HomeMy WebLinkAbout3000 GARFIELD AVE - Building PermitsI Apc��cant to t�ii in a�� saacas axceot enoso w�enin neavy Goraer tinas ana sign all ao��ooriate aeclarations.
. CiTYOFcoSran�ESA C/O�NSTRUCTIONPERMIT P������/ ya3 �o�NO UNITNU._
�ProjectAddress ��Cn (;+��FiELU ���
�)p,pplicant'sMailin Address �n� GARFirt.�
�Owner's Nanme �E Phone �S'� OY3Y
� JOOO -Ai2i/fLA CCSTN �%%3/3
.Address
Arch/Eng. License No.
Addreu ` �.,
Concractor's Name—,f�_{�,f�Phone
Addreu (mailingl �� ` �
Ciry License No.
LICENSED CONTRACTOR DECLARATION
I hereby altirm tha[ I am Iicensetl untlor provi5iOn5 of Cha t¢r 9(commGnCin9
with zection 7000) oi DIvi5lon 3 Of tho Business an r fe55 ns Cotle, antl
� my license is in full torce antl effect.
L�CBOSC CId55 LICUnS
Date Si9nature
W00.KER5' COMPENSATION DECLARATION
1 hereDy atfirm that I have a certiflWte of Wnsent to 5oH-inzure or a certificate
oi workers' CompensaHon Insuranco, or a cerWied cooY tnereof (Section
3800, Lab. C.) . �
Policy No. ' Company
8 Certifietl coDY is hereby /umishetl.
Certifietl copy is filetl with Ute ci[y Builtling Dlvision.
EXEMPTION FROM WORKERS' COMPENSATION OECIARFTION
(This section neetl not be complel¢tl ii [he permll is ior One huntlretl (5300) or
Iess). '
I CerLty thal in lhe perl0rmdnC¢ O/ Ibe work fOr whict this ¢rT�t is issuetl, I
shall noi emPloy any person In any manne� so t bec �e subject to [he
Wor���.Pmp e_o-sat_iop Laws of Cali ni
Da[e�.,_.)-L�.�1.i�519nature •^��
'NOr�eE: I(, a(ter making Ihis tleclar tion, you shoultl become subject to the
Workers' CompCnSation provisions ol lM1e Labo� CoUe, you must forthwitlt
comply with sucn proviiions or thi5 permi� shall be tle¢metl revOk¢tl.
GONSTRUCTION LENDING HGENCV
1 horeby af�itm [nat �here ii a conitruttlon Ientling aqency lor the Pertormance
OI Iho work for whiCh [his pnrmil I5 Issuetl (Section 3097 Civ. CJ
Lentler's Name
Lonaer'z atltlresz
OWNE0. BUILDER DECLARATION
I hereby attirm that t am exempt from lhe ConVacror'S l.icense Lnw for the
tollowing reason (Section 7031.5 Businass antl Proleszional Cotle: Any city or
tounly whlc� requires a permit lo consiruCt, altCr, Imp�ove, tlemolizh Or repair
any sVucture, prior to Its Issuance, also reqWres the applicant tor sucb permit
to file a signetl statement that he/sM1e I5 liconsetl pur5uant lo [he pwviSiOns o�
th¢ Contraclor'S Licenze law (Chapter 9,(Commencing witn Se[tion 7000) of
DiviSion 3 of lhe BuSinezs antl Prot¢ssions Cotle) or tM1at he/she is exempl
Iherefrom antl lhe basis tor the alleqetl exemption. Any violation of Section
'l031.5 Dy any applicanF for a pe�mlt subjects the aPPlicant to a Civil
�enalty of not more Man five huntlretl tlollars (§500).
I, as owne� of Ihe pro0e��y Or my omployees with wages as [Itei� sola
compensation, will tlo �he work, antl the Structure i5 no[ intentletl o� offeretl
1or sale ($eclion ]044, Business antl Prolessional Cotle: The Contracto�'s -
LiCenSe Law tloes nol apply to an owne� of a property who bulltls or imprOvls
thereon, and who tloes such work nlmsel(/herselt or throu9h hls or ner own
em0loyee5, PrONtled thal SUGh ImO�ovamenl5 afe not intentletl Or offeleC to1
sal¢. II, however, the builtling or improvemanl IS Soltl within one yea� 01 com-
pletlon, the owner wlll have Ihe burtlan O/ proving he/sbe tlitl not builtl o� Im-
p�ova forlhe pu�po5e Of sale).
❑ I, as owne� of the pro0erty, am oxclusluely Conlracting with Iic¢nsetl con-
tracto�s to consiruct lho O�oject ($aclion ]044. BuslnCss antl Pro/e55ions Cotle:
The Contractor's License Law aoes not apuly to an owner ol property who
builtls or improves [nernon, ana who contracts ror sucn projects witn a con-
tratlor(Sl IiCensC Ourouanl�to the Conlracto�'s License Law). I am aware thal
p�ooi o( lneit Worker'S ComP¢nsatlon in5uranCO Shoultl be provitletl lo m¢.
❑ I am exempt untler $ecUon B. & P� C. lor this reason
Date
Signatu
Drivers'
certity tnat I have reStl this apolicatlon antl state enat the above
�n is correcL I agree to comply with all tlty antl county ortlinances
laws relating lo builtlinq construction, antl hereby authorize repre-
ol tnis i y e er upon tho above-mentionetl property /or
Ourp ��'1 S_ �y�
k �G �N •�—+ Da !
��e.,., .�.�. 1c � X _
TVPE OFCONSTRUCTION NEW %�DD ALTERATION REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTM A p #/
DESCRIPTION OF WORK/USE OF BLDG. ��� � � ^
5 Main Building:
TVPE OF PERMIT GRADIrvG FOUNDATIOrv S7RUCTURAL T Front �,
❑ TENANT ❑ ELECTRICAI ❑ PLUMBING ❑ MECHANICAL 8 Rear'
❑ OTHER A
PROJECT DESCRIPTION S�.FT, oCCVPANC�v�y m�--� K Ri9ht D�
CONSTRUCTION TVGE �� �-� VAWATION S ..JIAJ $ Left 3 S�
ZONE canoirvG Cu.vDS. ACaES Ping. Ref. #
Remarks: Planning Notes:
Sink
Preventer
Irrigation
Dishwasher
Drinking Fountains �
Floor Drains
Floor Sinks -
GesService Outlets
Interceptors '
Kitchen Sink
Lavarories
Roof Drains
Reinspectian Fee � I S15
Duct - Under Ground
Duct � Sirucmral
Duct • Ventilating
Exhaust System ❑ Multiple �
Firepl/Fact. Blt. ICBO #
Heating System & Ducting
❑ ai oo,000 aTu O i oo,000 er
Reinspection Fee � $15
CMF 0865-46, rev. 10/fl4 White - Bulltling; Canary - qpplicant; Pink - Accounting; Goltlenrotl - Assessor
Showers
Service Sink
$ewer Cap ,
Sewer Connection
Solar Collectors
Solar Piping .
