HomeMy WebLinkAbout3315 FLORIDA CIR - Building PermitsPERMIT TYPE
- � e ! �
CITY OF COSTA MESA
BD/LDING DIVISION
77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Faz (714) 754-4856 • vnvw.ci.costa-mes .us
FOR INSPECTIONS CALL: (714) 754-5626
PERMIT NUMBER P07-00602
PLUM
JOB ADDRESS: 3315 FLORIDA CI CM
Vicin'rty: REAR OF HOUSE
STATUS:
DATE ISSUED:
ISSUED BY:
Suite/Unit:
ISSUED
12/03I2007
RMD
SCOPE OF WORK: REPLACEMENT OF AN (E) GAS LINE AT REAR OF PROPERTY FOR A SFD.
OWNER:
PHONE:
APPLICANT:
PHONE:
Address:
City/State:
BOZ7A,CHARLES M
714-743-6609
BROWN, CHRIS
7'14-$64-0587
A AMES PLUMBING, HEAT, AC
9911-LARSONAVE �
GARDEN GROVE, CA ZipCode: 92644
PLUMBING PERMIT_FEE SUMMARY
FLAN CHECK FEE: $0.00
PERMIT FEE: $33.30
TOTALFEES
Address: 3315 FLORIDA CIR
City/State/Zip: COSTA MESA, CA
Address: . .
City/State/zZip: � � �
License No. 250307
� � PHONE: 800-842-2637
CELI: 714-530-2440
$33.30 �
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�
�
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia staNtes antl related
regulations. (Ord. No. g2-28, § 1, 72-27-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE Of ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authonzed under this permit to be wnsidered legal, such work must wmply vrith all applicable codes, and all
required inspections and (inal approval must be obiained. Faiture to obtain inspections and finai approval will result in the expirafion of Mis permit.
COOE R. INSPEC710N TYPE
1616 Fixed System Final Fire Prevention
1266 Pool Spa Final
200 Final Re-Roof
201 Final Block/Retaining Wall
202 Final Factory Fire Piace
203 Final Sign
204 final0emolition
UA1E IN➢11RL COUE/ INSGECPONTYPE �A7E INTRULS
206 Final Mechanical _�/���
208 FinalPlumhing�]�J �a /D �7 r
210 Final Electriral(
212 Final Fire Preven�ion
220 Final Planning Approval
222 Final Site
250 FinafBuilding/Occupancy
WORKERS' COMPENSATION DECLARATION:� r
I hereby aHirm under penalty of perjury one of the follovring declaralions:
❑ I have and will maintain a certificate of wnsent to seB-Insure (or workers'
compensation, as provitled for by seclion 3700 0( the Labor Code, !or lhe
pertormance of ihe work for which this pertnit is issuetl.
❑ I have and vnll maiNain workers' compensation insurance, as requiretl by
section 3700 of Iha Labor Code, fw the peRamance of the vrork la which this
pertnit is issued. My workers' compensation Insurance carner and policy
number are:
�c-me-�-S�J-e ��,� cl
(This secfqn naed nof Ee ownpletaClflre pe�ml is va.�M at ane M1urWretl tlolarslSlPO/ a lea 1
(Pulicy,Number.(�(/0(I S f5 � '%iUU�
❑ I certify lhal in the peAormante of [he work for vfiich this permit i5
issued, I shall not employ any person in any manner so as to become subjecl
b the workers' compensation laws of Califomia, and agree lhat if I s�oultl
become subject to Ihe vrorkers' compensation provisions ol Section 3700 of
the Labor Cotle, I shall lo with comply with [hese provisions.
��.w�— — lZl�l /�/-�
`�aod�m �S� ture ��a4__T.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNL4WFUL AND SHALL SUBJECT AN EMPIOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000�, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
A'fTORNEY'S FEES.
