HomeMy WebLinkAbout3008 JAVA RD - Building Permits�
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CITY OF COSTA MESA
BIIILDING DIVISION
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>� = 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • wv+w.ci.costa-mesa.ca.us
`�. - ` ? FOR INSPECTIONS CALL: (714) 754-5626
�°�^"`' PERMIT NUMBER: BC11-00518
i._ �
PERMIT TYPE:
$ub Type:
JOB ADDRESS:
APN: 13924175
Vicinity:
Const Type: V•B
B COMBO
RES_ALT
3008 JAVA RD CM
SQ. FT:
Zoning:R1, ,
239
STATUS: ISSUED
DATE ISSUED: 1 111 812 01 1
ISSUED BY: KJB
Suite/Unit:
Primary Occ:
Valuation: $200,000.00
SCOPE OF WORK: 239 SQ FT SINGLE STORY ADDITION TO AN EXISTING RESIDENCE. ADDITION W ILL BE A NEW MASTER
SUITE AND BA7H. MAJOR INTERIOR REMODEL. REMODEL WILL INCLUDE: KITCHEN AND 2.5 BATHS. RESIDENCE WILL BE A
4.BEDROOM/3.5 BATH AFTER THE ADDITION AND IMPROVEMENTS. 359 SQ FT PATIO ADDITION. MECHANICAL TO INCLUDE:
1
FAU CHANGE OUT. 1 VENT FAN, 1 APPLIANCE VENT. ELECTRICAL TO INCLUDE: 57 LIGHT FIXT, 69 OUTLETS, 53 SW ITCHES.
1_SERVICE UPGRADE TO 200 AMP. NO RELOCATION OF SERVICE. PLUMBING TO INCLUDE: 2 BATH TUBS, 1 DISHWASHER,
t GAS (1-4 OUTLETS), 2 BAR SWKS, 1 KITCHEN SINK, 5 WASH BASINS, 4 TOILETS, 1 WATER
FiEATER.
REF: MM-11-18 FOR 8'-4" REAR SETBACK.
n.
OWNER: GqLE, RYAN AND CATHERINE Address: 3008 JAVA RD
Phone: 714d21-1035 CitylState/Zip: COSTA MESA, CA
APPLICANT: ANKRUM, C J Address:
,Phone: 710.-742-1750 City/State/zZip:
CONTRnCTOR: BLUE PACIFIC CONTRACTORS, INC License No. 936149
Phone: 714-7q2-1750 Address: 3111 W CNETRAL AVEUnit:
Cell: City/State: SANTA ANA, CA
ARCHITECT:
ENGINEER: MOR ENGINEERS
COMBINATION pERM1T FEE SUMMARY
Building Plan Check:
Building Fees:
Electrical Fees:
Mechanical Fees:
Plumbing Fees:
SMIP Residential:
SMIP Commercial:
Bldg Std Admin Fund
TOTAL FEES:
License No.
License No.C72911
$252.49
31,553.75
$230.62
$45.75
$240.50
$20.00
$0.00
$8.00
$2,351.11
HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE
thru Friday • 7:00 am thru 7:00 pm. Sa[urdays- 9:00 am ihru 8:00 pm. Pfohi
Unit:
Unit :
ZipCade 92704
PHONE:
PHONE:714-943-2384
- PER CMMC Sec. 13-279
urs - Sundays and the following Federal holitlays:
;p��ggyq[gQ��rqgQ��alifomia statutes and rf
regulations. (Ord. No. 9248, § 1. 12-21-92) - - �- — — --
EXPIRATION: P�RMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply wi[h all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of lhis permit.
COOE p. INSPECPON TVpE
1676 Fixed SyStem Final Fire Preventron
1266 Pool Spa Final
200 Final Re-Ropf
201 Final Block/Retaining Wall
202 Final Factory Fire Place
203 Final Sign
�20'4 Final Demolition
n���
UATE INIITIALS CODE� INSPELTIONTYPE
206 Final MecAani�yl
208 Final Plumbing
210 Final Eleclrical
212 Final Fire Prevention
220 Final Planning Approval
222 Final Slte
250 Final BuildinyOccupancy
ORTE IN1111RL5
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WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalry o( perjury one of the following declarations:
❑ I have and will maintain a certifcate of consent to sel4lnsure for workers'
compensation, as provided for by section 3700 of Ihe Labor Code, for the
performance of the work for which this permit is issued. �
❑ I have and vrill maintain wnrkers' compensation insurance, as requiretl by
secl'ron 3700 of the Labor Cotle, for ihe peAortnance o( the vrork for which this
pertnit is issued. My workers' compensation Insurance wrrier and policy
number are:
Carrier:
(This s2Cion neGtl n01= p'e� pe�m� 4 vaW af �undretl tloqa4 (5100) w less.)
