HomeMy WebLinkAbout2858 INROZ DR - Building Permits*. r. MF CITY OF COSTA MESA
� 9p BUILDING D/VISION
F� � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754�856 • www.costamesaca.00v
�. � FOR INSPECTIONS CALL: (714) 754-5626
~�"'�"°�� PERMIT NUMBER: P12-00204
PERMIT TYPE PLUM STATUS: ISSUED
APN: 13944405 DATE ISSUED: 11114I2012
. ISSUED BY: MDM
JOB ADDRESS: 2858 INROZ DR CM . Suite/Unit:
vicinity: , , � �
SCOPE OF WORK: WATER HEATER REPLACEMENT, SAME LOCATION
NOTE: Final approval of oermit shall not.tie qranted until access to the dw�
installation of smoke and carbon monozide alarms bv the city inpsector. S
OWNER: HUBBARD, MARK S � .Address:
PHONE: , _ � City/StatelZip:
APPLICANT: HUBBARD,:MARKS � � Address: ,
PHONE: �, � CitylState2ip:
CONTRACTOR: OWNER-BUILDER .
Atldress: PHONE:
Ciry/State: ZipCode: CELL:
ARCHITEC7:
ENGINEER:
2858 INROZ DR
COSTA MESA, CA
2858 INROZ DR
COSTA MESA, CA
License No.:000000
License No. PHbNE: ' • _ —
, License No. PHONE: ,,.� ,�
PLUMBING PERMIT FEE SUMMARY
PLAN CHECK FEE: $0.00
PERMIT FEE: $35.80
TOTAL FEES: - $35.80
:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DqyS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authonzed under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and flnal approval must be obtained. Failure to obtain inspections and f nal approval will result in the expiration of this pertnit.
LODE�, INSPECTIONTYPE pATE INTRULS CODEp INSPECTIONIYPE UATE INTRIp�S
7616 Fixed System Final Fire Prevention 206 Final Mechanical
7266 Pool Spa Final 208 Final Plumbing /a•�/. ��2 �
�
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final fire Preventlon
202 Final Factory Fire Place 220 Final Plannin9 Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
WORKERS' COMPENSATION DECLARATIO
I hereby aKrtn under penalty of perjury one of the following declarations:
❑ I have and will maintain a certifcate of consent to self-Insure for workers'
compensation, as provided for by sedion 3700 of the Labor Code, for the
perfortnance of the work for which Ihis permit is issued.
❑ I have and will maintain wvrkers' compensation insurance, as 2quired by
sedion 3700 of the Labor Code, for the pertortnance of the vrork tor which this
pertni� is issued. My workers' wmpensation Insurance carrier and policy
number are:
Carrier:
(This sec(ion need riw be camplete�MNe pertrMls veluetl et are �urMretlWllers (Ef00J orlessJ
Policy Number:
❑ I ceniry lhat in the performance of Ihe work for which this permit is
issuetl, I shall not employ any person in any manner so as to become subject
to Ihe workers' compensation laws of California, and agree that if I should
become subject to the workers' compensation provisions of Section 3700 of
the Labor Code, I shall forthwith comply with these provisions.
Appliwnfs SignaWre
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SU&IECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aKrtn that I am licensed under provisions of Chapter 9(commencing
with Seclion 7000) of Division 3 of [he Business and Pro(essions Code, and
my license is in full force and effect.
Lic. # Class #
Contrectofs SgnaWre Data
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affrtn that there is a construction lending agency for the
perfortnance of the work for which this pertnit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender's Adtlress:
oate
XOWNER-BUILDER DECLARATIONS:
I hereby aKrm that untler penalty ot perjury ihat I am EXEMPT FROM THE
CONTRACTORS LICENSE lAW for the following reason (Sec. 7031.5,
Business and Professions Code: Any city or counry which requires a pertnit to
construct, alter, improve, demolish, or repair any sVucWre, pdor to its
issuance, also requires the applicant for such permii lo fle a signed slatement
lhat he or she is licensed pursuant to the provisions of Ihe Contractors 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 the basis for
the alleged exemption. Any violation of Seclion 7031.5 by any applicant (or a
permit subjects the applicant to a civil penalty of not more than five hundred
dollars ($500).):
I, as owner of lhe property. or my employees with wages as Iheir sole
mpensation, WILL DO THE WORK, and the strucNre is not intended or
oftered 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 work himself or herself or through his or her own
employees, provided that such improvements are not intended or oHered for
sale. If, however, the building or improvement is sold within one year of
wmpletion, the owneo-builder will have the burden of pmving that he or she
did not build or improve for purpose ot sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRAC70RS to construct the project (Sec. 7044, Business and
Professions Code: The contractors License Law does not appty to an owner of
property who builds or improves thereon, and who contrects for such project with
a contractor(s) license pursuant m the Coniractors License Laws.).
❑ I am exampt under sec.
Business and Protessions Code for this reason:
905'!<8 (3I0])
Owner ID verifed by d , license. ❑ Yes ❑ No
Driver's License No. Expires: �� � A
Verification of Ownership by (type of document, i.e. - property taz 6ill or d!ed):
DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION:
❑ I hereby certify that no exrava6on fve (5) or more teet in depth into which a
person is required to descentl, will ba made in connection with vrork authonzed
by lhis pertnit and that no building sWcture, scaffolding, (alsework, or demolition
or dismantlinq thereof, will be more than thirty-six (36) teet high. (Chap. 3.2, Grp
2, Art 2, Sec. 341, Title 8, Cali(omia AdminisUativa Code).
❑ As owner-builtler, I will not employ anyone to do work which would
require a permit from ihe Division of Industrial Safety, as noted above, unless
such person has a pertnit to do such work from the division.
Appliwnt's Signature Date
Division of Industrial Safery Permit Number: ••
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant need to file and
certi(y a Business Plan for emergency response to release or ihreatened
relea5e ot a hazardous matenal? ❑ Yes ❑ No
(Section 25505 of the California Health and Sa(ety Code requires, with some
ezceptions, Ihat a Business Plan be fled with Ihe Costa Mesa Fire Department
by every business which has at any one time during a reported year a quan�ity
of hazerdous materials equal lo or greater than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic (eet of compressed gas at standard
tempereture and pressure).
2. Does or will the applicant or present or future building occupant need to file
a registration form for acutely hazardous materialsl � Yes ❑ No
(Section 25533 of the Califomia Health and Satety Cotle, with some
exceptions, requires registration with the Costa Mesa Fire Department by each
business which at any one time has on hand a quantiry of acutely hazardous
materials equal to or greater than a weight ot 500 pounds, or a volume of 55
gallons, or 200 cubic teet of compressed gas at standard tempereture and
pressure).
3. Does or will the applicant or present or future building occupant neetl to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous malerials)? ❑ Yes ❑ No
(Section 25534 of the Cali/ornia Health and Safery Code pmvides that the
Costa Mesa Fire Department may require the preparalion, certifcation and
filing with the Fire Department o( an RMPP by businesses which are required
to register acutely hazardous matenals with the Fire Department.
4. If an RMPP is presently required, has Section 25534 of Ihe California
Health and Satety Cotle heen fully wmplied with7 ❑ Yes ❑ No
5. Does or will the applicant or present or (uture building occupant require for
lhe work whiCh is Ihe subject of this application a pertnit for such conswction
or modification from the South Coast Air �ualiry Management District or from
any other air pollution control disMct or agency? ❑ Yes ❑ No
(Section 65850.2 of the Califomia Govemment Code requires that the requestetl
infortnation be fumished on applications for non-residential building pertnits).
6. Will any part of lhe facility to be wnstmcletl under [his permit be within
1000 (eet from the outer boundaries of a school? ❑ Yes ❑ No
(If "yes", the taciliry must meet the requirement of Sections 25534 and 42303
of the California Health and Safety Code).
7. If a Dertnit from Ihe South Coast Air Qualiry Management DisMct or other
air pollution control distnct or agency is required for the work which is the
subject of this application, have all of ihe disclosures prescribed by California
Health and Safery Code Section 42303 been made? ❑ Yes ❑ No
8. (If'yes', attach certificate of compliance from the appropriate air pollution
wntrol oKcer).
CERTIFICATE OF COMPLIANCE: I certi(y that under penalty of peryury the
information given above is correct. I agree to comply vrith all state laws antl
ciry ordinances regarding Hazartlous Materials and Emissions.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRV: I
certiy under penalty of perjury that 1 have read ihis application and state that
the infortnation given is correcl I agree to wmply with all state laws and city
ordinances relating to bui ing construction, and authorize representatives of
the City of Costa Mes� enter upon the above-0escribed property for
inspection purposes. I a re not to occupy or allow occupancy of any building
authorized by lhis pertnif u il final inspection.
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���������,� 77 FairDrive, C�st� IJ�esa,�CA 92G2� �
��� L 714-7C�4-5273 / Fa>: 7'14-754-4856
a�r��E� a�U��La�E� ����FNc�. �. ha��
Permil #
Discic,sures �: F.orrns for Owner-Builders Aaplyiny r'or Cons4ruction Per:mits.