Solar Tank
Swimming Pool w/Spe
Urinel
Warer Closet - .
Water Heater
Water Service
Auto-Wash
Isue Fee
Hoodor Typel ❑
Canopy Type II ❑
Retrigeration Sys[em
00.100,OOOBTU ❑100,000
System Repair/Alteretion
Fire Dampers
Fegisters
Issue Fee
S 3
S 3
Auromatic Washer
Construction Pole Sub.
Cooking Unit
Dishwasher
Fan
F.A.U.
Fixturer -
Device Boxes
Outlets
Switches
Garbage Dispoul
Generamr �Q5 KW
Reinspection Fee
3594 5/28/B5
Zone
Accessory Building:
Parkin9 Rery/Proyided
ELECTRICAL
� Trensformer ❑ 15-50 KW
❑ 50+KW
Meter ❑up to 700 amps
Meter ❑over 100 amps
Sub Panel
Morors 00.1 HP � 1 X- 8
Inc.Solar �9-15 HP �16�15+
Microwave
Pole Light
Range
; Standing Sections
5-15 KW Trash Compactor
$15 luue Fae
DEVELOPMENTSERVICES
2oning Approred By
Building Approved 6y _
I7.00 TL
FEES
5.3
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SUMMARV OF FEES
BUILDINGPERMIT 5 �0+6� SMIP $ ��U
PLAN CHECK 5 �� � 5� PERMIT
PLUMBING S ISSUANCE $
PLAN CHECK 25% $ ENERGV P.C. $
ELECTRICAL S GRADING $
PLANCHECK 50% $ MICROPILM 5
MECHANICAL 5 TOTALFEE $ I�•�p
PLAN CHECK ZS% $
i CONSTRUCTION AND PLANNING P��� 'PA'
APPROVALS Permit# Date Inspector p�ppROVALS Permit# Date Inspector
1. Temporary Electrical Service or Pole . 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding . �
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings , 5r�� ,, - � 58. Electrical Conduit-Undrgrnd.
8. Foundation � 59. Gas Pipe, � Undrgrnd., Test
9. Water Pipe-Undrgrnd. � 60. Backwash Lines, P-Trap, O Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11. Property.Sewer Line & House Connection 62. Backwash & Receptor-Final -
72. Sewer,Cap 63. Heater & Vent-Final �
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar SYstem-Final
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign � 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Fough Factory Fireplace APPROVALS Permit #
21. DuCts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping 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.;FrameandFlashing (a�518S ps 76. DryStandpipe
28. Lathin�g & Siding 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing . ' HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat i 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. F000 CERTIFICATE ISSUED
33. Final Electric Notes:
34. Final Heatin9 & Air Conditioning
35. Final Gas Pipe-Test �
36. Hood"or Canopy �; -
. ,
37. Final Facto�y'Fireplac8 �
� . i ,.
38. Final�Plumbirg -•
39. WatevService-Final
:i
40. Gas Service-Final � ;� , � .
41. Solar pomestic-Final "J
42. Backflow Preventer 'y •-
43. Backflow Irrigation ' � �
44. �Landscape Irrigation System�{ �
45. Sound Attenuation � �� � .
46. Handicap Regulations � ' .
:i
47. FINAL STRUCTURE & BUI��DING � S
48. Special Requirements Cortipleted � �
� �49. Electcic Release to Edison �
i`..
50. Gas Release to Southern California Gas Co • �
51? CERTIFICATE OF OCCUPANCY �
No. Date
�
NOTE� SHOW AND DIMENSION PROP9SED
PATIO COVER AND YARO AREAS
�
E.S: �
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is� �I!—r—,`-
I�' II
1 �� • I, ,. ji
I �. ��i- _:_ ��-
j:: =�
Building
V THESE PUNS MUS� BE CN JOB I.T ALL TIMES
IJ,AK� NO CHANGES' W�THOUT PRI00. APPROVAL'
OF DEPf. I
1HE ICfJI..`;CE CR L �TING 0 "... .. •n� OVAL �
CF PLA.pS A:ID SFECtf:� ".+ SFiALL NOi 6E COf�S U
TO EE A fEfiY.IT f=R, 0 l�� f.FfROVAL C`. ANY VIO�iION
6f L�Y CF THC ('ROVF!C �.� Cf THI; COGE. N� P:RHI� PRE•
Sl'N,11C T9 CP:E AUTfiClITY 7� i'A�TE OR CF�CEL iHE
PRGI':::=ttS CF THIS CO E SHALL BE \51LI6. CXCEPi IN SO
FAR !S 7NE NOkK GR US N:11� �in'Jn�T
II:E ItSUFNCE CF A fERY.!i BFSED L'!'C��� AN�
SPECIF!CFI:GnS S'iALI �0( FRNC:i iNE F71LDI.'" �QC,IPL.
FROM 7iiC��r.fTCR flEQUIRIM1'G 7HE CCRRCCTI�4 A�'%16
IN SqID FLA:�S F�� SPECIFICATIO':2 C3 (R��N PRCl6V�ING
BUILDING CF[Fd.T:CPtS EEING CFRR:ED OV THEREUNDFR WHE�
QE LHE FL
PLOT PLAI�
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DEPT.
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STRUCTUf�RL APPRDUAL ONLY
FO? �lcC?RICAL. PLU�181yG,
NFRTI�ti:. �rcr.;71�ATiN; A�+JD
!'."c'fi!�Ei'e';I:.?a �l�vflK
:VERSE SIDE� �D
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TNIS i:'i., . . .<r _�i.(.'.A?pi;`d'!
ROOF�SMEASNING-�� ';+��'=�TS
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Foa FbSr-geAs/
L�NNCC T/LN/.