LICENSED CONTRACTORS OECLARATION:
I hereby aKrtn that I am licensed unCer pmvisions of Chapter 9(commencing
with Section 7000) of Division 3 0l the Business and Professions Code, ana
my license is in lull torce and effect. -7
�Cicr# _2�$ G 3 G, ciass.#"�--J �-D
C�i�r--. _..,-___, i L/ `� /��
ConVa wre L,Da1eM11�
CONSTRUCTION LENDING AGENCY:
❑ I hereby affum that there is a ConsWction lentling agency for the
perfortnance of the v.ark fa vfiich llvs permit is issued. (Sec. 3097, Civil Code).
Lender s Name:
LenAer's Address:
Signalure Date
OWNER•BUILOER DECLARATIONS:
I hereby affirm thal under penaly ot perjury ihal I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the�following reason (Sec. 7031.5.
Business and Professions Cotle: Any city or wunty vfiich requires a pertnil to
conslrucC alter, improve, tlemolish, or repair any structure, pnor lo its
issuance, also requiras the applicant (or such perrnil to fle a signed statement
that he or she is licensetl pursuant lo lhe provisions ol the; Conlrectore
License Law (Chapter 9(commencing with Section 7000) ol'Division 3 0� Ihe
Business and Pmfessions Code) or thal he or she is exempt therefrom and
the basis lor Ihe alleged eaemption. My violaGon of Section 7031,5 �by any
applicant lor a permit subjects the apP�icant lo a civil penally ol not moie ifian
five hundred tlollars ($500).): �
❑ I, as owner of the property. or my employees with v2ges as their sole
compensation, WILL DO THE WORK, and Ihe structure is not intended or
oKered lor sale (Sec. 7044, Business and Prolessions Code: The Contractors
License Law does not apply lo an ovmer of property who huiltls or improves
thereon, and who does such work himself or herself or through his or har ovm
employees, provided Ihat such improvements are not intended or oHered for
sale. If, however, the building or improvement is sold within ona year ol
complelion, the ovmer-builder will have lhe burden of proving that he or she
did not build or improve for purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELY CON7RACTING WI7H
LICENSED CONTRACTORS to construct the project (Sec. 7644. Business and
Professbns Code: The contractors License Law dces not appry to an ovmer of
propeAy who builds or improves lhereon, and who contracts for such project with
a cmiracla(s) license pursuant to Ihe Cont2ctors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for Ihis reason:
SlgnaWre
]OS]<6�101)
Owner ID verified by driv� ❑ Yes ❑ No
Driver s License No. Expires:
Verificalion of Ownership by (type of document, i.e. - properly tax bill or tleetl):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certi(y that no excavalion five (5) or more leet in tlepth inlo Wfiich a
person is required Io descend, will be matle in connectbn with v.ork au�horized
by this pertnit, and Ihat no 6uilding struclure, sc�(ddirg, falsework, v demolitbn
or tlismantling Ihereof, will be more than thirtysix (36) (eet high. (Chap. 32, Grp
2, !vt 2, Set. 341, Title 8, Califomia Atlminislrative CoCe).
� As owner-builder, I vrill nol employ anyone to tlo work which woultl
require a permil !rom the Division of Industrial Safety, as noted above, unless
such person has a permit to do such work (rom I�e tlivision.
npplionfs S'gwWre
Division ot Industrial Salety Permit Number: _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or IuWre building occupant need to file and
cerlify a Business Plan for emergency response b release or threatened
release o( a hazardous malerial? ❑ Yes ❑ No
(Section 25505 of the California Nealth antl Salery Code requires, with some
eaceptions, that a Business Plan be fled with the Costa Mesa Fire
DeDartment by every business which has at any one time during a reported
year a quantiry of hazardous materials equal to or grearer than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas
al standar0 temperature and pressure).
2. Does or will the applicant or present or Wture building occupant need to Ne
a registration fortn for awtely hazardous materials? ❑ Yes ❑ No
(Section 25533 of Ihe Cali(omia Health and Sa(ety Code, with some
eaceptions, requires registration with the Costa Mesa Fire Department by
each business which at any one time has on �antl a quantity of acutely
hazardous materials equal to or greater than a v.eight of 500 pounds, or a
volume o( 55 gallons, or 200 cubic feet of wmpressetl gas at standartl
temperature and pressure).