Policy Number: ^�N1
I certify that in Ihe peAormance of Ihe vrork for which this permit is
ed, I shall not employ any person in any manner so as to become subject
to ihe vrorkers' compensation lavrs of Cali�omia, and agree that if I should
become subject to Ihe vrorkers' wmpensation provisions of Section 3700 0!
the Labor Cotle. I shall lorthvrith comply with these provisio .
����� � (
��canCs Signawre a�e . '
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 DOLLAF2S
(5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aHirm ihat I am licensetl under provisions of Chapter 9(commencing
with Section 7000) o! Division 3 of the Business and Professions Code, antl
my license Is in (ull force and eHect.
Lic. # .C4�% �l / S' �'7 Class # %3
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�r omraaor55ignaWre - ale
CONSTRUCTION LENDING AGENCY:
❑ I hereby af(rm �hat there is a consWction lentling agency for Ihe
peAortnance of tlie �+ork fa which this pertnit is issued. (Sea 3097, Civil Cotle).
Lender's Name:
Lender's Atldress:
SignaWre
OWNER-BUILDER DECLARATIONS:
I hereby aKrm that untler penalty ol perjury that I am EXEMPT FROM THE
CON7RACTORS LICENSE LAW (or the following reason (Sec. 7031.5.
Business and Pmfessions Code: Any city or county which requires a permit to
consWct, alter, improve, demolish, or repair any sWCWre, pnor to its
issuance, also requires the applicaN for such permit to file a signed statemeni
that he or she is licensed pursuant to the provisions o( the Contracrors
License Law (Chapter 9(commencing with Section 7000) of Division 9 of Ihe
Business and Professions Code) or that he or she is exempt therefrom antl
the basis for the alleged exemption. Any violation of Section 703L5 by any
applicanl for a permit subjecis the applicant to a civil penalry of not more than
five hundretl dollars (5500�.�:
❑ I, as owner of the property, or my employees with wages as their sole
compensalion, WILL DO THE WORK, and the structure is not intended or
offered tor Sale (Sec. 7044, Business and Professions Code: The Contractors
License Law does not apply to an owner of property vfio builds or improves
thereon, and who does such work himself or herself or through his or her own
employees, pmvided that such improvements are not intended or oKered for
sale. I(, however, the building or improvement is sold within one year o!
complelion, the owner-builder will have the burden o( proving Ihat he or she
did not build or improve for purpose of sale.).
0 I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH
LILENSED CONTRAC70RS to construct the prqecl (Sec. 7044. Business and
Pmfessans Code: The contractas License Law dces not apply to an ovmer of
pmperty wfio builtls or improves thereon, and who cont2cts for such projecl vrith
a contracta�s) license pursuant to the Contractors license Laws.).
❑ I am exempt un0er sec.
Business and Prolessions Code for this reason:
JOS]-46(3/01)
Owner ID verifietl by drive�ense. ❑ Yes ❑ No
Driver's License No. Expires:
Verifcation of Ownership by (�ype of documenC i.e. - pmperty taz Dill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby ceAify that no excavation fve (5) or more feel in depth into which a
person is required to descend, will be made in connection with work authonzed
by �his permi�, and that no building sWCWre, scaffolding, (alsework, a demolition
or dismanlling thereof, will be more than thirty-six (36) /eet high. (Chap. 32, Gry
2, Art 2, Sec. 341, Title 8, California Administrative Code)..
❑ As ovmer-builtler, I will not employ anyone to tlo vrork which vrould
require a permit from the Division of Industrial Salety, as no�ed above, unless
such person has a permit to do such work (rom the tlivision.
APOhranfs Signalure
Division of Industrial Safety Permi� Number: _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or (uture building occupant neetl to file and
certify a Business Plan for emergency response to release or �hreatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 0/ me California Health and Sa(ery Cotle requires, with some
exceptions, �hat a Business Plan be filed with the Costa Mesa Fire
Deparimen� by every business which has at any one time tlunng a reported
year a quantity o( hazartlous ma[erials equal to or greater than a weight of
500 pounds, or a volume of 55 gallons, or 200 cuDic feel ot compressed gas
at stantlard tempera(ure antl pressure).
