason (Sec. 7Q31.5, Business artd Pmtessions
Cotle: Any ciry or counry which requires a pertnit to construct, alter. improve, tlemolis�, or repair any sWcture, pnor to its issuance, also requires the aOPlicant tor such pertnit
to tile a signed statement Ihat he or she is licensed pursuem to the pmvisions of t�e Conlractors License Lew (Chapter 9(commencing with Section 7000) ol Division 3 ot the
Business antl Professinns Code) or thet he or she is e:empt therefrom and lhe basis for the elleged exemption. Any violation of Section 7031.5 by any appliwnt for a permit
ysubjects the applicant iP a civil penalty of not more than five hundred tlollers ($500).):
,�I � I, as owner of Ihe property, or my employees with wages as their sole compenselion, WILL DO TME WORK, and lhe stmcture is not intended or ottered for sale (Sec.
�7044, Business and Professions Cotle: The Contractors License Law does noi apply Io an mvner ot properry who builtls or improves Ihereon, and w�o dces such work
himselt or herself or through his or her own employees. provided ihat such improvemems are no� Intendad or oNered for sale. Ii, however, ihe building or improvemem is
soltl within one year of completion, the owne�-builder will have ihe burdan of proving that he or she did not build or improve lor puryose of sele.).
❑ I, as owner of the property, em E%CLUSIVELV CONTRACTINC WITH LICENSED CONTRACTORS to construct lhe p�oject (Sec. 7044, Business and Professions
Code: The contractors icense Lew tloes not epply to en owner of propetly who builtls or improves thereon, and who contracis for such prolect wiN a coniractor(s)
license pursuant t�lhe ontractors Licensa Laws.).
❑ lam
Business and Protessions Code for ihis reeson:
Dare:
Owner ID verified by dn�ar's license. -�Ves ❑ No
Verification of Ownership �y Qype ol tlocument, i.e. - property taa biil or deed):
DIVISION OF INDUSTfl�AL SAFETV PERMIT CERTIFICATION:
❑ I hereby cenity tha� no ezcavation five (5) or more feet in tlepth into which e person is required lo descend, will be made in conneclion with work authorized by ihis
permit, end that no building sWc�ure, scaflolding, lalsework, or tlemolition or dismantling thereol, will be more ihen Ihiny-six (36) feet high. (Chap. 32, Grp 2, Art 2, Sec.
341, TiBe 8, Celiftl�nia Atlministreliva Cotle).
❑ As owner-builder, I will not employ anyone to do work which woultl require e permit from the Division ol Industrial Sefety, as notad above, unless such person has a
permit to tlo such work fmm ihe division.
SignaWre: Data:
Division of Intlusirial Sa�ery Permit Number:
CODE I. INSPECTIOHTYPE
1676 Fixed System Final Fire Prevention
1266 Pool Spa Final
200 Final Re-Raof
201 Final BIocWRetaining Well
202 Final Factory Fire Place
203 Finel Sign
204 Final Demolition
QAjE INTRIALS
SODE� INSPECTIONTYPE
206 Final Mechaniral
208 Final Plumbing
210 Final Electncal
212 Final Fire Prevantian
220 Final Planning Approval
222 Final Site
250 Final Builtling/Occupancy
�.1 JW_
f ' �
�� � L''a�ta �2eda �'u,%�'du� Dic�i¢io�
OWNER-BUILDER
VERIFICATION
CAddress: _�1--�-1� � �� T� /� ii Permi[ #:
A city or county, which is required to give notice pivsuant ro Section 19830, shall attach to such notice, and, as
a condition precedent to issuing a building pennit, require the completion and require the retum 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 retum this infomiation in the envelope provided at your earliest opportunity ro avoid
unnecessary delay in processing and issuing your building permit. No buildine permit will be issued until this
verification is received. �
��1 personally plan to provide the major labor and materials for consm�ction of the proposed
property improvement. � Yes ❑ No
(—? �?I (have/have not)1�%/4 �/ Q� signed an application for a building pertnit for
the proposed Work.
3. I have contr2cted with the following person (fimi) to provide the proposed construction:
Name
Address
Phonc ( )
City _
Contractor's Lic. No.
4. 1 plan ro pro�ide portions of Ihe work, but 1 have hired the following person to coordinate,
supervise and provide the major work:
Name
Address _
Phone ( )
City _
Con[racror's Lic. No.