3. Does or vrill the appliwM or present or tuture building occupant neetl to
prepare an RMPP (Risk Management and Prevention Program for acutety
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of Ihe Califomia Health and Safety Code provides that the
Costa Mesa Fire Department may require the preparatioq certification antl
filing with the Fire Department o( an RMPP by businesses which are reQuiretl
to register acutely hazardous materials vnth the Fire Departmenl.
4. I! an RMPP is presently requiretl, has Section 25534 0( lhe Califomia
Health and Safety Cotle been fully complied with? ❑ Ves ❑ No
5. Does or will Ihe applicanl or present or (uWre building occupant require for
the work which is ihe subjecl o( this applicaUon a p0rtnil (Of SUCh cOnSINcfiOn
or modificalion (rom lhe South Coast Air Qualiry Management DiSVict or (rom
any other air pollulion wntrol dislncl or agency? ❑ Ves ❑ No
(Section 65850.2 of the Califomia Govemmenl Code requires ihat Ihe requestetl
intortnation be fumished on applications lor norrresidential building permits).
6. Will any part of t�e (aciliry lo be consWcted under this pertnit be within
1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
Qf yes', the (aciliry must meet the requirement of Seclions 25534 and 42303
o( Ihe Califomia Heallh antl Salety Code).
7. It a pertnit trom the South Coast Air Qualily Management District or other
air pollWion control dislrict or agency is required for the work which is t�e
subject o� this application, have all of the disclosures prescribed by Califomia
Health and Safely Code Seclion 42303 been made? ❑ Yes ❑ No
8. Qf "yes", attach certificate of compliance (rom the appropnate air pollution
control offcer).
CERTIFICA7E OF COMPLIANCE: I certify that under penalty of perjury the
inlormalion given above is wrrect. I agree to comply with all state laws and
city ordinances regarding Hazardous Materials and Emissions.
SignaWre Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalty of perjury that I have read this application and state Ihat
the information given is correct 1 agree to comply with all state laws and ciry
ortlinances relating to Duiltling construclion, and authorize representatives of
the City ot Costa Mesa to enter upon the abovedescribed pmperty for
inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permit until final inspection.
SiqnaWre of �egai s) Da�e
��Q���.—� ��-Y-� l LI `I /G�l
AnCI� orAut�orTp,tl irant.tia Date
�1
October 24, 1969
3315 Florida Cir.
Costa Mesa, Calif.
92626
Mr. Richard D. Hanhart
Director of Building Safety
City of Costa Mesa
Post Office Box 1200
Costa Mesa, Calif. 92626
Dear Sir,
At the request of one of your inspectors, and Mr. Gary Smity of Suburbia lnc.
I am requesting that the floor tile in the garage of lot 13, tract �r1�3-be /o G 9 3
permitted to remain in its present position, I am of e un erstan �ng that
the floor tile is of a combustible nature. I wou7d like to take this opport-
unity to relieve the City of Costa Mesa, and your staff of any liability that
may occure from the floor tile that has been laid in the garage.
I request that all of your consideration be given in this matter and in the
inspection of the above property.
Yours truly,
��� �/���
Charles M. Bozza
..
CITY OF COSTA MESA REQUEST FOR OCCUPANCY
TRACT N0, /� DATE 30_�9
LOT NO. ��
ADDRESS _S��%S �IOf7Gt'q ��YG/�-
�'p.S��+ /Ylescz
The developer of.the above entitled tract desires to sell the
above set forth lot prior to the time that the tract has been
completed and its streets accepted by the City of Costa Mesa .
The undersigned, by ex2cuting this agreement, acknowledges
that �-they) (� were� advised
that this tract has not been given final inspection nor has
it been accepted by the City of Costa Mesa as having complied
with the conditions of approval which were imposed by the city
at the time the final tract map was appxoved.
The city assumes no liability £or the enforcement of the conditions
necessary for approval other than those conditions protected by
surety bondo
The undersigned agrees to indemnify and hold the city harmless
from any claim resulting in damage or p�rsonal injury to the
undersigned by reason of the aforementioned uncompleted condit3on.