� '�n!lPQ.RT,Q�ITI NpTIGE TO ?ROP�RT1' 01�INER
Dear Propert�� Owner •
An application for � building permil has been submitted fn your name listir�c��ourself as the builder_ oi the
properly improvements.specified at pi�s� � 1r��Z, .�}21�
We are providing..you with an Owner-8uilder Acknowledgment and Information Verification Form to malce you
aware of your responsibilities and possibie'risk you. may incur by haviny this permit issued in your name as the
Owner-Builder. We will not issue a building permit until.you have read, initialed your.understanding oi
each provision, signed, and returned this form.to us at.ouc official address indicated, An.agent of the
owner.cannot execute this notice unless you, the property owner,,obtain the prior.a.pproval of the permitting
authority.
Read and inrtial each statemenl below fo signify you understand or verriy this inlormation.
�1. I understand'a frequent practice of unlicensed persons is to have ihe property ownerobtain an "Owner-
Builder" building p�rmit that erroneously implies thal the property owner is providing his or her own labor and
material personally. I, as an Owner-Builder, may be hsld liable and subjeci to serious financial risk for any
injuries sustained by an unlicensed person and his or her employees while working on my property. Niy
homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder
and am aware of the limi'ts of my Insurance coverage for injuries to workers on my property.
�. I understand building permits are not required to be signed by property owners unless they are
responsible for the construction and are nol hlring a licensed Contractor to assume this responsibillty.
y�l understand as an "Owner-Builder" I am the responsible party of reco[d on the permit. t understand that
I may protect myselt from poienfial financial rislc by hiring a licensed Contractor and having 3he permit filed in his
or her name instead of my own.
�. I understahtl Contractors are requir.ed by law to be licensed and 6onded in California and to list their
license numbers on permits and contracls.
I understand it I employ or othenvise engage any persons, other than Caliiomia licensed Contractors,
an he toial value oi my construction is af leasi five hundred dollars ($5D0), including labor and materials, i may
be considered an "employer" under state and federal Iaw.
�, I understand if I am considered an "employer" under state and federal law, I must register with the state
nd federal gov�rnmenl, withhold payroll taxes, provlde workers' compensatlon disability insurance, and
contribute to unemploymenl compensaiion for each "employee." I also untlerstand my failure to abide by these
laws may subject me to serious financial risk.
�7. I understantl under Caliiomla Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannoi legally build them with the intent to offer them for sale, unless all work is performed
by licensed subconiractors and the number of structures does nof exceed four within any calendar year, or all of
the worl; is performed under contract wilh a licensed general building Contractor.
/. �
8. I unders[and a�, an Owner-9uilGer i( I s�ll the: property �or whicli this permil is issued, I may be holcl liable:
for ny financfal or personal injuries� sustained hy any suhsequenl owner(s) thaf resull �rom any latent
construction defects in thE� w�rl<manshlh or materials.
y� 9. 1 understantl I m�y obtain mone mformahon regardiny my obhgalione. as an "employer" from tPic In[ernal
kev�niie S?NIC4', II1F. Unitecl States Small 5usin�ss Administration, fhe California D�panmenl of B�nefil
PaymenTs, and the California Division of Industnal .4ccidents. I also understand I may contac( Ih<_� Caliiornia
Contraciors' S:aie License Board (CSLB) at 1-000-321-CSLB (2752) or www.cslb.ca.yov for more in(ormaiian
abocd licensed conrractors.
`M10. I am aware ot arid consent to an Owner-Eiuildcr building p�rmd applied for m my r,ame, and under;,and
�ial I�arri tl�ie party legall � �nd finanaally responslhle Por pro�osed construcYlori activiry aLthE: following address�
z`ss� 1.� �_ � c,.� �.
�^ 4�1. I aare� tnat, as the party legally and financialiy responsible for this proposed construcfion activity, I will
aoide by all applicable laws and requirements that yovem Owner-Builders zs well as employers.
P� �2. I agree to notiiy the issueroftFiis form immediately ofany additions, deletions, or changes to any of the
information I have provicied on this form. Licensed contractors are regulated by laws designecl to protect the
`public. If you contcacf witli someone who does not have a license, the Contractors' State License Board may be
�mable to assist you with any fi�ancial loss you may siistain as a result of a complaint. Your only remedy against
unlicensed Contractors may be in civil courf. It is also important for you to understand that if an .unlicensed
Contractor or employee oi that individual or firm is injured while workiny on your property, you may be held
liable for damages. If you obiain a permit as Owner-Builder and wish to hire Coniraciors, you will 6e responsible
ior veriTying wnether or not those Contractors `are properly licensed and 4ne status. ot .'tneir workers'
r.ompensation insurance coverage. -
Before a building permit can be issued, this form must be completed and signed by the property owner
and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's
driver's license, form notarizafion, or other verrficafion accepfable to the agency rs required fo be
presented wrren the permil is issued to verity th operty owner's sigr,afure.
Signature of oroperty owner Daie:I L� ��'�IZ---
Note: The iollowing Authorization Form is required to be completed by the property owner only when
designating an agent o( the property owner to appl}� for a construcfion permii for the Owner-Builder.
AUTHOR(ZATIOM O'r AG�NT TO ACT ON PROP�P.TY OWN=R'S B�HALr
cxcluding the Noiice to property Gwner, the execution of which I undersiand is my personal responsibility., I
hereby authorize the following person(s) to acf as my agent(s) to apply ior, sign, and file the documents
necessary io ob'tain an Owner-Builder Permit for my project.
Scope of Construction Projeci (or Description of Work):
Projeci Location or Address:
Name of Authorized Agent:
Address of Authorized AgenY.
Tel No
I declaro under penalty of perjury that I am the property owner for the address listetl above and I personally iilled
out the abov� informatiqn and certify its accuracy. IVote: A copy of the owner's driver's license, form
notarrzation, or other verification acceptable to the agency is required to be presenied when th� permit is issued
to verify the property owner's signaiure.
�roperty Owner's.5igndture:
314ES-30 CHLBO Jan 1, 2009 OB Packet �emplate
Date:
2of2
� PflOJECT p00HE55: UNIT:
OWI�EH'SNAME: zRSB INR07 DR
`aooeEss: ZABARSKY, OSCAR P
� NEW OR�TNBEACH,CA 92660
\
979-7037.
AXCNIENGINEEfl: ftUDY RODRIGOEZ NEG.NO.: CZ��,tO
eonness: 141%2 BOWEN ST
PEflMIiTEE: G.G. CA 92643
aoosess: BRIDGEPORT Bi7ILDERS ( 714 ) 241-907'1
124 E. GEARY
SANTA ANA � CA 92707
LICENSED CONTflACTOP UECIAMTION: I �eteEy affirm Ilu� I am ticensed unCer Drovisions of Ctwpter 9([Ommentinp with Set�ion
7000) ol Orvision 7 al t0e Business ana Pml¢sii0ns Laae. anE my license is in tull lorce and ellecl.
cirr uc.: 1 � 1/�y Qq sTare uc.: 312 0 6 3 �ss: ,���
�am', ��.Zir_/—I-� Signature:
WoHNEflS'COMPENSpT10NDELLABATION: Ih¢r¢Oyallirml�allhaveatetli�iWtealmn5 osel6insureoraceniticatealWorkers'
Comp¢nsation Insurance. or a cetlifieA caoY �hereof (Section 3800, LaD. C1.
POLICY NO.: Y WC ^ I 1 Z S G S E%P. ORTE: O 3 I S Z I 9 2
camear+r: GLODEN EAGmLE IN
� � Cetliiiea CODY �5 heroGy lumii�ed. y� Cetli�ied toOY �5 �il¢0 wiP .e tiry Bui10�� Division.
G .,ele:���V/�� ApplfcanL•• �
EllEMPiION IPOM WOflMEPS' COMPENSRPON OECIAflRTION: (ittis uqian neeU mt be wmdeteA if the p2rmt is ta ane hunOreA (StUO) or less�.
I cerlity Ihat in Ihe Dedo�mance ol t�e work �or wNch Ihis perml is rssuea. I shall no1 empby a`ry person in any manner so a5 io become
sub�ectto ine warkers' CAmpensatian LawS-ol Califomia.
Oaie: Sqnamre:
NOTICE: II. atier makinq t�is Eeclaratim. yrou shw10 Eecome w�ject to !he Woders' ComDeasation prmdsions of t�e Labor
cotle. ro� m�si lonnwim como�Y •��n sucn pmvivons or Ms ce��u� snao oe eeemee revokea.
CONSTNUCTION LENOING AGENCY: I flereGy affirm�itutthere is a constmction IenJinq aqency lor t�e peAarmance ol ��e work br
wNc� I�is permit i5 issue0 (Settion 309j Civ. C�.