5. 1 will provide some of Ihe worh but I have contracted (hired) the following persons to
provide the «'ork indicated:
Name
t042<6 �Rev.tl/04�
Address
Phone Type of �Vork
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
ELECTRICAL PERMIT
Job Address:
Suite No
Vicinity:
Parcel Nunmber:
Applicant:
Address:
Owner:
3261 IDAHO LN
MASTER BEDROOM
13906511
GROB, DENNIS
1048 IRVINE AVE
SUITE 570
NEWPORT BEACH, CA
GROB, DENNIS R
Address 1048 IRVINE AVE
SUITE 570
NEWPORT BEACH, CA
Contreaor: OW NER-BUILDER
Address:
ISSUE FEE
Temp service test
Res. alc package
New Res (1-2 units)
New Res (3+units)
Pool / Spa
Lighting Fixts
Recept Outlets
Switches
Non Res Appl
Res Appl
Service to 200a
Service to 1000a
Service over 1000a
Motors to thp
Motors to tOhp
Motors to 50hp
Motors to 100hp
Motors over 100hp
Communication drops
Sub panel to 200a
Pole Light Pkg
Sign Circuits
Temp Pwr Pole
Intermed Pole
ISSUED BY:
Phone: 714-886-7623
Zip 92660
Phone: 714-886-7623
Zip: 92660
Phone:
Zip:
License: 000000
Status: ISSUED
Applied: O6l02/2006
Issued: O6/02/2006
SCOPE OF PERMIT
ELECTRICAL PERMIT TO ADD 858SF TO SFD. WORK TO INCLUDE: ADDITION OF MASTER BEDROOM
WITH WALK-IN CLOSET, MASTER BATHROOM AND GREAT ROOM.
REF#:BO6-00583
WORK TO INCLUDE: 6 LIGHT FIXTS, 24 OUTLETS, 9 SWITCHES AND 1 SERVICE TO 200A.
823.50
$0.00
$0.00
$0.00
$0.00
$0.00
$6.60
$24.92
59.90
$0.00
$0.00
$30.50
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
50.00
$0.00
$0.00
$0.00
$0.00
Quantity
0
0
0
6
24
9
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
FEE SUMMARY
Temp Dist System / Lighting
Busway /100 ft
Standing Sedion
Misc Eledrical Equipment
Transformers up to 1 kva/kw
................up to 10 kva/kw
.................up to 50 kva/kw
.................up to 100 kva/kw
..................over 100 kva/kw
Low Voltage Equipment
Low Volt Wiring Sysiem / Ckt
Misa Conduit
Misc. Conductor
Cirws ( gen or ride)
Circus (mech ride or lights)
Christmas Tree Stand
Fireworks Stand
Other Electrical Fee
Investigation Fee
Plan Check Fee
Reinspection Fee
$0.00
$0.00
$0.00
50.00
50.00
$0.00
$0.00
$0.00
$0.00
$0.00
50.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
TOTAL CALCULATED FEES E95.42
Quantity
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and-related
regulations. (Ord. No. 92-28, § 7, 12-21-92) �
EXPIRATION: This permit shall automatically expire and become void il work is not commenced within 180 days, or if work is suspende�abandoned
for a period ot 180 days. /
INSPECTIONS: In order for the work authorized under ihis permit to be considerad legal, such work must comply with all��licable codes, and all
required inapeetlona and final approval must be obtained. Failure to obtain inspections and final approval will resull in tha ezpiration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626
WORKERS'COMPENSAnON DECLARATION:
I hereby aflirtn under penalry of perjury one of t�e followinq declarations:
❑ I have end will meintain e certilicate of consent to self-Insure tor workars' compensation, es provided for by section 3700 of the Labor Code, for the peAormance of the
work for which ihis permit is issue0.
❑ I have and will mainlain workers' compensation Insurance, as required by section 3700 of che Lebor Code, for the peRortnance ot Ihe work tor whiU this pertnit is issuetl.
My workers' compensatlon Insurence carner entl policy number are:
Carrier: Policy Number:
(fhis seclion need nol be completetl il the permit is velued ef one hundred dollars (S )00) or /ess.)