2. Does or will �he applicant or present or tuNre building occupant need to file
a registration form for aculely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the Cali(Ofnia Healm antl Safery Code, wim SOme
exceptions, requires regisira�ion with �he Costa Mesa Fire Depanmenl by
each business which a� any one time has on hand a quantity of acutely
hazardous materials equal to or greater Ihan a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standartl
temperature antl pressure).
3. Does or will the applicant or present or fu�ure building occupan� need to
prepare an RMPP (Risk Management and Prevention Program for acutely
haZartlou5 material5)? ❑ Ye5 ❑ No
(Section 25534 of the Califomia Healm antl Safety Code provides thal the
Costa Mesa Fire Department may require the preparetion, certifcation and
filinq with the Fire Department of an RMPP by businesses which are required
to fegi5ief acUtely haZartloUs materials wilh the Fire DepaRmenl.
4. If an RMPP is presently require4 has Section 25534 0( the Calilomia
Health antl Safety Code been fully complietl with? ❑ Yes ❑ No
5. Does or will the applicant or present or (uture buildinq occupant require (or
the work which is the subject of �his applica�ion a permit for suc� wnsWction
or modifcation Irom Ihe South Coast Air Quality Managemenl District or from
any other air pollution control district or agency? ❑ Yes ❑ No
(Sectbn 65850.2 of ihe Califomia Govemment Code requires that the requested
informa�ion be fumishetl on applications fa non-resitlential builtling permits�.
6. Will any pah Of lhe faCility to be constmctetl untler this permit be wilhin
1000 leet from the outer boundaries of a school? ❑ Ves ❑ No
Qf "yes", the facility must meet the requirement of Sec�ions 25534 an0 42303
o( lhe Cali(omia Health antl Sa(ely Code).
7. If a permit fmm the South Coast Air Quality Managemenl District or other
air polWtion control district or agency is required (or the vrork which is the
subject of ihis application, have all of the disclosures prescribed by Calitornia
Healih and Safety Code Section 42303 been matle? ❑ Yes ❑ No
8. Qf "yes", auach certificate of compliance from the appropriate air pollution
contml oKcer).
CERTIFICATE OF COMPLIANCE I certify that untler penalry of perjury the
infortnalion given above is correcL I agree ro comply with all state laws and
city ordinances regarding Hazardaus Materials and Emissions.
Sgnawre oa�e
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalty of perjury that I have read lhis application and state thal
the intortnation given is wrrect. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize �epresentatives o(
the City o( Cosla Mesa ro en[er upon the above-descnbed property for
inspection purposes. 1 agree no[ to occupy or allow occupancy of any builtling
authorized by this permit until final inspection.
Sign�(LeflalOwner�� D le
!-� -L11f�
�Antllor Aul�onze0 Applicant � Date
�'�''� v'`+f'� W ncar�ant to nu �n au :Pxes ex�ePt tnose witni� nea�y noraer nnes aoa sisn au avc�ovr�ate aeciaratio�s. 606,2 � �/,27/�86 '
, 5.00 .
CITY OF COSTA MESA CONSTRUCTI.ON PERMIT MIT NO. TRACT NO. LOT NO. UNIT NO. ' �� � ' � '
� � �� c� aJ � .
Proj�ct Address _ ' _, •
Applicant's Mailing ddress m � TYPE OF CONSTRUCTION NEW ADD ALTERATION REPAIR �
�� ❑ CONVERSION ❑ DEMOLISH ❑ OTHER q p, # ZOne .
� Owner's Name Phone %/'7/� DESCRIPTION OF WORK/USE OF BIDG.
Address - �� �-� S Main Building: Actessory Buildin9:
� Z
ArCh/Eng. LiCenSe No. TVPE OF PERMIT GRA�ING�� FOUNDATION STRVCTURAL T FrOnt p
Address � (� ❑ TENANT ❑ ELECTRICAL lld PLUMBING ❑ MECHANICAL .B Rear ' N
ConVactor's Nam (y Ptione � � OTHER A _ _ . , _ �
n PROJECT DESCRIPTION Sp. FT. OCCUPANCV K Right G
Address (ma'f g) � � -
CONSTRVCTIONTVPE VAWATION$ S Left R
CityLiCenseNo. ������� r_ 20NE G0.A�INGCU.VDS. ACRES
LICENSEO CONTRACTOR DECLARATION Ping. Ref. # � Parking Req./Provided E
1 hereby atflrm that I am Ilcensetl untler prov15I0n5 of Charte� 9(commencin9 Remarks � Planning Notes: � �,r M
wi[h s¢ction ]000) of Division 3 of Ihe Buslne55 antl Professlons Cotle, and � '' � T
T IICClISC IS Il11UII,pIn antl eftect. /� '� r � � S
��Licen� C}�is!^�/ ����r^`y� " � . . '
Oate ���� 6 r s�9 � L�4 t � P�UMBING � FEES .