LENDEN:
p00PESS:
OWNFP BWLDEB UECIABRTION: I AereCy atliim tlut I am e.empi imm the Conttactors' State Lice�¢e law loi ihe lollovnng reasan
(Section 70.17.5 Business and Professional Coae: Any city ol wunty wNch requires a Dermil to wnstruci, alter. im0�ove, demalish, or
repair any siNciwe. prior lo ils issuance, aho repuires Ine aOD�icant lor sucn ce�mit to lile a sipneA stalement ihdt hUshe is IicenSea
I OursuanuoNeOmvisionsollheConiracmri S�a�eLicenulaw�Clupter9�cammencinO���Stttion7000�oIDivivon3alt�eBusiness
ann Pmlessions Canel or �nai ne/sne is eeempt inerelmm ano �he �asis for tne allepea eeemD�ion. Any violation ol Section 7037.5 Oy
any apDlicant for a Dermit su0iecls I�e aD0liCant lo a[ivil penalty of not mort tAdn live hunCreO Eollars (SSOU).
I, as owner of ine propeny ai my employees vriln waAes as Ineir Wle campen5atlon, vnll Ea tAe work, an0 Ihe
❑ stmclure is nm intenae0 or ollereG lor sale (Secuon 70A4, Business and Pmlessional Code: T�e Contracmrs' State License Law
aces not apoly lo an owner ol a o�openy wM ouilJs or imo�oves inereon, ana wlro Aoes sucn work nimsell/hersell or IhmuAh
hi5 or hei own em0loyee5, pmvia¢E Iha� SUGh impmvemenis aie noi inientlEd or o��CrCA im Sala II, however �he huilding m
improvemeni is sa�a wllAin one year ol wmpl¢Iion, t�e owne� will Mve Ihe OurGen ol Dmvinq he/she tliU nol bui10 Or impmve
lor ihe ourpose o� sale�.
�
I, a50wner oi I�e pmperty. am eMcluvv¢ty cantractinq vnih licensea comraciors �o cansirutl I�e prolecl �Section 700C, Business
❑ an0 Prolessions CaUe: 7�e Wntractors Stare Liceiae law Eces not appty ta an o-xner of pmpetl wM OUAGs onm0« lhereon
CITY OF COSTA ,MESA - BUILDING PERMIT PERM NO: B 05308`_
PERNIT NO: B U53085 PLAN CHECK NO: N GOVT: N SUFP: N
CONSTRUCTION TYPE; V-N PERMIT TYPE: STR PtiRPOSE: ADD
JOB DESCRIPTION : 2605F 2ND FL RESIDENTIAL ADDITSON SQ FT: 11,000
CLAIM VALUE: 11,000.00 CALC-VALUE: 11,OOO.UO GROliP OCC: R-3 /
COMMENTS: REF: B52977
M� i! iE±f� if if iE'Y.� if if ai 1F M ii �h ff 1f 3F iE iF k� iF iE iF ie iF iF #F IF if iE IE IE aF IF iE if� dE iE iF lF iF if if )h iE if 1F iE ib if iF 1t iF 1f If le if iF iF iF If iE If 3F if R iP ?E i'r iE if R� iE Y' 1E if� # IF
Z O N I N G R E Q U I R E M E N T S
S E T H A C K S
------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING ---------
FRNT: FT TN REAR• =T IN FRNT; FT IN REAR: rT iN
LEFT; FT IN RGHT; FT IN LEFT: FT IN RGiiT: FT IN
PARKING REQ • PROV: PARCEL: 13944405 ZNE: REF NO:
PLANNING N6TES>
i ,.
k iE ic 3c iF 3F i'r 3E iE iM1 3f IE iE iF iF ie if iE iE if iF iE iHf if i'r iF if if ac jE i!-iF iE if iE iF iE iE �E lE 1E IF ik iE it iE if if iF if jF K N� iE iF 3E if 3F !'r ii l"r ff aF 1E #4 3E Ie.3F'lE iE Y if If ii 3e jf ii� IE
D E V E L O.' P M E' N T S E R V I C E S R E Q U I R E M E N�T S
ZONING APPROVED BY;' ,- -' 'i DATB:
BUILDING APPROVED Hi' •� '` � DATE:
�*P*�**���N*****�D�a����� DATE: :�
r � ifiE3flElFiE±eRiFiF . �rR#
3i�iEiE1f1F#iE3FiEiFiFiEif�(�1EiEiElFiffEielFiEiElfiE?fiEiEiE�1f�E3i�ifiEiEM�iiif .ii E3!�iEifif-ifiElt�iFiEihifif%IEiFifi!�iF)ki'r�leiFiciFifiiR?EaEieiEikieiFiF}!�
LEGALIZATION:N F E E S M A.,R Y STRUCTURAL SEGNENT;Y
�•
BLDG PMT PLUMBING ELECTRIC MECHANZC FIRE SMIP/RES GRADING
PERAIIT 126.00 � 1.10
SMZP/NON-RES
PI.AN
Z5SUE FEE
BUILDING-DIV-> PERMIT ISSUE PLAN-CHECK
TOTALS----> 127.10 0,00 0,00
REVENUE DIVTSION TOTAL5--> COLLECTED:
BLDG PMT PLUMBING EI�ECTRIC MECAANIC
126.00
i TOTAL PAZD DUE
127.10 127.10 ,OU
✓12'7,1U OVER/SHORT: .UO
F'IRE SMIP/TOT GRADING PLAN-CHECK
i i,io
anA who ConlraCtS IDr Sut� prol��5 wilh a Conlratiar�s) IitenSe pur5uanl lo I�e CanlraCi0r5' S�ale Litense Law�. I am awar¢ �(.a(.{(-j(.{(.j(.j(-{(.{(.{(.{(.ir 1F iE 1f 1F If IF IF 3k 1E 1FIE if�ifiF�li�iE iF Ifit � iF !f lE iE if 3f iF iF IF�7fiF iF iF K�if 1E i6 if�ii�iF if 1k 3F 1P 3E iiiE iF iF 14# fFif iF iEaF 1E iF iFi:�if� Ifii�#F 1f 1E iF
mai o��� ol meir Worker's CamDenution insurance snoula ee D«� �o me. I N D 1 V I 1� U A L F E E � B }� fi A K D � W N
� i am exem0� �Oer Seciian: B. d P. C.
mnnareason. TYPE QTY D E S C R I P T I O N UNiT COST TOTAL COST
nate °v'"Bf' SeR 11000 REROOF BY VALUa RESZDENIAL NdZONE 1.00 11,000,00
I tlo trerz0y cendy �nat i am aware al an0 untlerStanE ��e �epuirem¢ms ol faliforrva HealN an0 Salery CaUe Sections 25505. 25533. an0 END OF F E ES
2553a and �na� 10� any lutme �ui�amp occupam wilVvnll nm (circle one) nee0 �o comDN ��� ��tl state coCes anG �Ae requiremen�s lar a
pe�rtui lOr tanslmtlion Or moEificalbn Imm I�e Air a4ty Managem¢ni DaVici, flesbential conSVuc(qn appliqliOnS are C�¢mpi imm r
these prov¢ions
Oale'. FDMkanC
I �ereby ceriily Ihai I Iwve reaG t�is aDD�itatmn and Slate lld� I�e a�ove iniotmation 5 corrCCi. I agrte lo mmD�Y ��h all Ciry and COunry
ordinancesana5lalelaw5ielalinglo�uileingconSlNtlionatbher¢�yau�hOrii epresentatWesaf��is�ntlleahave�m¢nlionetl
piopeny loi m vection purtmes
�a�e � j� � /�� Signa�ure:
�rivei's License or Social Securiiy x: �+�
,� 164L46 Whne—Bulltlmg�, Green—Coao Enlo¢ement: Canary—ApP���ant; Plnk—Revenue Goltlonrotl—Assessor
�i .lu�9it9?-'.�,5<+9;; �^'
°�1TG: O%/7G.�';: '1���.!' _...,
�
,
s
CONSTRUCTION AND PLANNING P��� �A
_.APPROVALS Permit #�_ `� te Inspector qppROVALS Permit # Date Inspector
.
i. TemporarY Electrical Servic��r Pole � 52. Pool & Equipment Location /�
2. Soil Pipe-Undrgrnd. �� � 53. Steel Reinforcement .y
3. Electrical Conduit Utility-Un4�gmd. r 54. Forms
r
4. Electrical Conduit•U�drgr�d. 55. Electrical Bondi�g �
5. Steet Reinforcement� 7..,Z4.� D� 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER�GUNITE
7. Footings 7 24y�,( �� 58. Electrical Conduit�Undrgrnd.
8. Fpundation � 59. Gas Pipe, O Undrgrnd., Test �.
9. Water Pipe-UndrgrnA. �!� �; 60. Backwash Lines, P�Trap, O Undrgrnd.
70. Structural Floor System � � 61. APPROVAL TO DECK �� �
11. Property Sewer Line & Ho�nnection � � 62. Backwash & Recepmr•Final '
12. Sewer Cap �� 63. Heater & Vent�Final
13. Roof Drains • '� !
�: {n ,, 64. Plumbing SYstem � Final t'��
14. Rough Plumbing � .� 65. Electrical-Final 1?
15. Rough Electrical�Conduit 66. Solar SYstem-Final �
16. Rough Electric Wiring 67. Fencing & Access Anproval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electriwl-T 6ar 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. Dutts, Ventilating 71. Product Piping O Gas ❑ Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Rooi Framing 73. Undergrnd. Storage Tank O Gas ❑ 0�1
25. Roof Sheathing ]�.q�'( Q(� 74. Overhead Hydro
26. T�Bar Ceiling (Structurall & Monocoat 75. Dry Chemical
27. Frame and Flashinq �•Zt-�[( f�� 76. Dry Standplpe
28• '�� & Siding (2��j( (o� 77. FIXED SYSTEM FINAL
� 29. Insulation - � D'l'�� �+G.�� 78. FIRE PREV. FINAL
30. Drywall Nailing S'�"q( �p �i'y='y�L HEALTH OEPT. REQUIREMENT
31. Plaster Brown Coat '�, ' 79. FINAL INSPECTION
.