BY �
Purc asez
B&
Developer a
representat
BY '
Lender
.... . ^r•cm�� ur�v�ur
JOBADDRESS 3315 Florid
GENERAL CONTRACTOR pyme
AP No. LOT
1 ECTIONS
s.
GAS � � l
WATER -d (y S \ G
ROUGH PLUMBING I
PROP. SWR. LINE OUSE CON.
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING ANO AIR CONOITIONING
TEMPORARV SE
UNOERGROUN�
ROUGM WIRING
TftENCHES
FLOOR SVSTEM
BON� 6EAM CI
SHEATMING
POWER
FORMS � STEEL REINF.
� STEEL REINFORCE (�
FRAME AND FLASHING r�
LATHING - IN � OUT r�,
PLASTER, BROWN COAT
$TRUCTURAL, FINAL
1NG, VENT., REFRIG. AN� A.C., F
P�.,MBING, FINAL ANO GAS TEST ��/
ELECTRIC, FINAL
BWLOING, FINAL �
SPECIAL REOUIftEMENTS �\
.- 7-1 V7
ILDING PERMIT N0.
�
SUBCONTRACTOR
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� COSTA MESA BUILDING-SAFETV DEPARTMENT
P.O. BOX 1200 COS7A MESA, CALIFORNIA 92626
For Applicant to Fill in Completely
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kPR 24-69Pp�o001288� *** 152.25
�MSA
APPLICATION FOR BUILDING PERMIT
EI OA ERECEIVE DATEISSVED
%r'� SJaa-G� _s-,/_i>Q
PEFMIT NO.
.�.. � .�r��.-. .
Z. ._______ ___ ' _" _, ___ _ -- _ - /
a U CITY Santa Ana NOL �F7-7O�� TRACI� ���
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p N LENDER d States n�ational Bank
�� BRANCH 1 Broadwa Avenue
J N OWNER
m� ADDAESS San Die o� California � n,u
J m ARCHITECT TEL. 5 (.Ll.D
a occa ea�a R. Dorius 67`'j-116#
Z Q FIRE �
Wrc ADDPESS 2 12 E. Coast Hw . Corona D M 20NE � rv
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W Z APPROVED
J O CONYRACTOR pwner B�'
m Z
J � ADORESS
w W TEL. Z E NO.OF
Z� CITV NO. � P�'� �
W 0 STAYE CITV VARDS APPROVED
y K IIC. NO. Q Q LIC. NO. MAIN BVILDING
_� SIZE NO.OFBLDGS. (FROMC/LSYREET)
OF LOT LOO % NOW ON LOT O RONT FT.
USE OF / `�
EXI5YING BLDG. J
� SIZE OF NO OF
Z NEWOLDG. ZZOO S. Ft�qOOM$ % STORIES 2 L.SIDE O FT.
EMERIOR WALL flOOF OIDPO OS
�% COVERING U CO COVERING WOOQ REAfi FT. �
J USE OF BUILOING ANO �^10RK TO BE PERFOFMED OIS7ANCE BET.
a MAIN BLDGS.
a
Q VAR. qW
� Residenca w attached era e c.u.P.,w t/- S'-�
� APPROVED
N
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VI heraby acknowletlBe that I have reatl chis aPPlication entl state HOI.D FOR SPl
� that xhe abova information Is corract and a0�ae to comply wiM
� oll laws regulatinB builtling construction, antl I shall no[ employ
F any person in violatian o� the workman's campensetian laws ot
y the 5[oie of Californie.
zI hereby certity tha[ I em properly licensetl es o contracror untler �/OD SQ. FT. \
tha Stete of Calitornia Business entl Professions Cotle, Dlvisicn 3, THE AMOUNT SH04
Chapter 9, antl that sueh Iicenses ere in full forca antl affect, or I THE PURPOSE OF ESl
am ozempt from the provisions of the State ol Californla Basinass VALVATION
nnU Profassions Cotle vislo 3, or 9.