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L7QoP PAnO � �
Ftan,e 1" q .�
SLOPE TO DRAIN �
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16 i�.d.l. ft�sniN(�
� �(Mao F[oo,C
Gavsr,euc riv.v
SIDE ELEVATION
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CONSTRUCTION DETAILS
0" ROOF CONNECTION
DETAILS
CONT.
LEOGER
CONT.
LEDGER
SOLID BLOCK
I/2�� DIA. % 5�� LAG SCR
AT 32�� O.C.
DETAIL I
CR 8 CL ��TECO��
GRIPS OR JOIST
HANGER
3�8�� DIA. % S�� LAG SCR.
AT �6 �� O.C.
DET
�" OR. LIGHT WEIGHT ROOF
ONLY CONNECTION DETAILS
D�,oPrgrrr
.���c�s n�rartt�rrr
B[!ILDING SAFEI'Y DIVISION
OWNER: �� q �,r r 1AN6
ADDRESS� ?n�n l'R.e,�i�tc
CONTRACTOR:
ADDRESS�
RAFTERS
CARPORT, PORCH OR PATIO
NOT SUPPORTING CEILING
SIZE SPACING SPAN
2"x4" 12"O.C. 9'-6"
16" 8'-0"
24" 6'-6"
32" 6'-0"
48" 5'-0"
2"x6" 12" 16'-6"
16" 14'-6"
24" 12'-0"
32" 10'-6"
48�� 8�_���
2"x8" 24" 15'-b"
32" 13'-6"
48" 11'-6"
4"x6" 24" 17'-0"
\ 32" 15'-0"
ac�� v. � _���
-2�XFACIA-MIN.REO.���XB" 24^ 21'-O"
\ 32�� 19 � _���
� 36" 18'-0"
48" 16'-0" '
RAFTER "x10" 32" 22'-0" ,
36" 21'-0" •
APPROVED METAL 48" 20�-0" i�
HANGER i 72" 17�-0"�
DETAIL 3
PATIO COVER
TYP PLANS
DATE �
PHONE� �y� °�'� y
LIC. NO.
PHONE�
RAFTERS
LIGHT WEIGHf ROOF COVER OF
LATH, FIBERGLASS, ALUM.
SI2E SPACING SPAN
2"x4" 16"O.C. 9'-6"
24�� 8�_���
32" 6'-6"
48" 5'-6"
2"x6" 16" 16'-6"
24" 14'-6"
32"• 12'-0"
teu tnl_nll
2"x8"' 24" 19' -0"
32"'—"'-1-5' -6"
48" 13 6"�
NEADERS
LICHf WEICHT ROOF ONLY
SIZE POST SPACING
4x4 � 6'-0"
4x6 . - 9'`0"
4x8�1�210"�
�4x10 2l2 15'-0"
PORT,—PORCH�OR PATIO
_SIZE : POST SPACING
4x4 5'-0"
4x6 8'-0"
4x8 10'-0"
4x10 12'-6"
APPROVED FOR
BUILDING PERMIT
By Date
GENERAI. NOTES•
l. These plans mus[ be
kept on the job at
all tlme during
construction.
2. All framing to be
Douglas Fir �,Z .
grade minimum.
3.. Raftere may not
attach to facia ex-
cept for l0U roofs
as shown on details;
201i raofs mus[ use
a con[inuous ledger
attached as shown
on details #1 6U2.
4. Light weight roofs
may a[tach [o facia
for 14' span max.,
apans over 14' must
use a continuous
ledger as shown in
details fi3
:�L�7
(77a) 754-5273 • Fax (7ta) 75a-4e56 • www.ci.costa-mesa.r��LDWG PERMIT �� hAIH UFilvt, �va �v. mcan, �.r amm
Jobnddress: 3000 GARFIELDAV
Suite:
Vicinity:
Parcel Number: 14113436
Applicant: SORGE, DAVE
Address: GTY pp COSTA MESA
77 FAIR DRIVE
COSTA MESA, CA 92627
Owner: LANE, GREGORY S
Address 3000GARFIELDAVE
Contractor:
Address:
Zip:
Arch :
Address:
COSTA MESA,CA
Phone:
Zoning:
Phone: _
� r_
Zip: 92626 �
Phone:
Zip: 92626
Phone:
License:
Eng:
Address:
ISSUED BY:
Status: ISSUED
Applied: it/17/2000
Issued: 11/17/2000
Phone:
Zip: License: License:
SCOPE OF PERMIT
CONSTRUCT 70 LF. OF BLOCK WALL PER CITY STANDARD. NO FEE. qTY PROJECT.
Plan Check: $0.00
Permit: $0.00
SMIP Res: $0.00
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $0.00
SETBACKS
MAIN STRUCTURE Front 0- 0
ACCESSORY Front 0- 0
PARKING ez%stinq: o
NOTES:
Rear 0-0
Rear 0- 0
Required: 0
FEE SUMMARY
PLANNING & ZONING
Lek 0- 0
Lek 0- 0
Pro osed: 0
Calc Valuation:
Claim Valuation
Right 0-0
Right 0-0
$zoo.00
$o.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit Shall automatically expire and become voitl if work is not commenced within 180 days, or if work is suspended or abandoned
tor a period of 180 days. ,
_�. ,
INSPECTIONS: In order far the work authorized under this permit lo be considered legal, such work must comply with all applicable codes, and all
requlred inspeetions end ilnal approval mus� be obtained. Failure to obtain inspections and final approval will result in the expiration of ihis permit.
FOR INSPECTIONS CALL: (714) 7545626
2446-bfi (NW)
WORKERS'COMPENSA710N DECLARATON:
I hereby affirtn untler penalty of perjury one of the following deGaraiions:
❑ I have and will maintd�� e certificate of consent to self-Insure �or workers' campenution, as pmvitletl br by section 3700 0l the Lebor Code, for the pertormence of the
wark for which Ihis pe�it is issuetl. . .
i
❑ I hava and will maintain workers' compensation Insurance, es required by section 3700 of Ihe Lebor Cotle, for the pedortnance of ihe work tor which Ihis pertnit is issueG.
My workers' compen5atlon Insurence carner and policy number ere:
Carrier: �'f
Policy Number:
(This sectian need not be Gomple(ed i! (ha permit is velued af one �undred dollers ($100) or less.)