32. Electrical Power Meter-Final � •80. FOOD CER IFICATE ISSUED
..
33. Final Electric ,: Notes:
34. Final Heating & F,ir Conditioning �
35. Final Gas Pipe-Test '�
f f �C��
36. Hood or Canopy ' �� � �
37. Final Factory Fireplace �
38. FinalPlumbing � `,Z-Z -l•jl- s'w•e�•Ce �e� �(�^6�
�--�
39. Water Service-Final =
40. Gas Service�Final .
41. Solar pomestic•Final
42. Backflow Preventer �
43. Backflow Irrigation �
44. Landscape Irripation System
45. Sound Atteauation
46. Handiwp Regulations
47. FINAL STRUCTUFE & BUILDING lz Z.-t��
48. FINALPLANNING � '
�
49. Electric Release to Edison �:
50._ Gas Release ro Southern California Gas Co �; �/,
51. CERTIFICATEOFOCCUPANCY ,
No. Oate
PflQIECTRODNE53: z$SB INROZ �tZ UNI7:
OWNEfl'SNRME: 'J,ABARSKY� �SCAR P '
AUONESB: 3 NARH ONNa
� NEWPORT HEACH,CA 9266U
979-i032
FNCNIENGINEER: RUDY RODRIG(7EZ NEG.NO.: CiE321O
FODPESS: S 4 Z% 2 BOWEN ST uxR:
. G,G. CA 92643
vewamee: BRSDGEPORT BUILUERS/hkqMFl�, ( 719 ) 241-9077
nooeess: 129 E. G�ARY
5ANTA ANA CA 9270'%
LICENSEO CONTMCTOfl OEClAMT10N: I hereby aifirm ihat I am licensed unCer pmvisions oi Chap�er 9(commencinp wiN Seclion
7000) of Oivision 3 of ihe Business and Pwfessions Code, an0 my license' in fvll lorce antl ettect.
cin uc.: 0 i 715 9 gTTTE UC.: 3 [ U 6 3 S:
Date: _�.���� 9� iqnaNra: f�� /
WOBREBS' COMPENSITION UEIXAMTION: I �erehy attirm tAat I have a certiticate of consent to s�-insure ar a ceniticate oi Workers'
ComPensation �ns�anLa, orl ie�fi¢O,cooy Ihereoi (Sectian 3800, Lab. Cl. �� i z� 9 2
roucr xo.: GLODEN EAGLE yN Exr. o�re: �
COMPRNY: �-y( �
� CetlifeE c OY �s here6y /umisheU. LJ'Ce '� copy is 1i1e0 the ciry BuiiOinq UiWsion.
..e: � �� � AppliwN: � /
�
IXEMPfION FBOM YlOBKEBS' COMPENS�TION DECIAMTION: Qhis seclion neetl not Ge camDle�ed i� �h e�mii is for one hundreG (5100) ar less).
I certiry Ihat in the performance of the work tor which ihis Dermii is issued, I shali nat emDloy any person in any manner so az to become
suble�� ro the Warkers' Campenution Laws ol Califomia.
Oate: - SlOnature:
NOTICE: Ii, aRer making this tleclaration, you should become su6ject ro tAe WOBers' Compensation pmvisions ol the Labor
Cotle, you must forthwit� comply wiN suc� pmvisions or this De�mit shall he tleemeU revoked.
CONSTIIUCTION IENDINC �OENCY: I hereby aflirm that there is a cansWction Ien0in0 agency for I�e peAormance of the woB for
which this Dermit is issuetl (Seciion 3097, Civ. C).
lENOEfl:
aooeess:
OWNER BWLOEB OECUMTION: I �ere6y attirm that I am exempt from the Cont2ctors' State License Law lor the foilowinp reason
(Section 7031.5 Business anA Protessional Coae: Any ciry oi counry which requires a Dermit lo consimct, al[er, impmva, demolis�, or
repair iny stmcWre, O�or ro ifs issuance. alm aquires t�e appliwnt for sucA permit to lile a siqneE statement that he/s�e is IicenseE
pursuant ta [he prodsions oi ihe Contractars' State License Law �ChaO�er 9(commencinA ��� Section 70W) ol Uivision 3 0l t�e Business
and Pmfessians Cotle) ar Ihat he/she is exempt thereimm an0 Ihe basis for the alleqed axemption. Any violation ot Section 7031.5 hy
any applicant lor a permit subjects the aDO���nt Io a cidl penalty of not mom Ihan five hunAaA aollars �5500�.
I, as owner of the D�oDenY or my employees wit� wages as iheir sole comDensation, will tlo the wo�C, anU the
❑ simcturais notintenAea aratteretlforsale(Secnon 7004, Business and PmfessionalCoAe: The Coniractors' State Lic¢nse Law
dces not aDO�Y �o an ovmer of a D�operry who builds or impmves Nerean, and w�o Oces such work �imsetl/herselt or [�roupA
his or her own employees, proviOeA that such imD�ovaments are not inten0e0 or oflared for sale. Ii, however t�e buil0ing ar
imD�ovement is so10 witMn one year oi comp@tian, [he owner vrill have tAe �urtlen ot Orovinq he/she Oi0 not bui10 or improve
i for the Durposa of sale).
I, as owner of the pmDerty, am exclusively wntracting wiN licensetl cantracrors ro wnsimct Ihe D�olect (Section 7094, Business
❑ an0 Pmlessions Code: The Cantactars' State Lic¢nu Law dces not appH �o an ovmer of pmperty who bml0s ar impraves therean
and who caNractstar such pmjects wtth a contracror(s�license Dursuant to the Contractors' State License Law�. I am awara
that proof ot t�eir Worker's Compensation insurance shoulA be D�a��Oetl Io me.
� I am exempt unGer Section: B. d P. C.
. �or this reason:
Date: Owner. �
I Oo hereby certiry Nat I am aware of and understan0 the requirements of Califomia Healih antl Safery CoOe Sections 25505, 25533, antl
25534 an0 that I or any luture UuilAing occupant will/will noi (circle ane) neetl ro comOb m�h sai0 state coUes and Ue requirements for a
permit lor consimction or moEificatian irom the Pir �ualiry ManaOement District Nesitlential constmction apDlications are exempt from
tAese prwisions. .