SfB^eture o� , D�
Permittae %� - .�---� 5a9 �
Authorizetl Agent
USE OF NEW�
BUILDING
VARDS APi
ACCESSORV
BET, MAIN
ACCESS. BI
DATE
REQUIP.FMENTS
m
�� �
0
IN UNDER VALUATION IS FOR '
ABLISHING /a PERMIT FEE ONLV: �
¢
m
PERMR FEE $ %. 5O j
PI1aN CHEGK $ . /� E
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,�a. as LL
TOTAL FEE 5
�vnrv�rt gOZZA. CHARLES uH�� 12-4 69
��08ADDRESSA1TDA33�5 Florida Circle �«fopT�A _ W^oBUILDINGPERMITNO. 31159
I. E
SOIL
GAS
'V WATER
ROUGN PLUMBING
PROP. $WR. LINE � HOUSE CON. �
SPRINNLING SVSTEM
MISCELLANEOUS
ROUGH NEATING AN� AIR CON�ITIONING
TEMPORARY SERVICE OR POLE
UNOERGROUNO � POWER �
ROUGH WIRING
TRENCHES FORMS � STEEL ftEINF.
FLOOR SVSTEM
BOND BEAM � STEEL REINFORCE �J
SHEATHING
FRAME ANO FLqSHING
LATHING - IN n OUT ❑
PLASTER, BROWN COAT
:TURAL, FINAL
h_ ., ING, VENT., REFRIG. AND A.C., FINAL
PLUMBING, FINAL AND GAS TEST n
ELECTRIC_ FINAL
VALUE
SUBCONTRACTOR
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COSTA MESA BUILDING-SAFETV DEPARTMENT -""�
P.O. BOX 1200 COS7A MESA, CALIFORNIA 92626
APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Complete/y
RECEI D T REC IV D DA IS D
BUILDING � -
AODRESS � �' ��
p PERMIT NO.
OWNER � �G�.S . /�Gt.Z A.P.NO. ' �I
MAII � BUILDING �� �
ADDRESS ADORESS s .(�
TEL. TRACT A� LOT BLOCK
CITY NO.
CANSTRUCTION W p` A P
IENDER
i/
BRANCH
OWNER
ADDRE55 A UE �'��J /1
ARCHITECT TEL SE SCT(.'L�
OF ENGINEER N .
FIRE
ADDFESS ZONE TVPE GROUP
APPROVED
CONTRACTOR �C�/���jr� BV DATE
ADDRESS �
TEL. ZONE NO.OF USE OF NEW
CITV NO. P�� BUILDING
STATE CITV �'ARDSAPPROVED VARDSAPPROVED
LIC. NO. � �IC. NO. MAIN BUILDING ACCESSORV BUILDING
S12E NO.OF BLDGS. (FROM C/L STRE�]
OF LOT NOW ON LOT FRONT F'I��� ' FT.
USE OF �5 µ
EXISTING BLDG. J T. FT
SIZEOF NO.OF pc� FT. FT.
NEWBLDG. ROOMS STORIES L.SIpE
EXTERIOR WALL FOOF �
COVERING COVERING REAR FT. FT.
USE BUILDINGAND;WORKT08E.PERFOR D DISTANCEBET. BET.MAIN&
� � �" ' �%�O MAIN BLOGS. ACCFSS. BLDGS.
-/`�['/1 VAR. # DATE
`U 7�? L�C. U.S / ` C.U.P. qW APPROVED
APPROVED
I hereby acknowletlga that I have reatl this application antl state
ihat xhe above information is correct antl apree to comply wlth
all laws regulating building consvuction, antl 1 shall not employ
any person in violation of the workman's compansation laws of
the State of Calitornia. m
I hereby certify ihat I am properly licensetl as a conttactor untler SQ. FT, o
the State o( California 8usiness antl Professions Code, Divisicn 3, THE AMOUNT SHOWN UNDER VALVATION IS FOfl
Ghaprer 9, antl that such licenses are in tull force antl etfect, or 1 THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: Q
am ezempt from the provisions ot ffie Stare of Celifornia Basiness VA W ATION
antl Professions Cotle, Division 3 Chapter 9. /, W
A �U PERMIT FEE $ .J � �
Signanre of �/ � �j�� m
Permittee � �� �� PL4N CHECK $ E
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Authorizetl Agent � � LL
TOTAL FEE §
� OWNER BC
\JOB ADDRESS
, GENERAL CON
l- `�o.