� WORK RS' COMPENSATION DECLARATION Bef Si�k ' ShOw2f5 �
II hereby alfirm that I have a certifiwte of consent ro selt-insura or a certlticate . ELECTRICAL FEES
of Workers' Comoenwtion Inzurance, or a certlf tl tooY � ereof (Soction Back(IowPreventer ServiceSink
� 3800, Lab.. � d r��/�' . Automatic Washer Transformer � 15-50 KW
Policy No.���L'�i,���� ComPanr-��i��f�����Lw` Backflowlrri9ation SewerCaP " ConstructionPoleSub. ❑ SO+KW' .
❑-�'ertifie copy Is her¢by furnlSheU.
8 Cer "pe ilatl with the tlty �Qlldjp�p�� Bathtuhs Sewer Connection Cooking Unit . Meter �uV to 100 amps
Dale �� APPlicant .E''(///� 1— �- .
EXEMG ON ROM WORKERS' COMPENSATION DECLARHTION Clarifiers 5018! COII¢CLO�S Dishwasher Meter ❑Ov2� 1008mps .
(This seciiOn n¢etl not be com0letetl if the permil is iar One huntlretl (E300) or
iess) DishvYasher Solar Piping Dryers ❑Gas ❑Electric Sub Panel �
I certify Ihat in the performance of the work for which this perm�t Is Issued I
shall nOt ¢mploy any pelson in any manner so as [o becOme subject [o t�le Dfiftkiny FOuntdifl5 $Oldf Tdf1k Fdfl
Morors O0.1 HP 01 h- 8
Workers' Compensation Laws oi Califomia.
Date Signature Floor Orains Swimming Pool w/Spa F.A.U. Inc. Solar �9-15 HP �16-15+
NOTICE: If, afte� makin9 thi5 tlecla�atlon, yoa shoultl become subject to the
Worker5' Compensation provi5ian5 ot the LaOor'COtle, you must fo�thwith FI00� SinkS
Urinal Fixtures Microwave
cOmply with su<h provisions Or thi5 pe�mit shall be tlCemetl revoketl.
CONSTRUCTION LENDWG AGENCV � GaSService Outlets WaterCloset
1 hereby afli�m that fhere is a constrvc[iOn lentling agency for the perfo�mance D¢vicC BOx¢5 P012 Light �
of the work (or which this permit iz i55ued (Section 309� Civ. C.) ,
Lentler•s Name Interceptors Water Heater � Outlets Range
Lender's AOtlress. KitChen Sink � Water ServiCe ' - ' -
OWNER BUILOER �ECLARATION SWitCh¢5 Sign
I hereby aftirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash Garbage Disposal Standing Sections
foliowing reason (Settion ]031.5 Bu5ine55 antl Professional Cotle: Any tify or
munty whicn reqWres a permit to construct, alter, improve; demolish or repair P—Trap Laundry Trays Generator 065 KW �5-15 KW Trash Com actor
any 5truclure,'prior to its issuance, alm requires [he applican[ fo� such pe�mit P
to file a signe0 5[atemen[ thdi he/she Is licensed pu�suant to the provisions of qoOf Drains
fhe Contractor'S License Law (ChaOter 9(commencing with Section 7000) of
Division 3 of ihe Bu5ine55 antl' P�oteszions CotleJ or that he/she i5 exempt �
[herefrom antl the basis for the allegetl exemption. Any violation of Section � .