Date: Applicant:
I �ere6y certity Ihat I �ave 2a0 ihis apDlication a state that the a�ave iniormation is wrrect. I apree to compty with all ciry antl co
ortlinancesanOstatelawsrelatinptahuildingcon mctionanOhereWtau,thorizerepresentativesafihiscirytoenterupontheabove-menf netl
property lor in pection p ses. Q�(�(�(/..i� ��/ ✓`� ^J�N1 •
Date: Siqnature:
oriver's �icense ar Socia� securiry x: _
16C1-46 W�ite—Builtling: Grean—CaCa EnlorcemanC Canery—Applicant; Pink—Ravenue:
CITY OF COs'TA MESA - DUILDING PERMiT
PERMIT UO: B 0524'17 PLAN CHECR NO: U08%0-41 S
CONSTRUCTIUN TYPE: PERMIT TYPE: STk
JOB DESCRIPTION : 7.665r 2ND cL RESZDENTIAL ADDITION
PERM NO; 3 052477
GOCrT; N SUPP: N
PC7RPUSE: ADD
SQ FT:' 260
CLATM VALUE: �O,DU0.00 CALC-VALliE: 17,94U,00 G�OiIP OCC; R-3 /
COMMENTS; }{
le 3i� ic if ii� 3(� iE 3c 7(� 1F k It !E?(� li� iE if� # 3f �lf iE 1e iE iE �i� 3f Y� �lE iE i(� 3i iE 3(� jb 3F iF ii� �Yr iF �k 3F �li k�lE �li� # iE ii* # 1t %iF I'r 3f��iF \� iE 1E i'r �1F i:�ii� i'r iE �1i� lf iF 3f if #ii� iF 1't ii� IF IF iE �IE�H�
Z O N 2 N G 1� E Q i7 I R a M E N T S
S c T B A C R S
----- ------ MAIN HUILDING ---------- -------- ACC�SSORY BUILDING
FRNT: 31 F'P IN REAR: FT IN FRNT: FT IN REAR: FT IN
L�tFT: 17 F'f TN RGHT: i0 FT IN LEFT: FT IN RGHT: FT Il�
PARRZNG REp� PROV• PARCEI�: 139?4405 `/.NE: R1 REF �O:
PLANNING NZ7TF.5> r'OR AN APPROXIMATRLY 271 SQ. FT, SECOND s'TORY AllD1T30�, ONLY
%
N� #� M� IP )f iF K� iF �F iF iE i4 li-#(� if iE af- 3F k� iP N� 1E 3E�3E i4lf iE iE 3(� �if }�. iE iE �lE if �f- iE iE 3'r 3(� 7(-',c if # 3f� 14 ie jh if 3E iP IE Y� �l+r iE aE 3f ae * 1i� %� �lE k iE Y�-7f• iF #��l'r�iE if i't 3t• 3E �I(• �1F if N�
D E V E L O P M E N T S E R V I C a S R E� U I R E M E Ai'�l S
ZONING APPROVED BY �d UATE: Co 2� i
BUIi.U2NG APPRQVED HY : llATE; �
AFPLSCA'iIOAt ZSSU�,D BY: I� TL DATE; �o. 2-I 1
N��1E%ki43(�ifjFififiE�%i6347E�i'rii�3Ei(�ii-K� .. . . ,- . .. �R' -.��iF£iFlFif�cAifi�.Tr}.1e#K�*-afN��iY�3f. ., . .x...iFii�
k�ifif%i'rkiEl(�1EiElFifiEif3P�K-iE7F3eiE1E3(iflFlflEiEjP3(�if�iFiEif36N��(�i6XiEff �ie�F%3Ei4N-�FIF�f-?(�3fN�}:•ifi!�%�N-i(�iF3!if3i�3i��lEKk?63EiERf:+i{(:(.}•,K.g
LEGALIZATION:N F E E S U M M A R Y STTiUCiURAL SEGMENT:Y
HLDG PMT PLUMHING ELECTRI(: MECiiANIC FIRE SNIP/RES GRAi�ING
PERMIT 189.00 • 1.25
SMIP/NON-zES
PLAN 122.85
ISSUE FEE
HUILDING-DZV-> PERMIT ISSUE PLAN-CHECK TOTf�L PAID D[7E
T'OTALs'----> 190.26 0.00 122.85 31.3,11 313.11 ,UO
REVENUE D.TVISION TOTALS--> COiLECTiD: 190.26 OVER/SHORT: ,�0
Hi,DG PMT PLUMBING aLECTRIC MaCHANIC FTRE SMIF/T01 GRAUII�G PLA\-CHnCK
ia9.00 1.26
iF iF 3f 3P iF �lf i4 �YE N� Y.� 3F le 3f iE ?4 R 3F i(� �F 3E ii 1f 1E iE aF iE iF if N� iF 3E iE if #f kk IF #�±F 3E if 3t� jf iE a(� iF if� ic #E fE # 76 i'r lF h'� 7f 1t i'r 1f �#f i6Y� jF±i jb iF N� �F i4 34 } i'r ii� 3i� iE aE # 1F Ii�
S h U I V I D U A L F E E B R E A K D O W N
TYPE QTY D E S C R I P T I 0 I�E UNIT COST TUTAL COST.
SFR 260 DWE-TYPE V-WOOD FRAME -GOOD 65,00 17,99Q,00
END OF rEES
�i {'r:'C`C�)_�'i.C'CYVO[,� �r-.�..
JHTF: Cc'_,/a! TT�';, _ �,
CONSTRUCTION AND PLANNING POOL �A
Date Inspector Date Inspector
APPROVALS Permit # -�. t, , APPROVALS Permit # �
l. Tempo�ary�Electrical Service or Pole .��r 52. Pool & EquipmeM location "� f
2. Soil Pipe-Undrgrnd. -� �- 53. Steel Reinforcement
3. ElectriCal Conduit UtilitY-Uniirgmd. . � 54. Forms •r
4. Electrital Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement - 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPflOVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit�Undrgrnd.
S. Foundation ��7� '�i 59. Gas Pipe, O Undrgrnd., Test
9. Water pipe�Undrgrnd. „ S 60. Backwash Lines, P-Trap, O Undrgmd.
10. Structural Floor System � 61. APPROVAL TO DECK �
11. PropertY Sewer, Line & HouslConnection � j� 62. Backwash & Receptor�Final �
12. Sewer Gap " 63. Heater & Vent-Final �.'
13. Roo4 D{ains 1 � �� ,-' 64. Plumbing System - Final ;�>
14. Rough Plumbing _ � � 65. Elect�ical�Final '
15. Rough Electrical�Conduit ' ' 66. Solar SYstem-Final
i6. Rough Electric Wiring� 67. Fencing & Access Approval
17. Rough Wiring Sign � 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit #
21. Ducts, in Structure 70. Undergronnd Nydro
22. Ducts, Ventilating 71. Product Piping O Gas ❑ Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.StorageTank OGas ❑Oil
25. Root Sheathing 74. Overhead Hydro
26. T�Bar Ceiling (Structurall & Monocoat 75. Dry Chemical
27. Frameand Flashing 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulat�on 78. FIRE PREV. FINAL -
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. ElectriGal Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Eiectrfc Notes:
34. Final Heating & Air Conditioning �
35. Final Gas Pipe-Test �
36. Hood or Canopy !
37. Flnal Factory Flreplace
38. Final Plumbing
39. Water 5ervice-Final
40. Gas Service�Final
41. SoVar pomestic-final
42. Backflow Preventer '
43. Backflow Irrigation
44, Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING 2 Z_.�� /�i��
48. FINAL PLANNING
49. Eiectrit Release to Edison
50. Gas Release to Southem California Gas Cn
51. CERTIFICATE OF OCCUPANCY
No. Date
,
S
PflOJECTP00HES5: 2RSS 3NROZ Dk UNIT:
OWNEA00 ESS: LABARSKY� OJCP.R P ,
3 NARBONNE
NEWPt�RT BEACH,CA 97,6E0
979-1032
RflCHIENGINEEfl: RUDY RODRZGOEZ AEG.NO.: C2�SO
aooeEss: 19172 BOWEN ST
PEflMITTEE: G,G. CA 92643
P�DflESS: BRIDGEPORT Bi]ILDERS���,p� ( 714 ) 241-9077
129 E. GEARY '1QY"
�S��IT� �,�A N' CA 9z707
LICENSEO CONTBpLTO lAB 10 ereby allirm thal I am licensea un0er Omvisions of C�ap�er 9(commencing wi�� Section
7000� o� �ivlsion 3 of Ine Busmess antl Pm�essions Code. an0 my license is in full lorce an0 eHect.
c�rr uc.: ,.��/�7 15 srnTe uc.: 312 0 6 3 ass:
ate:��IS._f�_/ �.�— Signa�ure'. _ . _ _ - — _
WOBREFS' COMPENSATION OECLABATION: 1 Aere�y ailirm Iha� I have a certi�ica[e ol consent to -insur¢ or a ce�ifica�e a� Workers'
ComDensa�ion InSurance. or a cenitied copy lhereol (Seclion 3604 Lab. C�.
POLICYNO.: PY�TC_IS'11G'f E%P.OATE: O3ISZI92
COMPRNY: GLODEN EAGI,E IN
� Certifietl coOY �s here�y fumis�ed L}{ Certilied copy is lile wii e city Builtling Division.
_,�e;�/�y_( /_/_ ApplicanC
E%EMPTION PBOM WONHERS' COMPENSATION DECLAHRTION: (ihis sec�ion neee nat be camplete0 il lhe mit is �or one hunUred �$100� ar less).
I cetlily ��ai in �he petlormance oi Ihe work for which Ihis permit is issuetl, I s�all noi employ any persan in any manner so as to become
sublect lo the Workers' Compen5ation Laws ol Calilomia.
�ale: Signalure:
NOTICF. It, atter making Ihis declaration. you shoula become sublect �o lhe Workers' Compensation pmvisions oi lhe Labor
Catle. you mus� �ort�with comply wiih suc� pmvisions or ��is permil shali be tleemetl revoked.
CONSTBOCtION LENOING RGENCY: I hereby affirm that there is a constmctian lending agency br tAe pedormance of Ihe work for
w�lch Inis permit is issuetl (Section 3097. Civ. C).
LENUEP:
aooRess:
OWNEfl BUILUEB OECUflATION: I hereby allirm �hal I am exempt imm �he Conlracbrs' Sia�e License Law �or Ihe �ollowing reason
(Seclion 7031.5 Business ana Pmfessional Code: Any ciiy oi counry which reQuires a permit �o consimcl, alier, improve, Oemolish, or
repair any 5irutWre, priar �o i�s issuance, also requires �he applicani for such permit ta �ile a signed s�a�ement thai helshe is licensetl
pursuant m Ihe pmvisions oi Ihe Conlracmrs' S�a�e License Law (Chapter 9(commencing with Section 7000� o� Division 3 0� �he Business
anU Prolessions Code) or Iha� he/she is exempl Iherelmm and Me basis for the alleped exemp�ion. Nny viola�ion o� Section 7031.5 by
eny applicanl for a permil sublecis the applican� ta a civil penalry of no� more I�an five �untlred tlollars (5500�.