❑ I canity that in the partormance of Ihe work for which this permil is issuad, I shall not employ any person in eny manner so as to become subject to Ihe workers'
compensation laws of Cel'rfomia, and egree ihal lf 1 should become subject to ihe workers' compensation provisions ot Section 3700 0l Ihe Labor Cotle, I shall tonhwlih
comply with Ihese prohsions.
Applicam SigneWre: Dete:
WARNING: FAILURE TO SEWRE WORKERS' COMPENSATION COVERAGE IS UNUWFUL PND SHALL SUBIECT AN EMPLOYER TO CRIMINAI PENALTIES AND GVIL FlNES UP TOONE HUNDRED
T}IOUSAND DOLURE (5100.OW1. �N ADDITION TO iHE COST OF COMPENSATIIXJ, DNMGES �1S PROVIDED FOR IN SECTIIXJ 31O80F iHE L4BOR CODE, IMEREST, ANO ATTORNEV'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aHirm that I em licensetl under provisions of Chapter 9(commencing with Sedion 7000) ot Division 3 of the Business antl Professions Cotle, and my license is in full
force end eHecL Lic. N Class k
Conirectors SignaWre: Date:
CONSTRUCTON LENDING AGENCV:
❑ I hereby aflirtn that there is e construction lending agency for the peAormance oi �he work for which this permit is issued. (Sec. 3097, Civil Code).
Lenders Name: Lentler's Address:
Signature: Date:
OWNER-BUILDER DECLPRATIONS:
I hereby aHirtn ihet under penalty of perjury Ihat I am EXEMPT FROM THE CONTRAC70RS LICENSE LAW for Ihe following reason (Sec. 7031.5, Business entl Professions
Cotle: Any city or counry which requires e permit to consimcl, alte�, improve, tlemolish, or repair any structure, prior to its issuance, also requires the applicant lor such pertnit
to file a signed statement Ihat he or she Is Ilcensetl pursuant to the provisions ol Ihe Contrectors Ucense Lew (Chapter 9(commencing wi�h SecNon 7000) of Division 3 01 the
Business and Professions Code) or that he or she is exempt therefrom anA the basis tor tha alleged ezemption. Any violation of Sectlon 7031.5 by any appliwnt for a pertnit
subjects the epplicant to a Givil penalty of not more than live huntlred dollers ($500).):
❑ I, as owner oi the property, or my employees wit� wages as thair sole compensation, WILL DO TME WORK, and Ihe structure is not intended or oHeretl for sale (Sec.
7044, Business and P�otessions Code: The Con�ractors License Law tloes not apply �o an owner ol properry who builds or improves thereon, anG who does such work
himself or herselt or tnrough his or her own employees, pmvidetl that such improvements are m� Inlentletl or oflered tor sale. tl, howevar, tha buildiag or improvement is
sold within ona year oi completion, the owner-builder will have tha burden of pmving t�at he or she did noi build or improve tor purpose of sale.).
❑ I, as owner of the property, am EXCLUSNELY CON7qACTING WITH LICENSED WNTRACTORS to conslmct ihe prolect (Sec. 7044, Business antl Professions
Code: The contractore ��cense Law does not appty to an owner ot propetly who builtls or improves Ihereon, entl who comracts tor such project wlih a contrector(s)
license pursuant to iha Canlrectors License Lews.J.
❑ I em exempt under sec. BuSiness and Pmfessions Code tor �his reeson:
Signature: oate:
Owner ID verifietl by tlrivers ��canse. ❑ Yes ❑ No Dnvels License No.
Veriticetlon of Ownership by (�ype oi daumanl, i.e. - properry tax hill or deetl):
Expires:
DIVISION OF INDUSTRIAL SAFETV PERMIT CER7IFICATION:
❑ I hereby cenify ihat no excavation fiva (5) or more feet in Oepth imo which a person is requiretl to tlescend, will be matle in connection wiih work authorized by this
permit, and that no 6uiltling siructure, scaftoltling, falsework, or demolition or tlismantling ihereof, will be more than ihiny�si: (36) feet high. (Chap. 32, Grp 2, Art 2, Sec.
341, Titla 8, Celifomia Atlministra�ive Coda).
❑ As owner-builder, 1 w�ll not employ enyona to tlo work which would require a permit fmm the Division of Industnal Sefery, as noted above, unless such person hes e
pertnit to do such worK �rom the division.
Signeture: Date:
Division ot Industrial Safery Pertnit Number
CER7IFICATE OF COMPLIANCE AND AUTFIORVATON OF ENTA�: 1 cehity under penalry oi perjury ihat I have read this epplication end state that the iniormation given is
correct. I agree to comply With ell steta lews end city ordinances relating to building conslmction, antl authodze representatives oi ihe Clry of Costa Mesa to emer upon the
above-described D�aPeM �a� �nspection purposes. 1 egree not to occupy or allow occupancy ot eny building authorized by this pertnit until finel inspection.
Si naWr f Le Owner(s� Da
c� A.,, 9,� f�� „ t�.z r�
AntllOr A 'zed ' nt D Ie
CODE �• INSYECTIONTYPE
1618 Fixed System Finel Fira Prevention
1266
200
201
202
203
204
Pool Spa Final
Final Re-Roof
Final BIocWRetaining Wall
Final Factory Fire Place
Final Sign
Final Demolilion
PAIE INTRIALS
� �
CQOE 1 INSPECTION TYPE
206 Finel Mechanical
20B Finel Plumbing
210 Finel Eledricel
212 Finel Fire Prevention
220 Final Planning Approval
222 Final Site
250 Final Buildingi0aupancy
PAIE lI�L6
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DECLARATION OF AUTHORITY
FOR AGENTS OF PROPERTY OWNER
TO APPLY FOR PERMITS " �
3000 GARFIELD AVENUE
Sireet Address
Bldg. Permit #
This Permit #
141-134-36
AP Number
I(we), ��i2PG �� {Q ( S� �� , declare that I am the Owner of TiUe
of the above reference3 real property, and that I(we) hereby authorize:
Ci7y aF Cor;a r✓lEsa �7 ' �) 7 � `i - �os9
Name Telephone No.
7 � ��,� �2��Y,
Street Address
GoSYA r'�JESA CA %Z(o2/a
City State Zip
to obtain permits in my behalf, as owner/builder, for
at the above referenced property.