� I cetlity ihat in ihe pertormence ol th work� r which this permit is Issued, 1 shell not employ any person in any manner so as to become subject to t�e workers'
compensetion laws Celitomia, end re t t il I should become subject to the workers' compensation provisions ot Section 3700 of the Labor Code, 1 shall forthwith
comply with ihesa p ons. ` C _^I ��
Applican� Signature: ��. l�l� Da�e: Ll �`
WARNINO: FAILURE TO SEC R ORKERS' PENSATIO COVERAGE IS UNLAWFUL AND SHA�L SUBJECT AN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FlNES UP TOONE HUNORED
THOUSAND DOLLAFE (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAM4GE$ A$ PROVIDED FOP IN SECTION 3]O60F THE LABOR CODE, IMEREST, AND ATTORNEV'S FEES.
LICENSED CONTRACTORS DECLARATION:
I herehy aHirm that I am licensed under provisions of Chaptar 9(commencing with Section 7000) of Division 3 of the Business antl Professions Cotle, and my license is in lull
force and ettecL Lic. N Cless n
Contractor's Signature: Date:
CONS7RUC710N LENDING AGENCY:
❑ I here6y aflirm ihat ihere is a consWciion lending agoncy br ihe pedormance of ihe work for w�ich ihis permit is issuetl. (Sec. 3097, Civil Coda). �
Lendefs Name: Lentler'S Adtlress: ��
Signature: Data: '
OWNER•BUILDER DECLARA710NS:
I here6y attirtn iha[ under penalry of perjury Ihat I am EXEMPT FROM TME CONTRACTORS LICENSE LAW for the tollowing reason (Sec. 7037.5, Business antl Professions
Cotle: Any ciry or county which requires e pertnil to consiruct, aller, improve, demolish, or repair eny strucWre, pnor to its issuance, also requires the applicant tor such pertnit
to file a signed statement lhet he or she is Iicensed pursuant to the provisions of tha Coniractors License Law (Chapter 9(commencing with Section 7000) of Division 3 ot the
Business and Professions Code) or t�at he or she Is exempt t�erefmm end the basis tor the allegetl ezemption. Any violation ot Seclion 7031.5 6y any applicant tor a pertnit
subjects the applicant to a civil penalty of nol mora than tiva hundretl tlollars (5500).):
(� I, as owner of the property, or my employees with weges as iheir sole compensation, WILL DO THE WORK, and ihe structure is not intendetl or oflered tor sale (Sec.
7044, Business and Professions Code: The Contrac�ors License Law dces nol apply to an owner of property who builds or impwves thereon, anC who dces such work
himself or �ereell or ihrough his or her own employees, provitle0 that such improvemenis ere not intended or oHered for sale. If, however, ihe building or improvement is
sold within one year of completion, Ihe owner-builder will have ihe burden of proving that he or she did not builtl or improve tor purpose of sale.).
❑ I, as owner oi the property, am E%CLUSIVELV CONTRACTNG WITi1 LICENSED LONTRACTORS to wnstruct the project (Sec. 7044, Business and Professions
Code: The contractors License Lew tloes not epply to en owner of property who builtls or Impmves thereon, antl who contracts for such projact with a conirector(s)
license pursuant to tha Contractors Licensa Lews.).
❑ I am exe t under se Business antl Protessions Code for this reason:
Signatura: - Dat � —
Owner ID ven ietl by tlnvels li anse. Ves ❑ No Drivels License No E:pires: � `
Verification of Ownership by (type of daum t, i.e. - propetly taz bill or deetl):
DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION:
❑ I hereby certily �hat no excavation five (5) or more feet in depih into which e person is requireC to descend, will be matle in connec�ion with work authorized by this
permit, antl that no builtling strucWre, scalloltling, talsework, or demolition or dismantling �hereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Ttle B, California Atlministrative Cotle).
❑ A5 owner-builder, I will not employ anyone to tlo work which would require a permil irom ihe Division ot Industrial Safery, as noted ebove, unless such person hes e
permit to do such work Irom the division.
Signature: Date:
Division of Industnal Safey Permit Number.
CERTIFlCA OF COMPUAN E I D AUiHORIZA710N OF ENTRY: I cenity unaer penalty ol perjury that I have read this application and state Ihat the infortnation given is
correct. I agr to wmply witl II ate laws and ciry ordinences relating to building consiruction, and authonze representatives oi the City ot Costa Mesa to enter upon the
above-descn r e tor i p ion purposes. I agree not to occupy or ellow occupancy of any builtling auth nzed by this permit umil final inspection.