I, as owner al the pmperly or my employees wilh wages as Iheir sole compensation, will Oo �he woB, antl the
❑ simclureis notinlen0etl oioltered Iorsaie(Seclion 7044, Business and ProfessionalCoOe: The Con�raciors' Siate License Law
does no� apply �o an owner of a pmperty who builds or impmves �bereon, antl who aoes such work himsell/hersetl or Nrou9h
his or her own emplayees, pmvitlee ihal such impmvemen�s are not intended or offered for sale. Ii, however ihe building or
improvement is sold wilhin one year o� complelion. Ihe owner will have the burden ol pmving he/she did not 6uiltl or improve
for ihe purpose al sale�.
I. as owner o� Ihe property, am exclusivety conirac�ing wi�h licensetl con[rac�ors �o cons�Nct the pmlec� (Section 7044, Business
❑ antl Pmfessions Cotle: The ConVac�ors' Stale License Law does not appry to an owner of Dropeny who builds or imD�ove5lAereon
I antl w�o conlracls �or 5uch pmlecls wiih a conlracior�s�license pursuan� to ��e ContracloK S�a�e License Law�. I am awa�e
thal proo� of Itleir Worker's ComOensalion insurance shoul� be providetl to me.
� I am exempl under Section: B. 8 P. C.
�or Ihis reason:
Date: Ownec
I ao nereby cenify Inat I am aware ol antl untlerstan0lhe requiremenis of Calilomia Healin antl Safery Code Seciions 25505, 25533, an0
25574 an0l�ai I or anY �uture builtling occupani will/will noi �circle one) nee� ta compiy wi�h saia slale codes antl the requiremenls for a
permii for consimc�ion or modilicatian Irom Ihe Air Oualiry Managemen� Distric�. Fesitlential con5�mc�ion applica�ions are exempt imm
IhESE plOVISi005.
�ale: ApPlicanl'.
I hereby cerlilyihat I haverea0 Ihis appbcation and s�ale��atthe above in�ormation is correct. I agreeto comDly wi�� all ciry antl couniy
ortlinancesandslatelawsrelatinglobuil0ingcon9mctionane�erebyam�ori� r¢pBsenlaiiv olthiscity�oenleruponlheabove-mentioned
�perry for ms ction pur oses.
Oate: ��� �q � Signature'. _� �
v
Onve(s License or Social Sewrity N: �.���
t6<i�<6 W�ne—Bwldinq: Green—Cotle Enb¢emenC Canary—AOPlican�; Pink—Revenue: Goltlenroe—Assessor
CITY pF COSTA MESA - BUILDING PERMIT PEAM NU: P 053086
PERMIT N(�: F 053006 PLAN CHECK NO: hi GOVT; N SUPP: N
CONSTRUCTION TYPE: V-N PERNIT TYPE: PLJ PURPOSE: ADD
JOB DESCRIPTION : 260SF 2ND FL RESIDENTIAL ADDITION SQ FT;
CLAIM VALUE: CALC-VAL(JE: GROUP OCC: R-3 /
COMMEiJTS: REF• B5247'1
�t***u��t*#x��titx�*�-��t**i��t*�t*�tit�ttrir***i�i�x�***+t**f��rit���t�r�*�c�x�*�t•���*�tu�*�t�*�**�:-*���i�*�ti��t**-�t?�i��t��x�
Z O N I N G R E Q U I R z M E N T S
sETBAcxs
------------ MASN BUILDING ---------- --------- ACCESSORY 8t7ILDING ---------
FRNT: FT IN REAR: FT IN FRNT: FT IN REAR; FT IN
LEFT: FT IN RGAT: FT IN LEFT: FT IN RGHT: FT IN
PARKING REQ • FROV; nARCEL; 13994405 ZNa;• Rr.F NO:
PLANNING NbT'ES>
?
if 3E iF �R if �E �1F *�1E9't!F # I(� if 3F 1e it 1F 3E iE iE iF af dF k 1F iE if iF f� �lf iP iE 3f �1f iF iE 3F if if �)E 1E 3f !F iE #.if 1F 3E If if iF i41k if ii� iF if aF iE iF iE fF 3E iF ie aE �N- i?- iE�lh R iF a%iF i? i(� if �IE
D E V E L O P M E N T S E R V�I C E S� R E Q U I R£ M n N T S
ZONING APPROVED BY DATc;
BUILDING APPROVED BY ; ' DATE;
APPLICATION ISSUELI BY• - ,. DATE: 7�i�
if�lFiFiEK�1tiF3FififlEiflEaf�Eitatlki6-kif�'��4 . . R'iF£'£� � . � � *ie3fieiEiFiFiPi'r�k �cir� r xii�#�
if iE iP if 3F iE iF iE iE iE jF 3(� iE iF !f 3E iE iF iE 3f if iE } jF 3f 3c if ie 3f iE iF if 1F jF 3E iE *�)f iE if iF iF i4 3i� i(� iE aE lE iFlf iE i(� iE IE iE if iE i'r IE 1E �E IE iE )E if i'r ie i41E iF iE � if� i't �F if it�iF
LEGALIZATION;N F E E S U N. M A R Y STRUCTUiAi, SEGNENT:N
HLDG PMT PLOMBZNG ELECTRIC MECHANIC FIRE SMIP/RES GRAUING
PERMIT 2.00
25$ SMIP/NON-RES
PLAN
ISSUE FF.H 3,00
BUILDING-DIV-> PERMZT ISSUn PLAN-CHECK POTAL PAID DUE
TOTAiS----> 2.00 3,00 0.00 ;,00 5.00 .00
REVENUE DIVISIO�1 TOTALS--> COiLECTED; 5.00 OVER/SHORT; ,OU
BLDG PMT PI�UMBING cLECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN-CHECK
5.00
3E iF iE if 1E IF iE IE ie if iE If 3f 1F fF ai ie iF iF 1flf iE 3f if 3e if iE 3f af i%jF if 1E iF iE 1f IE if iE if iE �F 3E if # fE 3f ik IE i� ir i: 3i� if iE if iF 1F M 3F )E iE if ji af i� 3'r jf 3f 3f �F iF iFlF � i� i4 ih if
I N D S V I D U A L F E B B R E A K D O W N
T'YPE QTY D E S C R I F T I O N UNZT COST TOTAL COST
PLU 1 GAS SERVICE 2,00 2,00
END QF FEES
0! 00093191-,riUQ9&iSi B ��-�
DATE: 67,'26.�92 TIf'tF: :;:'i2
^
CONSTRUCTION AND PLANNING POOL 'A /
APPROVALS Permit #�.._- yDate Inspector qppROVALS Permir # Date Inspector
7. Temporary Electrical Service,,2r Pole _�� 52. Pool & Equipment Location j�
2. Soil Pipe-Undrgmd. � ,� 53. Steel Reinforcement ^,
- 3. Electrical Conduit Utility-Unyzgmd. � 54. Forms `;,
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. Eiectrical Conduit�Undrgrnd.
8. Foundation ' � y 59. Gas Pine, � Undrgrnd., Test !`
9. Water Pipe-Undrgrnd. �,f - 60. Backwash Lines, P-Trap, O Undrgrnd. i'.�
10. Structural Floor SVstem %S 61. APPROVAL TO DECK �{
11. Property Sewer Line & House Connection � 62. Backwash & fieceptor-Final '�
12. Sewer Cap ;/ % 63. Heater & Vent�Final �;<%f
E.7 ;;?
13. Roof Drains �� �/: 64. Plumbing SYstem � Final i��'
14. Rough Plumbing � 65. Electrical-Final �
15. Rough Electrical-Conduit � � 66. Solar System-Final '
16. Rough Electric Wiring 67. Fencing & Access ApProval
77. Reugh Wiring $�n 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace ' - APPROVALS Permit #
21. bucts, in Structure . 70. Underground Hydro
22. Ducts, Ventilating � � 71. ProductPiDing OGas ❑Oil
23. Gas Pipe-Rough & Test 72, Underground Flush
24. Roof Framing � 73. Undergrnd.StorageTank OGas ❑Oil
25. Roof Sheathing _ � 74. Overhead Hydro
26. T�Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing � 76. Dry Standpipe
28. Lathing & Siding � 77. FIXED SYSTEM F�INAL
29. Insulation � ' 1� 78. FIRE PREV. FINAL
30. Drywall Nailing '� HEALTH DEPT. REQUIREMENT
37. Plaster Brown Coat '` 79. FfNAL INSPECTION
32. Electrical Power Meter-Final �1 80. FOOD CERTIFICATE ISSUED
33. Final Electric � �' Notes: .
34. Final Heating & Air Conditioning �� �
, 1 1
35. FinalGasPipe-Test 7�$p�l)� L�,p� � .
36. Hood or Canopy � -
37. �Final Factory Fireptace - '
"38. Final Plumbing - 7,I,�U!'% L�(7
�39. Water Service�Final � ' '
40. Gas Service�Final . ,
41. Solar pomestic-Final . �
42. Backflow Preventer � �
43. Backflow Irrigation - '
44. Landscape Irripation System � .
45. Sound Attenuation �
46. .Handicap Regulations � �
47. FINAL STRUCTURE & BUtLDING ;� �
� ,,.