2. Should any person become an employee engaged in the improvement of the property, I(we) shall im-
mediately provide Worker's Compensation Insurance coverage and cause a certificate of that coverage
to be filed with the Building Division of the City ot Costa Mesa, as required by State of California laws.
3. As owner/builder in fact, I understand and accept that my responsibilities do not transfer to any other per-
son, company or corporation.
4. I agree to indemnify and hold the City of Costa Mesa and its employees or officers harmless from any
claim resulting in damage or personal injury to myself or any other parties as a result of work authorized
by the permits from the City of Costa Mesa.
5. I declare under the penalty of perjury that the foregoing is true and correct.
O dU
Executed this � day of C'M y� , at � , California.
C%1e�15� �Il� d- l�1Rf'G 2_ '�'I�o�l�'"�v
Printed Narr� � Date
/
signamre
NOTE: This authorization does not grant authorization to perform the work as owner, it solely provides
for limited power of attorney to secure this permit in any behalf.
►`�' "��: ��
on9�a6 (Rev. P/91)
(714) 754•5273 • Fax (714) 754-4856 • www.ci.costa-mesa.glHLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
�ob Address: 3000 GARFIELD AV
Suite:
Vicinity: HOUSE AND GARAGE ROOF
Primary Occ: R3 Type of Construction: V-N
Parcel Number: 14113436 Zoning:
Applicant: RAY, ROSS
Address: 2192 AMERICAN AV
SUITE A
COSTA MESA, CA
Owner: LANE, GREGORY S
Address 3000GARFIELDAVE
COSTA MESA, CA
Contractor. ALL WEATHER ROOFING
Address: 2192 AMERICAN AV
SUITE A
COSTA MESA, CA
Zip: 92626
Arch :
Address:
Phone:
Phone: 949-232-7663
2ip: 92626
ISSUED BY:
Phone:
Zip: 92626 .. �
Phone: 949-646c86 4 �
�
License: 739271
Eng:
Address:
Status: ISSUED
Applied: 10262006
Issued: 10262006
Phone:
�
,�
r
5
Zip: License: License:
SCOPE OF PERMIT
TEAR OFF (E) ROOF MATERIALS, INSTALL 1 LAYER OF 30# FELT ON A 3:12 PITCHED ROOF AND REROOF W/40 YEAR ASPHALT SHINGLES
ON ATTACHED HOUSE AND GARAGE, APPROX 24 SQUARES. REPAIR AND REPLACE SHEATHING AS NEEDED.
FEE SUMMARY
Plan Check: $0.00
Permit: $125.25
SMIP Res: $0.58
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $125.83
PLANNING & ZONING
SETBACKS
MAIN STRUCTURE Front 0- 0
ACCESSORY Front 0-0
PARKING Existina: ' o
Calc Valuation: 55,eoo.00
Claim Valuation: ss,aoo.00
Rear 0-0 Left 0-0 Right 0-0
Rear 0- 0 LeN 0- 0 Right 0- 0
Reauired: 0 Pr000sed: 0
NOTICE: The work authorized by ihis permit shall comply with all applicable handicap access requirements under California statutes and related
regulatlons. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced withln 780 days, or il work Is suspended or abandoned
I for a pedod of 180 days. '
INSPECTIONS: In ordar for the work authorized under this permit to be considered legal, such work must comply with all applicable cotles, and all
. requlred inspectlone and final approvel must be obtalned. Fallure to obtain inspectlons end (inal approval will result in the expiration of this permit.
fOR INSPECTIONS CALL: (714) 7545626
zeae-ea �amo)
WORKERS'COMPENSAnONDECLAAAnON: �
I hereby eHirm under penalty ol perjury one of Ihe lollowing tleclarations: , .'' ,. ',
❑ I have and will meintein e certiticate ol consent ta selFlnsure for workers' compensation, as provitletl lor by section 3700 of the Lebor Cade, for the peAortnence of ihe
wark tor which this permit Is Issuetl.
❑ I have arW will maintain workers' a�pensetion ��surence, az required by sectipn 3700 of Ne LaOor Code, lor ihe peAortnance ot iha work fo� which ihis perm�� Is Issuqd.
My workers' compensallon Insurence wrner entl polity number are:
Cerrier: - � Polity Number:
(This secfion need nof be compleletl il (he pemtlt ls veluetl ef one huntlretl dol/ers (5700) or less.)
O'� � �etllty that in the peAortnance af the work tor whlch lhis permit is issuetl, I shall not employ any person in eny manner so as ta Docome subject lo the workera'
_.--compen4atlon laws of Celitomla, and rea that tl I s�ould become sub�ea to the workere' wmpensetion provisions oi SecUon 3700 0l the Labor Coae, I shall fort�wit�
comply with tl�es rov ions. _
Appl`�IcenlSlgnaWre: �00/1 (il� CjDete:" O ��—O�
WARNINO:FAILURETOSEWREWOfi(ERS'�P� OWERAGEISUMAWRILM1D51W.LSUBIECTANEMPLOYERTOCRIMINA�PENALTIESMlDCMLFlNESUPTOONEHUNDRED
TlqUSM1D DOUAftE �St00,000), W ADDITION TO TME CWT OF OOMPENSATqN, qA1A4GE5 AS PROVfDED FOR IN SECTION BJOBOF THE LABOR CODE, INTEREST, NJD Ai10qNEY'S FEES.
LICENSED CONTRACTORS DECIARATON:
I here�y ettirm that I am Iicensetl,}�ntlergrovisions ot Chepter B(commencinq wlih Sectian 7000) ol Dlvislon 3 at.ihe Businass antl P of�ssions Cotle, and my Iicense is In tW
io�ce ona eeecL cic: a__'7�Y'.C7 C �C��aqs x rC—� `�
Cantractor's�5lgneturei � f/ oa�e:� /n-2 �L�
� �
CONSTRUCTON LENDING AGENCY;
❑ I �ere�y aNirm t�at lhere is e consiruction lendinp epency br ihe peAormence al the work for which t�is permit is issued. (Sec. 3097, Civil Code).