I. ECTIONS
sm�
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W PTER
ROUGH PLUMBING
LOT
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGM HEATING ANO AIR CON�ITIONING
TEMPORARY SERVICE OR POLE
UNDERGROUN� � POWER �
ROUGH WIRING
FLOOR SVSTEM
BONO 6EAM � STEEL REINFORCE
SMEATMING
FRAME ANO FLASHING
Circle
F.
� LJ � Ll
PLASTER, BROWN COAT
:TURAL, FINAL
h. _� ING, VENT., REFRIG. AND A.G, FINAL
PLUM6ING, FINAL AN� GAS TEST n
ELECTRIC, FINAL
BUILOING, FINAL
DATE �_
BUILDING
SUBCONTRACTOR
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COSTA MESA BUILDING-SAFETV DEPARTMENT
P.O. BOX 1200 COSTA MESA. CALIFORNIA 92626
JUL —1-70cnsa0� 018 �*****5.00
APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Completety
RECEI D 8 O TE RECEIVEO D E ISSUED
a���o�N� . /S � GD ' " _�` 7v
ADORESS
R T NO
OWNER pf+Z� A.P. NO. �� D�
BUILDING ' �
MAIL 22/` `Ge� ADORESS3
ADORESS�.d 1
/ TEL. TRACT LOT BLOCK
CITY �C�3%jj%GU/�St%� N�-�S
CANSTRVCTION W A
LENDER L
/l
BRANCN
OWNER
ADDRESS VA E
ARCHITECT TEL. S 5
OR ENGINEER N
FIRE
ADDRESS ZONE TVPE GROUP
APPROVED
CONTFACTOR L(��[Jj� BV DATE
AODRESS 20N NO.OF USE OF NEW
CITV NO` �� P�� z BUILDING �
STATE CITV `�AflDSAPPPOVED VAROSAPPROVED
U0. NO. LIC. NO. MAIN OUILDING ACCESSOPV BUILDING
SIZE NO.OF BIDGS. (FROM C/L STREET
OF LOT NOW ON lOT ROM F FT.
USE OF �
EXISTING BLDG. FT FT
SIZE OF NO.OF *
NEW6LOG. FOOMS STOFIES L.SID fT. FT.
EXTERIOR WALL ROOF
COVERING COVEIiING REAR ' FT. FT.
USE BUILDIN ND WORK TO BE PEPFOFMED DISTANCE BET. BEf. MAIN &
MAIN BLDGS. ACCESS. BLDGS.
VAR.,ie DATE
C.U.P.qW qPPROVED
APPROVED
I hareby ecknowletlge that 1 heve reetl [his apP���ation antl rtata
thet the abovo intorma[Ion is corract antl ep�ee to comply with
nll lows reBulating builtlinp conztruction, antl 1 shall not employ
nny porson In violation o( [he workman's compensaHon laws of
tha Staro of Californie.
I hernby carUty Not I um proparly licensed as a contrector untler SQ. FT.
tho Staro of Californ(n Businoss antl Profeuions Cotle, Divisicn 3, TME AMOUNT SHOWN UNDER VALVATION IS FOR
Choptor 9, antl that such licenses era In full foree and etfect, ar I THE PVRPOSE OF ESTABLISHING A PERMIT FEE ONLV:
am axompt from the provlSiOns Of the S[eSe ot Calitornia Businecs VALVATION
antl Profossiona Cotle, Division 3, Cheptar 9. p/� pERM1T FEE 5���
p V"
SIB�ntura of ���J //
Parmlttea %// a S V PI,AN CHECK $
(% ��Authorizotl Apant �+ �.
TOTAL FEE $ �