48. FINAL PLANNING - �. ,
49.-Electric Release to Edison �.
�: ; �
50. Gas Release to Southem California Gas Co ,' j �
57. CERTIFICATEOFOCCUPANCY
No. Date
�
J
Pfl0.1ECT ADOPESS: . UNIT:
UWNEfl'SNAME: 28SH INROZ D2Z
nooeess: 'LABARSKY, OSCAR P
3 NARHONNE
NEWPOR7' HEACH,CA 92660
AflLN/ENGINEEH: 9% 9— i O B 2 flEG.NO.:
aooxess: RUDY RODRIGUEZ C2iiw310
14172 BOWEN ST
PEPMITTEE: G,G, CA 92643
aooeess: SMALi.COMH WIRING INC, (714)556-8591
136 E. GARRY At1E
cn��Tn ��)n (-p
UCENSE� CONTflACTOKOFt[AflFTOR "IIRRby al�irm thal I am licensea unAeijrtaVisiO f p er 9 �commencinA wii� Seciion
LITY LIC.: STATE LIC.: � NSS:
�11��5 —
Oale: Signaiu�'_�._ _ . — _ - - _
WONNENS' COM NSATION E ATION: I he� a lum �nat I ha� ce ihcate oi consent to selbinsure or a cenilicate oI Workers'
Compensa�ion Insu�ance, or a renilied copy Ihereal (Section 3800, LaD. C�.
roucrwo.: WC68004433-02 EXP.ORYE:
COMPANY: ('('j�''
^ CertlGed Wp}RShE'Ye�y �wN51�e4. ' y �5 e city BUAtlmg lv' '
.e�'������ A I'3 f �
t
EXEMPTIONFBOMWOflREBS'COMPENSRTIONOECIABATION: (TAi55ec1ionneeOno�becompleteai�t�epermiti5�oronehu�qre0�$1W�orle55�.
1 certily ihai in ��e pedormance ot Ihe work for whi[h �his permil is i55ueA. I shall no� employ any perSon in any mann¢r so as la Oetame
sub�¢tl Io �he Workert' Compen5aiion Laws ol California.
Date: SignaWre:
NOTICE: II. after making t�is aeclaration, you shoul0 became wbleci to t�e Warkers' Compensation provisions ol tAe Lahor
Cotle. you musl lonnwilh compty wilh such provisions or ��is permit shail be Oeemed revokeU.
CONSTPUCiION LENOING AGENCY: I nereby aliirm iha� there is a consimction lending agency lor ihe pertormance oi �ne work lor
w�ic� Ihis oermii is issued (Section 3W7. Civ. C).
LENOEfl:
AOOflESS:
OWNEB BUILOEB DECIABRTION: 1 �ereEy aflirm Ihai I am ExemD� <<om I�e Caniraciors' Slaie tit¢n5e Law tor IAB lollowinp reason
(Section 7031.5 Business ana Pmlessional COtle: Any cily ol county w�ic� repuires a Oe�mil �o conslNct, alter. im0�ove, Oemolish. or
repair any StmcNre. Orior to ils issuance, also require5 the applicant �or such permii lo lile a SiBned Statement IAai hC/5Ae is licensetl
pursuanliolhe pmvi5ion5 olihe Coniratlors' Slate liten5e Law�C�ap�er9�tommencing wiih $et�ion 7000) of�ivision 3 ollhe Busine55
antl Prolessions Cotle� or I�al he/she is exempllherefram anU �he basis lor �he allegeU exemD�ion. Any viala�ion of Sec�ion 7031.5 by
any apolicant for a Dermil sublecis ihe applicant to a civil penalty ol not more ihan live hunAreO dollars ($500).
I, as owner ol ihe D�openy or my employees wilh waAes as iheir sole comp¢n5ation, vnll do ihe work, antl t�e
❑ simcmre is fwi imenCeU or oflerea for sale �Section 70aa, Bus�ness and Pmieuional CoGe: ihe Cantracmrs' Siaie License Law
Coes nat appN �o an awner ot a pmp¢rty who builGs or imp�ovu I�ereon, antl w�0 GOes su[h work himsell/herull at IAmugh
his ar her own ¢mpby¢¢5. proviEeC ihai such impmvemeni5 ar¢ no� in�entleC or ufl¢retl �or sale. It, however Ihe �uilding or
impwvemenl is 5dG wil�in one year of com0letion, ih¢ ownG�'MO �av¢ ihe Ourtlen ol prodnp he/she tliU no� 6uild or imDrwe
lor ihe puroose ol sale�. ,
I, as owner of ihe proDetlY. am exclusively conimcting with Iicense0 coniractors to conslmcl the pmject (Section 704a, Business
� antl Pmlessions Code: Tne Contracmrs' Siate License law aoes not apDly �o an owner ol pmperty who �utlas or impmves ihereon
antl who coniracis br sucA pmlecls wilh a contradoqs)lic¢nse Dursuanito Ihe Conlraciors' S�a�e License Law�.l am aware
Ihai pmo� oI Iheir Work¢r'S ComOensa�ion insurante ShOWd he pmviDeU �o me.
� I am exemo� untler Sec�ion: B. 8 P. C.
lor ihis teason:
Dale: Owner.
I Oo �ereby cenity ihat I am aware ol ana untlerS�anE �he requiremenis oi Cali�omia Heallh anG Sale�y Cotle Sections 25505, 25533, antl
25534 antl tha� I or any lulure builOmg occu0anl willlwili not (circle one) neetl b comply with saitl slale codes an0 Ihe repuiremenis �or a
permil lm consimcuon or moUilicalian �mm Ihe Air Oualily Managemenl Oistricl HeSiUenliai consimclion aDPlicalions are exemp� �mm
I�ese pmvisions.
Daie'. Ap li�
I heie0y certify�hat I have read this ap ca�ion and s�a�e I�at 1 abo+e informaiionis corre . I aB�eeio compty with all ci�y an0 counry
orainancesandstatelawsrelaunglobuilding , �er Ihorizerepresenl ' 'olihistirylo¢nteru ntheabave�mentionetl
o�operty ior in��eclion purposes.
�ate�.(���j Signa .
Oriver's license or Socfal Setuniy a: �,� �� ��'
i6at�a6 Wbite—Butltlmg', Green—Code Eniorcemenf, Canary—APplicanC Pink—Ravenuo: Golaenrotl—Assessor
CITY OF COSiA MESA — BUILDING PERMIT PERM `D: E 053064
PERMIT NO: E 053U64 YLAN CHECK NO: N GOVT: N SUPP: N
CONSTRiJCTION TYPE: PERMIT TYPE:; ELE PURPOSE: ADll
JOH DESCRIPTION ; 260SF 2ND FL RESIDENTIAL ADDITION SQ FT:
CLAZM VALUE: CALC—VAL"JE: GROUP OCC; R-3 /
COMMENTS; RE: B52977 PRIMARY BLDG. PERMIT.
iF iF iE iE IF iE i6 iF 3F iE 1E # iE �IE # if iF lf iE iE iF IE 3f If if� N� iE 1E IE �E �(-�lE Y.� iE iE iE iF if 3f iE 1E if If ik if if iE if iP iF K if 3F �E if� if iE 3E?6 it ie iP �lE iF 3E iP 1F �E iE iF 3E iF lf �F aF?f # ic iF
2 O N I N G R E Q U I R E M E N T S
S E T H A C K S
------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDItvG ---------
FRNT: FT TN REAR; FT IN rRNT; FT IN REAR; FT IN
LEFT: FT IN RGHT: FT IN LEFT; FT ZN RGHT; FT IN
PARKING REp• PROV; PARCEL: 13944405 ZNE: REF NO;
PLANNING NtSTES>
i
if �IR 1f af if iE if iE iE iE �E iE iF ii� jF jF iF �f iF if If !E 3E iE �f if iF iE IF �K 1F df �f ii� {F �1F ik iF ff 3F if 1E 1E �lf iF 3E if �lE iF 3F 3E ie iF 3f 1F # 3E if if� iE jF �f IE IF iF �l(- iE �1(� if li 3f iF ie 1?� iE �E 1F iE i(�
D E V E I� O P M E N T S E'.R V i C E S R E Q U I R E M E N T S
20NING APPROVED HY llATE:
BUILDING AFPROVED BY ; .• DATE:
APFLICATION ISSUED bY•� DATE• Z—_S"' �
1FaE1ffflElE�EiFltifiFjElFiE3EiEiFiF3Fik3EiE t £iFiFi(�ifififi4-1ffF3FaFi6 iEjh
iElfit�ifiFifiElEikiFiF3EiEk?E�Iflfiiif?E3E�f1f*�EiEiF3Fi[�f3EiEifiE�fi4iF3E �FiE� �iEiElfiEiEiFa£3E�f•iFiElkjeififiPitiFiE�l!�if�E*�EiE3E�Ek�1t�iFifiE7hiF
LEGALIZATION:N F E E S U M M A R Y STROCTURAL SEGMaNT;N
BLDG PMT PLUMBZNG ELECTRIC MECHANIC FTRR SMIP/RzS G�ADING
PERMIT
PLAN
ISSUE FEE
BUZLDING—DIV—>
TOTALS---->
1g50�
15.00
PERMIT ISSUE PLAN—CHECK
18,75 15,00 0,00
SMIP/NON—RES
TOTAL PAID DUE
33,'15 33,75 .00
REVENUE DIVISION TOTALS--> COLLECTED; 33.75 OVER/SHORT; 00
BLDG PMT PLUMBZNG ELECTRIC MECHANIC FIRE SMIP/TOT GRADINC, PLAN—CHECK
33.75
If it iE iE 3F k if iE k 1E if IE #f 1f if ik if iF If IE #t iF 1Eif if iP )f IE Ik if iE 1E !E 1f IE iE if k 1f iF iE iF iE iE if iE iE if if if aE ie if %� iE iE !F iE if iF i6 iE iF Y.� iE 3E iF i'r 7E i'r i4 iE If iF i't if !i� i(� iE
I N D I V I D U A L F E E B R E A K D O W N
TYPE (,�TY D E S C R I P T I O N t7NIT COST TOTAL COST
ELE il FIXTURES LIGHTING 1 ST 20 EA. .'75 8,25
ELE 10 RECEPT/O{7TLET 1 ST 20 EA. ,75 7.50
ELE 9 RECEPT/SWITCH END10FTFEES EA, ,75 3,00
�l1 OQ09�G9�i-0^093G99 '*c� 7
JA'iEe D'i26.`9f fIGE: i'::.'