Sia re OI Leaal Owner(51 �� Date
AnNOr Auihonzed AppliWn�
COpE t, INSPECTONTYPE Q�¢, ��j
7616 Fixed System Final Fire Prevention
1266
200
201
202
203
Pool Spe Final
Final Re-Rool
Final BIocWRetaining Well
Final Factory Fire Place �
Final Sign
204 Final Demoli�ion
CODE� INSGECTIONTYPE
206 Final Mechanical
208 Final Plumbing
210 Final Electrical
212 Final Fire Preventlon
220 Final Planning Approval
222 Final Sile
250 Final Building/Occupancy
eei� �ne�s
: ' ALY�
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address:
Suile No
Viciniry:
Parcel Number:
Applicant:
Address:
Owner:
Address:
Contractor:
Adtlress:
3261 IDAHO LN
ADDITION
13906511
GROB, DENNIS
10481RVINE AVE
SUITE 570
NEWPORTBEACH,CA
GROB, DENNIS
10481RVINE AVE
SUITE 570
NEWPORTBEACH,CA
OWNER-BUILDER
MECHANICAL PERMIT
Phone: 714-886-7623
Zip: 92660
Phone: 714-866-7623
Zip: 92660
Phone:
Zip:
License: 000000
ISSUED BY:
SCOPE OF PERMIT
MECHANICAL PERMfT TO ADD 858SF TO SFD. WORK TO INCLUDE: ADDITION OF MASTER
BEDRDOM WITH WALK-IN CLOSET, MASTER BATHROOM AND GREAT ROOM.
REF#:BO6-00583
WORK TO INCLUDE: 1 REPAIR/ALT COOLING/HEAT AND 3 VENT FAN/SINGLE DUCT.
ISSUE FEE
Inst FAU <100 k BTU
Inst FAU >100 k BTU
Repair/Alt CoolingMeat
Inst / Rep. Recess Wall Htr
Refrig Sys <100 k BTU
Refrig Sys >100 k BTU
Gas Piping
Factory Fireplace
Hood w/Mech Exhaust
VAV Box
Vent Fan I Single Duct
Appliance
Fire Dampers
Smoke Dampers
Inst or Relocate Appl Vent
Air Handlers < 10000cfm
AirHandlers> 10000cfm
Floor Furnace
Floor or Suspend Heater
$23.50
$0.00
$0.00
$13.70
50.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$21.75
$0.00
50.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Quantiry
0
0
1
0
0
0
0
0
0
0
3
0
0
0
0
0
0
0
0
FEE SUMMARY
Repair / Alt A6sorbtion Unit
Repair / Alt Refrigeration Unit
Ventillation System
Evaporative Cooler
Commercia l I nci nerator
Domestic Incinerator
Comnressors / Absorotion SVstems
Upto3hpl100kBTU
3 To 15 hp / 500 k BTU
15 To 30 hp / 7,000 k BTU
30 To 50 hp / 1,750 k BTU
Over 50 hp / Over 1,750 BTU
Boilers
Up to 3 hp
3To15hp
15 to 30 hp
30 to 50 hp
Over 50 hp
Other Mechanical Fee
Investigation Fee
Plan Check Fee
Reinspedion Fee
TOTALCALCULATEDFEES
Status: ISSUED
Applied: O6/022006
Issued: O6/02/2006
�uantiry
$0.00 0
50.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00
$0.00
$0.00
558.95
NOTICE: The work aWhorized by this permit shall comply wilh ali applicable handicap access requirements under Califomia statutes and related
regulations. (Ord. No. 9248, § 1, 1247-92) -�
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 7 BO days, or if work is suspend� abandoned
tor a period of 7 BO days. //
INSPECTIONS: In order for ths work authorized under Ihis permit to be considered legal, such work must comply with all applicable codes, and all
requlred Inspectlona and final approval must be obtained. Failure to obtain inspections and final approval will result in ihe expiration of this permit.
FOR INSPECTIONS CALL: (71A) 7545626
cano-co {aw�
WORKERS' COMPENSA'nON DECLARATION: '
I hereby affirtn under'pena�ry ol periury one oi the followinq tleclarations:
❑ I heve end will maintain a certiticata of consent to sell-Insure for workors' compensation, as pmvidad for by section 3700 of the La6or Code, tor the pertormenca oi the
work lor which lhis permit is issued.
❑ I have end will mainidin workers' compensation insurance, as requiretl by section 3700 of the Lebor Cotle, br the pertormance ol the work br which this pertnit is issued.