Lentlefs Neme: LentleYs AOdress:
Signeture:
Date:
OWNER•BUILDER DECLARATIONS:
I here6y eHirm ihat under penalty ol perjury that I em EXEMPT FROM THE CONTRAC70R5 LICENSE LAW lor �he following reeson (Sec. 7037.5, Busineu end Professions
Code: Any ciry or county whic� requires e pertnit to consWcl, aller, improve, tlamolish, or repair any strucWre, prior to its luuance, elso requires Ihe appliwnt lor such permit
lo file a signed stetement Ihet he or she is ticensetl puBuant to the provisions ot the Coniractors License Lew (Chepter 9(commencing wiih Section 7000) oi Dlvision 3 oi the
Business end Pmfessions Code) or iha� he or she is ezempt Iheretrwn and Ne basls tor the ellegeC exemption. Any violation of Section 7031.5 by any appllcent for a permit
subjects the epplicant to e chril penalry tl� rw� more than tive �untlred ddlars (5500).):
❑ I, es owner of the property, or my employees wl�h wages as Iheir sde compensation, WILL DO THE WORK, and the strucwre is not InlenOed or ofleretl tor sale (Sec.
7044, Business end Professians CAde: 7Tie Contractors License Law tloes rrot apply to an owner o� property who builtls or Improves thereon, end who does suU work
himself or herselt or through his o! her own employees, provided that such Improvements are not intended or ottered for sale. 11, however, the building or improvement is
sold within one year of completion, the ownao-builtler will have ihe burtlen of proving ihat he or she tlitl not build or improve for purpose ot sale.).
❑ I, as owner of Ihe property, am E%CLUSIVELV CONTRACTING WITH UCENSED CONTRACTORS to consiruct the projact (SeC. 7046, Busine55 and Pwfeulon5
Code: The conireaors License Law does not apply to an owner ol proparty who builtls or improves Ihereon, and who comrecls lor such pmject wit� a contwctor(s)
license pursuant to iha Contractors License Laws.).
❑ I am exempt untler sec.
Signature:
Owner ID ventietl by Onver's license. ❑ Yes ❑ No
Business and Profeuions Code tor this reason:
Venficatlon ol Ownership 6y (rype of doC�ment, i.a. - property ta�c bill or deetl):
DIVISION OF INDUSTRIAL SAFETV PERMR CERTIFICATION:
Drivets License No.
Date:
Expires:
❑ I hereby cetlify �hat no excavetion ���e (5) or more feet in depih into whic� a person is requiretl to tlescen4 will be made In connecilon wlih work eu�hodzetl by ihis
permit, and that no builtling s�ructu�e, scaflolding, talsework, or tlemolition or tlismanUing Ihereal, will be more then thirty-six (38) leet hig�. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Tille 8, Calilamla AtlmlNstrad�e Code).
❑ As owner-builtler, 1 wlll noI omploy anyone to da wark whic� wwltl requlra e pertnit fram the Divislon of Intlustriel Sefery, es noted ebove, unless such person has e
permit to do suc� work tmm the dihsion.
Signalure: Dale:
Division ol Industrial Sefery Parmit Number:
CERi1FlCATE OF COMPLIANCE AND A�1fMORVJITON OF EMRY: I cenity under penalry of perjury that I �ave read this epplicetion end state Nat the infortnaUon gNen is
cortect I agree to comply with ell stete laws and dry ordlnances relating to bullding construction, end eut�odze representatives of ihe Ciry ol Costa Mesa to enter upon ihe
ebove-tlescriDetl property for inspeciion puryoses. I agree not to occupy or allow occupancy ol eny building au�horizetl by ihis permit until tinel inspection.
COUE �. INSVECTIONTYPE
7818 Fixetl Syslem Flnal Fire Preve���a�
1266 Pool Spa Finel
200 Final Re-Roof
201 Final BIocWRelalning Well
202
203
204
Final Fectory Fire Place
Final Sign
Final Domolition
PAiE 1t�15
�
�'r i%/J
� �
��
LOOE� INSPEC710NTYPE
206 Finel Mechanicel
208 Final Plumbing
210 Flnel Elecitical
212 Finel Fire Prevention
220 Finel Planning Appraval
222 Finel Site
250 Flnal Building/Occupency
.�w' .
�
(714) 754-5273 • Fax (774) 754-4856 • www.ci.costa-mesa.c�.UILDING PERMIT n FAIR DRIVE, COSTA MESA, CA 92626
JobAddress: 3000 GARFIELDAV
Suite:
Vicinity: REAR OF PROPERTY
Pnmary Occ: R3 Dwellings/ Cong Res <10 Type of Construction: V-N
Parcel Number: 14113436 Zoning:
Applicant: EVONNE MORTON
Address:
Owner: LANE, GREGORY S
Address 3000 GARFIELD AVE
COSTA MESA, CA ' ' � �
Contractor. SOUTHERN CALIFORNIA ROOMS
Address: 14104 E FIRESTONE BL
. SAN7A FE SPRINGS, CA
Zip: . 90670
Arch :
Address:
Phone: 877-766-7666
Zip:
/
Phone:
Zip: 92626"
,:.
Phone: 800-607-5223
ticense: 827937
Eng:
Address:
ISSUED BY
Status: ISSUED
Applied: 08/01/2005
Issued: OB/012005
� Phone: � Phone:
Zip: - License: . � . License:
SCOPE OF PERMIT
CONSTRUCT 192 SQ. fT. ATTACHED PATIO COVER AT REAR OF PROPERTY. . �-
Plan Check:
Permit:
SMIP Res:
SMIP Com:
Other:
Inspectian:
Total
$63.21
$97.25 -
$0.50
$0.00
$0.00
$0.00
$160.96 ,
SETBACKS
MAIN STRUCTURE Fro�t 20- 0
ACCESSORY Front� 0-0
PARKING Existin : 0
FEE SUMMARY
Calc Valuation: 53,o95.0a
Claim Valuation: SO.oO
PLANNING & ZONING
' ' Rear - 70. 0 _ Left . 0- 0 � � ' " Right " ��0- 0
� � Rear 0- 0 Left 0-.0 �� , Right �� 0- 0
- - Required: �� 0 Proposed:'^;0•- .
. ,..;,
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requiremenis under Calitornia statutes and related
regulations. (Ord. No. 9248, § 1, 12-27-92)
� EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and ell
requlretl inspectlona and Iinal approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of ihis permit.
FOR INSPECTIONS CALL: (714) 7545626
:a,uoe ��vw�
WORKERS'COMPENSAnON DECLAPATON: , � .
I hereby eXirm untler penalry ot perjury tlne ot the following dedaretions:
❑ I hava end will meintein e certiflcate ol cansent to selt-Insure ta workers' compensetlon, es provided for 6y section 3700 oi the Lebor Code, br the pertormance ol t�e
work for which ihis permit is issued.