7031.5 Dy any appliCan[ for a permit subjects tne applicant ro a civil
�Odlty of mt morG Ihan tive huntlretl tlo11aR (5500). ,
I, as owner of the property or my empioyees with wages as their sole Reinsp¢ttion Fee $15 IRue Fee $ 3
compenution, will tlo me work, antl the sVucture is not intentled or offeretl Rei�Spection Fee $15 Iuue Fee $ 3
for saie (Se<tion 7044, Business antl Professional Cotle: The Contractor's � MECHANICAL FEES
LiCenSe LdN' tloes not apply to an Own¢r of a prope�ty who bulltls o� imp�oves
thereon, antl who tloes sucn work himseli/herself or through his or ner own DEVELOPMENT SERVICES REQUIREMENTS: -
employees, P�oNtletl that such Improvements are not Intentlotl or o/leretl for BOiler Hood or Type I ❑
wle. Ii, however, tne bulltling or improvement is soltl within one year oi com- Canopy Type I I ❑ Zaning Approved By Date
pl¢tion, Ine owner w711 have the burtlen Ot proving he/she tlltl not builtl o� Im- DuCt - Untl2� G�OUnd B�ildin A rovod 6
prove for tne purpose of zale). 9 PP Y Data
❑ I, as owner ot the property, am excluslvely contratting witn Iicensetl con- Duct - S[ructural Retrigeration System Applintion laued By Dat
tratto�stocansVucl the project (SeGtion ]044, Businessantl Professions Cotle:
The Contrac[or's LicenSe l.aw does not apply to an owner of property who Duct - Ventilating ❑0.100,000 BTU ❑100,000 BTU SUMMARV OF FEES �
bWltls or improves thereon, ana who contracts tor such proiecls with a con- '
tra<tor(s) ucense pursuant to the Contractor's License Law�. I am aware that BUILDING PERMIT $ SMIP $
Exhaust System ❑ Multiple ❑ System Repair/Alteration
o�oof of their Worker's Compensatlon insurance shoultl be provltletl to me. PLAN CHECK $ PERMIT
❑ I am exempt unaer 5ection B. & P. C for this reason Firepl/FacL BIt. ICBO �k Fire Dampers PLUMBING $� ISSUANCE $�
Date Owner Heating System & Ducting Registers PLAN CHECK 25% $ ENERGV P.C. $
1 nereby certify that I have reatl mis applicatlon antl state that the above ❑4100,OOOBTU �100,0006T GRADING $
intormation Is correct. I a9ree to tomply with all city antl county ortlinances � ELECTRICAL $
antl state laws relatin9 �o bWltling constructlon, antl nereby authorize repre- MICROFILM $
sentative5 o thi5 city to ¢nter upon Ih¢ above-mentioned property for . . PLAN CHECK $0% $ ��(�
Inspectlon p - G � MECHANICAL $ TOTA� FEE $�.�
Signatur Date �
Driver4' Ucense or 55 � Reinspection Fee $15 Issue Fee $ 3 PLAN CHECK 25% $
CMF OB65-46, rev. ]0/84 White - Builtling; Canary - Applicant; Pink - q��ounting; Goltlenrotl - Assessor `�
CONSTRUCTION AND PLANNING POOL & SPA
APPROVALS � Permit # Date Inspector� qppROVALS Permit # Date Inspector�
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location �
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms r�:
4. Electrical Conduit=Undrgrnd. 55. Electrical Bonding "
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd:
8. Foundation 59. Gas Pipe, � Undrgrnd., Test.
9. Water Pipe-Undrgmd. 60. Backwash Lines, P-Trap, �jUndrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK A�
�11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final'�
12. Sewer Cap 63. Heater & Vent-Final �
13. Roof Drains - 64. Plumbing System - Final
74. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
�J 16. Rough Electric Wiring 67. Fencing & Access Approval
77. Rough Wlring Sign 68. APPROVED FOR PLASTERING
18. Rough Electriral-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning ' FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit #
21. Ducts,in Structure 70. Underground Hydro .
22. Ducts, Ventilating 71. Product Piping O Gas ❑ Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd. Storage Tank O Gas ❑ Oil
25. Roof Sheathing 74, Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREV. FINA�L
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION � '
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. final Electric Notes: �,-$-�7 ��/j�.{�, R� p�,�,0,3 U•(LG (,�,p
34. Final Heating & Air Conditioning
35. Final Gas Pipe-Test
36. Hood or Canopy
�37. Final Factory Fireplace
38. FinahPlumbing
39. Water Service-Final
40. Gas Service-Final �
41. Solar pomestic-Final
42. Backflow Preventer
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING
48. Special Requirements Completed
.
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co �
51. CERT�FICATE OF OCCUPANCY
No. Date
JOB ADDRESS
GENERAL COP
or
DESCRIPTION OF
3 Fi� zoxs
Date � GROUP T &
^ � i' �flbi I n -s
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SUBCONTRACTOR
2742I
C05fA MESA BUILDING-SAFETY DEPARTMEM
P.O. BOX 1200 COSTA MESA, CALIFORNIA 9182E
For AppllcaM ro FIII In Complsfdy
TYPE OR PRINT
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DRBYY
COSTA MESA, CALIFORNIA
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• � TX� AMOYNT OMOWry UNO6N VALUATION 19 R TNi �
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VALUATION 7
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TOTifil. P66 �� 3v