My workers' compensation Insurance carner antl policy number ere:
Carner. Policy Number:
(This section need not be camplefed i! fhe pelmit is valuetl et one hundred dollers ($100) or less.)
$� I certily that in the p6dormance ot the w c br which this permit is tssued, I shall not employ any person in eny manner so as to become suDjecf to Ihe workers'
compensatlon laws 0� Ca' omia, and aq ihei if I should become subjact to l�e wotkers' compensation pmvislons of Section 3700 0� �he Lebor Code, I shall totlhwiih
compty wit� t�ese prohsi s. /
Applicen� Signalure: �1 Date: [� ��
WARNING: FNLURE TO SECUR ORKEPS' COMPE! ON COVERAGE IS UNLAW FUL AND SHAl1 SOBIECT AN EMPLOYER TO CRIMINAL PENALTIE$ M1D CNIL FlNES UP TO ONE HUNDRED
THOUSAND OOLLARE (E100.0�I� IN ADDITION TO THE WST OF COMPENSATION, DAMhGES A$ PROVIDED f-0R IN SECTIIXJ 31060F THE LABOR COOE, IMERESi, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
1 hereby aflirm that I am licensed under provisions of Chapter 9(commencing with Section 7000) ol Division 3 of the Business and Professions Code, antl my license is in full
force end eRect Llc. # Class k
Conirac�or's Signeture: Date:
CONSTRUCTION LENDING AGENCY:
❑ I herehy aHirtn ihat there is a construction lending agency for the performance ol ihe work Por which this pertnii is issued. (Sec. 3097. Civil Code).
Lenders Neme: Lender s Address:
Signature: Data:
OWNER-BUILDER DECLARATIONS:
I hereby ettirm ihat under penalty of perjury thet I em EXEMP7 FROM 7HE CONTRAC70RS LICENSE LAW for ihe following reason (Sec. 7031.5, Business and Professlons
Cotle: Any ciry or counry which requires a permit fo construct, alter, improve, demolis�, or repair any structure, pnor to its issuanca, also requires the applicant tor such pertnit
to file e siqnetl stetement that he or she Is licensed pursuem to the provisions of t�e Contracmrs License Law (Chapter 9(commencing wil� Sectlon 7000) of Division 3 of ihe
Business antl Professions Cotle) or ihet he or she is exempt ihereirom and Ihe basis br Ne elleged e:emption. Any violation oi Section 7031.5 by eny appliwnt for a permit
Msubjects t�e applicant to a civil penalry of not more ihen five hundred tlollars ($500).):
G� I, as owner of Ihe prOperty, or my employees with weges es their sole compenselion, WILL DO THE WORK, and the stmcture Is no( Intentletl or oHeretl for sale (Sec.
, 7044, Business and P�ofessions Code: The Coniractors License Law does no� epply to an owner ol propeny who builds or improves Iheraon, antl who does such work
himsell or herselt or (hrough his or her own employees, providetl ihat such impmvements are not intendetl or oHered lor sale. If, however, Ihe building or improvement is
soltl within one year of wmpletion, the owner�builder will heve the burtlen of proving thet he or she did not build or improve for puryose of sale.).
❑ I, as owner ot the property, am EXCWSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Cotle: The comractols License Lew tloes not epply to an owner ol propeny who builds or improves ihereon, and who comracts for such project with a comractor(s)
license pu�ent to tne Contraaors Licanse Lews.).
❑ I am exem� der c. Business and Professions Code for this reeson:
Signawre: � b
Verification of Ownership by (rype of documem, i.e. - pmpeny tax bill or deetl):
DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION:
Expires:
❑ I hereby cenify tha� no excavation five (5) or more feet in depih into which a person is requiretl to descend, will be made in connection with work euthoriied by ihis
pertni6 end Ihet no building stmcture, scaMolding, falsework, or demolition or tlismantling �hereof, will be more than ihiny-siz (36) feel hig�. (Chap. 32, Gry 2, Art 2, Sac.
341, Title 8, Califomi8 Admini5trative Code).
❑ As owner-builtler, I wi�l not employ anyone to tlo work which would reQuire a permil irom the Division of Industnal Safary, es notetl above, unless such person has a
pertnit ta do such wo�k from ihe division.
Signature: Date:
Divisian ot Indusirial Safery Pertnit Number.