❑ 1 have end wlll meintain workers' compenutlon Insurence, az requlretl by sectlon 3700 of the Lebor Code, for ihe pertortnance of Ihe wark for which this permit is issued
My warkers' compensation Insuran�e wrrier end poliq number are:
Cerrier:
Policy Num60r:
et one huntlretl dollers ($100) or /ess.)
1 certlly,that in the petlormance Ihe work for which this pertnit is Issued, I shell not employ any person In eny manner so es to become sub�ect to the workera'
�� �irompensetlan laws of Cellfomi , ntl e ree that if I hou10 bacoma su ject to the workers' compensatlon provislons ot Sectlon 3700 ot th� Lebor Code, I s�all fotlhwith
�comply wi—th-these provisians. . 1f/ {/�� �
APP tentif Sipnetura:, — . '�' <Dete� "a . d/ / �
��-.
W���MAILUR�E TO SECURE WORKERS' �PEf�1&1T10N COVEMGE 5 UMAW L AND SHPLL SU6IECT Ml EMPLOYER O CRIMINAL PENALTES AND CML FlNES UP TOONE MUNDRED
Tlql15AND00LL4RE�St00,000),1NADORIONT�TMEWSTOF(YJMPENSATION,D GES0.5PRDVIDEDFOfiIN5ECr10N3TO80FTNELABORCODE,IMEREST,ANDATiORNEVSFEES.
LICENSED CONTRACTORS
with Sectlon 7000) ot Divislon 3 ot.l�a,Businass end Profespjons Code, entl my license is In full
, � �r.ia�a � i ' . . � /� ,.
CONSTRUCTION LENDING AGENCY: " -
❑ I hereby aflirtn that there is e consWaion lending agency tor Ihe paAortnance oi Ihe work ta which Ihis pertnit is issuetl. (Sec. 3097, Civil Cotle).
Lentlels Name: Lentler's Address:
Signature: _ Dete:
OWNER-BUILDER DECLARATIONS:
I hereby eHirtn that under penalry of perjury that I em EXEMPT FROM TME CONTRACTORS LICENSE LAW �or the tollowing reeson (Sec. 7031.5, Business end Protesslons
Cotle: Any ciry or counry which requires e permit to consiruct, alter, improve, demolish, or repair any structure, pnor to its issuance, elso requires the epplicant lor such permlt
to file a signatl stetement tnet he or she �s �icansed pursuent to tha prmnsions W 1Te Contrectors Licanse Lew (Chapier 9(commencing with Section 7000) ot �Ivision 3 oi the
Business and Professions Catla) or that he or she I5 exempt therefrom end ihe basis for t�e alleged eaemption. Any violation of Saction 7031.5 by any eppllcant tor e pertnit
subjects the epplicant to a civil penalry ol not more than five hundred dollars ($500).):
❑ I, as ownar oi Iha property, or my employees with wages as their sole compensetlon, WILL DO THE WORK, antl the slrucWre Is not intandatl or ofleretl for sale (Sec.
7044, Business and Professions C�e: The Contrectors License Law does not apply to an owner of properry who builds or improves ihereon, and who does such work
himseH or hersatl or through his or her own employaes, provided i�at such improvemenis are not Intended or oHeretl for sale. It, however, ihe 6uildinq or improvement is
sold within one year of completion, �he owner-builder will have tha burden of proving Ihat he or she ditl not build or improve for purpose of sala.). '
� I, as owner of the D�aPertY. am E%CIUSIVELV CONTRAC7ING WI7H LICENSED CONTRACTORS to construct the prolect (Sec. 7044, Busineu and Professions
Code: Tha comreciors License LaW does not apply to an owner ot property who builds or Improves thereon, end w�o contracts tor such prolect wlth a contractor(s)
license pureuant to Ihe Contradors Licensa Lews.).
❑ I am ezempt under sec. Business and Professions Code for this reeson:
Signatura: Date:
Owner ID venfied by dnvefs licensa. ❑ Ves ❑ No Onver's License No. E:pires:
Vedfication ol Ownership by (type ot tlocumem, i.e. � propeM1y ta�c bill or deed):
DIVISION OF INDUSTRI/LL SAFETY PBAMIT CERTIFICA710N:
❑ I �ereby certify the� no exwvation frve (5) or more feet in depth Into which e person Is requlred to tlescend, wlll be matle in connection with work authonzed 6y Ihis
pertnit, afW that fw building stnictu�e, scattolCing, talSewoAc, w damolition or tlismantiing thereof, will he mwe than thirty-six (36) teet high. (Chap. 32, Gry 2, Ah 2, Sec.
341, Tltle 8, Celifomla AdminisiretiVa Cotle).
❑ As owner-Duiltler, I wlll not employ anyane ta tlo work which would require e permit trom t�e Division of Indusiriel Sefery, es noted ebove, unless such person has e
pertnit ta do such work Irom the diNsian.
SignaNre: Date:
Division of Intlustrial Safety Permit Number:
CERTIFlCATE OF COMPLIANCE AND A�MORQATON OF EHTAY: I cenify untler penelry oi perjury Ihat I have read this epplication antl stete thaf ihe informatlon given is
wrrect. I egree to comply with ell state laws and ciry ordinances releling to 6uilding construction, antl authonze representailves of Ihe Clry of Coste Mesa to enter upon Ihe
ebove-descnbed property for insDection puryoses. I egree not to occupy ar allow occupancy of eny building euthorized hy lhis Dermit until final inspection.
COUE I' INSPECTIONTYPE "— QAIF
1616 Fixed System Final Fire Preven0on
1266 Pool Spe Final
200 Finel Re-Root
201 Final BIocWRetaining wall
202 Final Fectory Flre Plece
203 Final Sign
204 FinalOemolition
COUE I INSPELTION TYVE
206 Finel Mechanical
20B Finel Plumbing
210 Finel Electrical
212 Flnel Fire Preventlan
220 Flnel Planning Approval
222 Final Site
250 Final Building/Occupency
r � / ��
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— — OdIE R�EL9
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ssmeiunw tw�
SITE PLAN
32.-0•
24'-0"
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74lOO E. FNiEH7[YYE�W.