CONSTRUCTION ANDPLANNING POOI A
APPROVALS Permit# ' Oate Inspector AppROVALS Permit# Date Inspector
%' ; .
1. Temporary Electrical Service oc Pole �i� 52. Pool & Equipment Location �"
2. Soil Pipe�Undrgrnd. �` 53. S[eel Reinforcement �„
3. Electrical Conduit Utility-Undrgrnd. j 54. Forms �,
4: Electrical Conduit�Undrgrnd.'� � 55. Electrical Bonding �
i
5. Steel Reirtforcement � 56. Rough Plumbing & Pressure Test
6. Eiectriwl UFER Grnd. . ' S7. APPROVAL TO COVER-GUNITE
7. Footings � � �' �� 58. Electrica� Conduit�Undrgmd.
8. Foundation j � � 59. Gas Pipe, O Undrgrnd., Test � �
9. Water Pipe-Undrgrnd. ��'- ^ �� � 60. Backwash Lines, RTrep, O Undrgmd. .-
70. Structural Floor System F' �,��, 67. APPROVAL TO DECK '��
71. Property Sewer Line &'Houie nnection �\ 62. �Backwash & Receptor-Final ,'=(
12. Sewer Cap �J� � � �l 63. Heater & Vent-Final �'�, �'�
13. Roof Drains � -S �i ! 64. Plumbing System • Final '�
74. Rough Plumbinq -, J 65. Electrical-Final �
15. Rough Electrical-Conduit � � '
�-� � 66. Solar SYstem-Final _
76. 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 FINA�
79. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace . APPROVALS Permit #
21. Ducts, in Structure ' 70. Underground Hydro
22. Ducts, Ventilating � 77. Product Piping O Gas ❑ Oil
23. Gas Pipe-Rough & Test 72. Underground Flush '
24. Roof Framing ' - 73. Undergmd,Storaye Tank O Gas ❑ Oil �.
25. Roof Sheathing � 74. Overhead Hydro
26. T-Bar Ceiling (Structuraq & Monocoat . � 75. .Dry Chemical �
27. Frame and Flashing 76. Dry Standpipe '
28. Lathing & Siding � � � 77, FIXED SYSTEM FINAL
29. Insulation _ : 78. FIRE PREV. FINAL . -
30. Drywall Nailing =. . � HEALTH DEPT. REQUIREMENT
31. Plaster 8rown Coat 7' 79. FINAL INSPECTION •
32. Electrical Power Meter-Final � `J � 80. FOOD CERTIFICATE ISSUED
33. Final Electric '/ 7��� {/ Notes:
/� (/�
34. ,Final Heatinq & F.ir Conditioning � � L�;�'
35. Final Gas Pipe•Test , / - ' .
36. Hood or Canopy . ' .%� ; � , �
37. Final Fattory Fireplace ' �-��"� � �- �
i%
38. Final Plumbing � � .
39. Water Service•Final 1 � �
1 •
40. Gas Service-Final , '
41. Solar pomestic-Final
42. Backflow Preventer
43. Backflow Irrigation
44. Landscape �rrigation System , .
45. Sound Attenuation
46. Handicap Regulations ' ' ,
47. FINAL STRUCTURE & BU�LDING �
C' �'
48. FINAL PLANNING ' � ;,f `
49. Elearic Release to Edison ���� .
50. Gas Release ro Southem California Gas Co I�(Y�- � . -
�
51. CERTIFICATEOFOCCUPANCY'
No. Date
Insulation Certificate
City of Costa Mesa
California 92628•1200 P.O.Box 1200
��c -IZ-Z-q � �
Permit Number /� �� � � �
a�sY O-��-n�� � i�
INumber entl slreet Ciry
County Subdivision _ Lo� Number
ROOF
Material
Thickness (inches)
EXTERIOR WALL�
Material
Thickness (inches) -�"
Description of Installation
Brand Name
Thermal Resistance (R-Value)
Brand Name _(/G���.t�.�
Thermal Resista e (R-Value) �
CEILING
Batt or Blanket Type �' Brand Name �i�G�
Thickness inches �� �
( ) '�J Thermal Resistance (R-Value) 3
Loose Fill Type Brand Name
Contractor's minimum instdlled weight/ftz_ Ib. Minimum thickness inches
Manufacturer's installed weight per square foot to achieve Thermal Resistance (R-Value)
RAISED FLOOR
Thickness (inches)
SLAB FLOOR
Material
Thickness (inches)
Width (inches)—
FOUNDATION WALL
Material
Thickness (inches)
Brand Name
Thermal Resistance (R-Value)
Brand Name
Thermal Resistance (R-Value)
Brand 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 Building Energy Efficiency Standards for new residential buildings contained in Title 24 of the
California Adminstrative Code.
�/a`�O ��j
General Conlrector (9uiltler) License Number
_�'r��r-� �C�,Cv__�r�- o,�,"_�r �?.� . 9, � 9 9/
igna�ure and Ti�le Da�e
Sub-Contractor (Insulation Installer)
Signature and Ti�le
1901d6
License Number
Da�e
VnnCR
JOB ADDRESS
GENERAL CO
'��AP No.139-4
'INSPECTIONS
SOIL
GAS
WqiER
$OUGN PLUMBIM
PROP. SWR. LINI
SPRINKLING SVS
MISCELLFNEOUS
UAIC
SUBCONTRACTOR
ROUGHHEATINGANDAIRCONDITIONING K���'����j��-`uR;�i
TEMPORRRY SERVICE OR POLE ��,• `d � � z� ij `^
UNOERGROUND � POWER �
ROUGN WIRING (�!' Qo�j� a�d �l �.
TRENCMES FORMS STEELREINF. •.li S�`^ �µ, y
FLOOR SYSTEM ' --- -- , . ' '
a
SHEr1THING
FRAME ANO FLASHING
P
STRUCTURAL, FINAL
HEATING, VENT., REFRIG. AND A.C., FINAL
PLUMBING. FINAL ANO GAS TEST n
�-
;�
a �;�
/� COSTA MESA BUILDING-SAFETY DEPARTMENT
V.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
' For Applicant to Fill in Comple[ely — Use Ink Only
BUILDING �1 Q (b ^f'N%�OZ �T
ADDPESS o[ b J CJ .1
F
�
a
a
�
�
�
F
C
w
F
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a
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a
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6�
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CC'
3
OWNER//� J/
MAIL T
AD�RESS ��'
CITV �'7�
CANSTRVCTI�N
BFANCH
A�ORE55
ADDFESS
CONTRACT�R
AD�RESS Z
CITV /
STATE �
IIC. NO.
SIZE
OF LOT
USE OF
TEL.
NO.
TE
CITV
LIC. N
INO O
NOWI
Separate permits are required for
electric, plumbing and heating work.
USE OF BUI�DING AND WOFK TO BE PERFOFi�
�
I hereby ecknowledge Shat I have reatl this epplication antl state
that the abo�a information is correct antl agree to comply with
all laws regu�ating bu(ICing construcHon, and I shell not employ
any person in violation of ihe workman's compensation laws of
the Stata of Celitornia.
I hereby cert�fy thet I em prope�ly Ilc¢nsed as a contractor untler
the State of California Business antl Professlons Cotle, Oivision 3,
Chapte� 9, ar�d thet such Ilcenses are in full force entl effect, or I
am exempt from the provlsions ot the Stete of Callfornia Business
antl Professio�s Cotle, D' islon 3, Chapter 9.
Signeture of
Permittee
Authorizetl ABent
PGI�
�Fe?6-���M<<.00?oio�: �rt��42.50
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AUTHORIZED A6ENT
FEE ,RECEI�ED
MAR 2 2 1963
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VALIIATION 18 POP TH8
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