CERTIFlCATE OF COMP CE ANO AUTHORIZATION OF EMTAY: I certity under penalry ot perjury ihat I have read ihis epplication antl state ihat the information given is
correct. I eg �e b comply i e �ate laws and city or0inances rela�ing to building consiruction, end eNhonze representatives ol t�e City of Costa Mesa to eNer upon the
ebove-desq ed pmperry to !) i ryoses. I agrea not to occupy or allow occupancy ol any building auihorizetl by t is permit until final ins0e���on.
_ �-a - o�
, Si9n ture Ot Legal Owner(s) Date
AnNOr Auihonzed Applican�
COOE �, INSFECTIONTYPE
1676 Fixetl System Final Fire Prevention
7266 Pool Spa Final
200 Finel Re-Raof
207 Flnel Block/Retaining Well
202 Final Factory Fire Place
203 FinalSign
20a Final Demolition
OATE TITIpL
CODE I INSVECTION TYPE
206 Finel Mechanical
20B Finel Plumbing
210 Finel EleUrical
212 Final Fire Preventlon
220 Final Planning Approval
222 Final Sita
250 Final Building/Occupancy
(714) 754-5273 • Fax (»a) �sa-aess - www.ci.costa-mesa.PcLUMBING PERMIT �� FAIR DRIVE, COSTA MESA, CA 92626
Job Address:
Suite No
Viciniry:
3267 IDAHO LN
ADDITION
Parcel Nunmber: 13906571
App�icant: GROB, DENNIS
Address: 10481RVINE AVE
SUITE 570
NEWPORT BEACH, CA
owner: ��%7%�:�Q,l�1+1i5 -.
Address r��'�_i(J; ��>�f,zy
�Izw�!+� �i'� �GI�
�,?�'� h'ID--
Contractor: O W N ER-BU I LDER
Address:
Phone: 774-886-7623
Zip: 92660
Phone: �% I'� ' �%`�i:�'��''�
z�P:G{ ��(�(E'c7
Phone:
2ip:
License: 000000
Stalus: ISSUED
Applied: O6/02/2006
Issued: 06/02/2006
a
ISSUED BY:
SCOPE OF PERMIT
' PLUMBING PERMIT TO ADD 858SF TO SFD. WORK TO INCLUDE: ADDITION OF MASTER BEDROOM
WITH WALK-IN CLOSET, MASTER BATHROOM AND GREAT ROOM.
REF#:BO6-00583
WORK TO INCLUDE: 1 BATHTUB, 1 SHOWER, 2 WASH BASINS AND 1 WATER CLOSET.
ISSUE FEE
Backflow irrigation
Backflow Preventer
Bathtub
Clarifier System
Connect (Ice,Soda,etc)
Dental Units
Dishwasher
Drain, Floor
Drain, Rainwater
Drain, Roof
Drinking Fountain
Expansion Tank
Gas Earthquake Valve
Gas (1-4 outlets)
Gas (Over 4 outlets)
Gas Repipe
Gas Service
Interceptors (Grease, Oil)
Interceptors (Sand Auto )
AMT
$23.50
$0.00
$0.00
$9.80
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
50.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
gN
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
FEE SUMMARY
AMT
Laundry Tub / Washer $0.00
Landscape Irrigation -$0.00
P-Trep $0.00
Pressure Regulator $0.00
Process Piping (per 10 N) $0.00
Receptors $0.00
Septic Tank $0.00
SewerCapforDemo $0.00
Sewer Conneol $0.00
Sewer Privale Line $0.00
Shower $9.80
Sink, bar $0.00
Sink, wmmercial $0.00
Sink, Floor $0.00
Sink, kitchen $0.00
Sink, service/mop $0.00
Spa (private) $0.00
Spa (public) $0.00
QTY
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
COMMENTS / SPECIAL CONDITIONS
Sump Pump
Swimming Pool
Trap Primer
Urinal
Vacuum Brkr BkOow(1�)
Vacuum BrkrBkFlow(5+)
Wash Basin
Wash Basin Set
Waste and Vent System
Water Closet (Toilet)
Water Heater / vent
Water Piping pnst or RepJ
Water Re-pipe
Water Service
Water Sokener
OTHER
VIOLATION
PLAN CHECK
REINSPECTION
ti�lllt9_LS1�1��V ��ltl �X-'i
AMT
$0.00
$0.00
$0.00
$0.00
$0.00
so.00
$19.60
$0.00
$0.00
$9.80
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
b72.50
orv
0
0
0
0
0
0
2
0
0
1
0
0
0
0
0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes' and related
regulations. (Ord. No. 92-28, § 1, 12-21-92) i'
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspen/or abandoned
for a period of 180 days. /
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applibable codes, and all
required inspectlons and final approval must be obtained. Failure to obtain inspections and final approval will resWt in the expiration ot this permit.
FOR INSPECTIONS CALL: (714) 7545626
WORKERS'COMPENSArON DECLARAnON:
I hereby aHirtn under penalty of perjury one of ihe following declarations:
❑ I have antl will main�ai� e certificate of consent to sel6lnsu�e tor workers' compensation, es provided for 6y section 3700 of Ihe Labor Cotle, for tha pertormance of the
work for which this permit is issued.
❑ I �ave and will maintaiP workers' compensefion insurance, as required by section 3700 of tha Labor Code, for tha pedortnance of the work for which this pertnit is issuea.
My workers' compen5ation Insurance carrier and policy number ere:
Carrier: Polity Number:
(This section need nat be cOmpleted i/ the permif is valuetl at ane hundred dallars ($700) or /essJ
FA I certify Ihat in the pedo�mance oi Ihe work for which this permit is issued, I shall not employ eny person in any manner so as to become sublect to ihe workers'
�� ` compensation laws of alNornia, an� 1 should become subjacl to ihe workers' compensation pmvisions ot Section 3700 of the Labor Code. I shall forthwith
comply with ihese pr� ions.
Applican� Signature: A, n � Da�e: �— ���
WARNING: FAILURE TO SEC qE WORKE SAiION CAVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FlNES UP TOONE HUNORED
THOUSAND OOLLARE (E100.0001. IN ADDITION TO THE COST OF CAMPENSAiION, OAMNGES AS PFOVIDEO FOq IN SECTION 3]O6 pF THE LABOR CODE, IfJrEREST, M!D ATTORNEI^S FEES.
��. LICENSED CON7RACTORS DECLARATION:
', bhereby attirm that I am lice�sed under provisions of C�apter 9(commencing with Section 7000) of Division 3 of Ihe Business antl Professions Cotle, and my licanse is in full
'� force end effect. Lic. x Class a
Contractor's Signature: �ate:
CONSTRUCTION LENDING AGENCV:
❑ I hereby affrtn that thpre is a construction lending agency for ihe pertormance of the work tor which ihis pertnit is issued. (Sec. 3097, Civil Code).
Lender's Name: Lender's Address:
SignaWre: Date:
OWNER-BUILDER DECLARATIONS:
I hereby aHirtn that untler ppnelry of perjury fhat I am EXEMP7 FROM THE CON7RAC70RS LICENSE LAW for the following reason (Sec. 7031.5, Business antl Professions
Cotle: Any ciry or counry which requires a permit fo consiruct alter, improve, demolish, or repair any stmcWre, prior to its issuance, also requires the applicant tor such pertnit
to file a signed statement that he or she is Ilcensed pursuant to ihe provisions ot the Contractors License Law (Chapter 9(commencing with Seclion 7000) of Division 3 of Ihe
Business and Professions Gode) or that he or she is enempt therefrom antl t�e basis for the allegetl exemption. Any violetion of Section 7031.5 by any applicant for e permit
sublecis iha appiicant to e ci�il penalty of not more Ihan five hundred dollars ($500).):
�I, as owner of the propeny, or my employees with wages as Iheir sole compensation, WILL DO 7HE WORK, and Ihe simcWre is not intendetl or ofleratl for sale (Sec.
7044, Business and Pfofessions Cotle: The Contractors License Law dces not apply to an owner of property who builds or improves ihereon, and who tices such work
himself or herself or through his or her own employees, providetl ihat such improvements are not intended or oflered for sale. If, however, the 6uiltling or improvemem is
sold within ona year of completion, ihe ownerbuilder wiil have the burden of proving that he or she ditl not build or improve for purpose of sale.).
❑ I, as owner of ihe properry, am E%CLUSIVELV CONTRACTING WITH LICENSED CONTRACTORS to consiruct the project (Sea 7044, BuSiness antl Professions
Code: The contractors License Law does not epply to an owner of property who builtls or improves ihereon, and who contracis for such project with a coniractor(s)
license pursuant to Ihe �ontractors License Laws.).
❑ I am exempt��er se Business and Professions Code br ihis reason:
Siqnature: � ,� J
Owner ID veritied y driver's license. ❑ Ves ❑ No Driver's License No.
Verification ot Ownership by (�ype ot tlocumen�, i.e. - pmperty tax bill or deed): �
DIVISION OF INDUS7RIAL SAFETY PERMIT CERTIFICA710N:
Ezpires:
❑ I hereby cenify that no excavation five (5) or more feet in tlepth into which a person is required to tlescentl, will be matle in connection wi�h work authonzed by this
permit, and �hat no building structure, scaHolding, falsework, or demolition or dismantling �hereof, will be more Ihan thiny-siz (36) feet hig�. (Chap. 32, Grp 2, Art 2, Sec.
341, 7iile e, Catltornia Atlminisirative Cotle).
❑ As ownervbuilder, I will not employ anyone to do work which would roquire a permit irom ihe Division of Industriel Safety, as noted ebove, unless such person hes e
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Num6er:
CERTIFICA7E OF COMPLI NCE AND AUTHORIZA710N OF ENTRV: I certify untler penalty ol perjury thai I have read this application antl state that the information given is
correct I agr to comply i a� state laws end ciry ordinances relaling to builtling consiruction, end authonze representatives of Ihe City oi Costa Mesa to enter upon ihe
above-describ property o i sp ction puryoses. I egree not to acupy or allow occupancy of any 6uilding authorized by this permit until (inal inspection.
�'a..�O f.
re � IOwner(s) � Dete
And/Or Authorized Applican� Da�a
COOE �. INSPECTIONTYPE
1616 Fised System Final Fire Prevention
1266 Pool Spa Final
200 Final Re-Roof
201 Fina1 81ocWRetaining Well
202 Final Factory Fire Place
203 Final Sign
204 Final Demoli�ion
AI�TE IMRIALS
LODE� INSPECTIONTYPE
206 Final Mechanical
208 Final Plumbing
210 Final Electrical
212 Final Fire Prevention
220 Final Planning Approval
222 Final Site
250 Final Building/Occupancy
�TE IMffULS
: /�
Lor 21
JR 37�� .
� � � 13134
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 977 C08TA MEBA. CALIFORNIA
For Applicanf io Fill In Compleiely
TYPE OR PRINT
BUILDING 326� �DAHO LANE
ADDRE55
C05TA MESA. GALIFORNIA
nwuro K $� � DEVELOPMEN7 CO.�ING.
r:
■ STATE . _ _ . _ TEL,
(OX 1 �0 I no, ov e�oae. p
r�ew nu i m
USE OF
EXISTING BLDG �
68TBACN LINe PnOM �O� 20�
CEMew OP srn6Hi REqR YARD
SIDE YARD I LEFY S/ I RIGHT S,
DESCRIPTION AF WORK
� �� � ����ED
FINANCE DEPT.
CITY OF COSTA MESA
APPLICATION FOR PERMIT
BUILDING
For Office Use Only
NECEIPT NO. PEPMIT NO.
nccs� o ar
BUILDING
FIRE
GOSTA MESA. CALIFORNIA
TYPE
ZONING
20NH NO. OF I U6E OP NEW
R�1 PLANB 2 BO�LDING `
tHOAt _ . __ _
(CBNTHR LINH 8TJ
APPROVED
�
BUILDING 4 �'AR NO. OF /
BiZE � + SE ROOMS O STORIES �
EXTERIOR Wql{. I ROOF WOOD SH I NGL ES
COVERING JL COVERING
USE OF BUILDIN6 9ND WORK TO BE PERFORMED
Sia le �'amil Resi e ce an
�ttatc e
PLAN 3-C
I HEHEBY ALKNOW��Ge TXAT 1 HAVE READ THI9 APPlJGT10N T�{g AMOUM BHOWN UNDER VALIIAT�ON �e FOR TH8
AND BTATE THAT YME ABOVE IB CORPER AND AOR¢E TO COM- pURPOBE OP EBTABLIBXING A PERMIT FEE ONLY,
PLY WITH ALL CIT'r OfiDINANGE6 AN BTATe WB R80ULATINO
BU�LDINo coNeTR o VALUATION /
SIGNA7URE OR /// //�� � PERMIT FEE $ ���/ �
PERMITTE $ Y��p/ % V -
� d/ �• PIAN CHECK S ��
AUTHORIZED AGENT ___ ___ T ,S-/�J`