: &W1A if 9PA7V� CA 9DB70
9q08071¢PJ�
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tyy��ppM O�NO
+�'a�
7-&TORY bFD
DRIVEWAY
18'-t
CITY OF COSTA MESA �
PLANNING DN[SION
SUBJECT TO BLDG. DEPI: REG.
NOTE: ADDITTONS, DELETInNS,
OR CORRECTIONS SHALL BE
APPROVED BY THE PLANNING DIV
BY.____��Z�i� DATE:�
�O� a�278
FflCWM
2-CAR
GARAGE
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J000 Oar19Nd Avo.
Cosm M�s�, CA D28t6
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ENCLOSURE�cR
N'.�01�]IDP/ 1Yi
F::IC�ti
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIq ORIVE, COSTA MESA, CA 92626
ELECTRICAL PERMIT
Job Address:
Suile No
Viciniry:
Parcel Nunmber:
Applicant:
Address:
Owner:
Address
3000 GARFIELD AV
REAR OF PROPERTY
14113436
EVONNE MORTON
14104 E FIRESTONE BL
SANTA FE SPRINGS, CA
LANE, GREGORY S
3000 GARFIELD AVE
COSTA MESA, CA
Phone: 800-607-5223
Zip 90670
Phone:
Zip: 92626
Contractor. SOUTHERN CALIFORNIA ROOMS
Address: 14704 E FIRESTONE BL
ISSUE FEE
Temp service test
Res. alc packa9e
New Res (b2 units)
New Res (3+units)
Pool / Spa
Lighting Fixts
Recept Outlets
Switches
Non Res Appl
Res Appl
Service l0 200a
Service to 1000a
Service over 1000a
Motors to 7 hp
Motors to 10hp
Motors to SOhp
Molors to t 00hp
Motors over t00hp
Communication drops
Sub panel to 200a
Pale Light Pkg
Phone: B00-607-5223
SANTA FE SPRINGS, CA Zip: 90670
License:827937 -
ISSUED BY:
Status: ISSUED
Applied: 08/01I2005
Issued: OBIO1I2005
SCOPE OF PERMIT
CONSTRUCT 192 SQ. FT. ATTACHED PATIO COVER AT REAR OF PROPERTY. REF.: BOS01278
ELECTRICAL TO INCLUDE: 4 LIGHT FIXTURES, 6 OUTLETS, AND.1 SWITCH.
$23.50
50.00
$0.00
$0.00
50.00
$0.00
$4,40
$6.60
5i.�o
$0.00
$0.00
50.00
50.00
30.00
50.00
$0.00
50.00
50.00
50.00
30.00
50.00
30.00
Quantity
FEESUMMARY
Temp Dist System / Lighting
Busway /100 ft
Standing Section
Misc Electncal Equipment
Transformers up to 1 kva/kw
................up to 10 kva/kw
.................up 10�50 kva/kw
.........:.......up to�100 kva/kw
................:.over 10o kva/kw
Low Voltage Equipment
Low Voll Wiring System / Ckt
Misa Conduit �
MiSC.-Conductor �
Circus ( gen or ride)
Circus (mech nde or liqhts)
Chnstmas Tree Stand�
Fireworks Stand '
Other Electncal fee '� ` -
i
tn4estigation Fee
Plan Check Fee
Reinspection Fee
,
Quantity
50.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
ao.00 0
50.00 0
50.00 0
50.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 .
50.00
$0.00
50.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requiremenis under Californla statutes and related
regulations. (Ord. No. 92•28, § 7, 12•21•92)
EXPIRATION: This permit shall automatically expire and become vold if work Is not commenced within 1 BO days, or if work Is suspended or ebandoned
(or a pedod of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all appllcable codes, end all
required Inapactlona and flnel epproval must be obtained. Failure to obtain inspections and final approval will result In the expiratlon of this parmit.
FOR INSPECTIONS CALL: (714) 754-5826
:i5irili�J]
WORKERS'COMPENSAnON DECLARAnON:
I hereby eKrm unAer penelry ot per�ury one oi Ihe I011owing tledaretlons:
❑ I heve end wlll malniein e ceNflrate ol consent to selt-Insure tor workers' campensetlon, as provitle0 for by secllon 3700 0l the Lebor Code. �or the pertortnance of the
work for w�icli Ihis pertnit is issuetl.
p I have antl wlll meinteln workers' compensatlon insurarra, as requlr9tl by sectlon 3700 of Ne Lebor Code, lor the pertortnance of che work tar whkh Ihis pertn% is Lssued.
My workers' compensatlon Insurence carrler end policy num6er ere:
Cerrler. Policy Number:
(T�ecHon need nof be cromplefed /l fhe permlf Is velued et one hunCred dWlars (5100) or Iess.J
I certlfy ihat In ihe pertortnance of th ork br w�ich this permit Ls IssueQ I shell not employ any person in any manner so es to become sub�ect to Ihe warkers'
compensetion laws of Califom ; a pree et II I should become sub�ect to Ihe workers' wmpensatlon provisions of Sectlon 3700 ot the LeEor Cotle, I shall toMwlN
comply with ifiese provlsions,
qpplicent Signeture: Dete: � � '�'�_
W�RNINO: FNLURE TO SECURE WORNERS' COMPENSATION CO�ERAGE IS AND SHN1 SU6IECT AN EMPLOYER TO CRIMIPUL PENALTIES AND CML FlNES UP TO pJE HUNDRED
7�10USAND DOLIAFE (E100,000),IN ADDITIIXJ TO THE C0.5T OF GUMPENSATION. GES AS PROVIOED FIXi IN SECTION 3108OF TME Lr1BON CODE, IMEqEST. AND �TTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I nereby eMirtn that I em Iicensetl untler pr k
lorce enC eHect. Lic. M
Ce��rectors Signemre:
Section 7000) of DlNslon 3 ot the Business end Profesytqns Catle, end my I�cense Is in tull
�Class a ��l _
�i�/e_ . �/ Date: ^' i "i� . .
CONSTRUCTION I.ENDING AGENCV: `�
❑ I hereby aHirm thet there �s e constructfon lendlnp agency for the pertormence ol the work for which Ihis permlt is issuetl. (Sec. 3097, CIWI Cade).
LO�dar's Name:
SIB^ature: _
OM�NER-BUILOER DECLAFiATONS:
Lentlnfs AtlAra55:
Date:
I lrereby affirm thet u'Wer penafry ot pe'jury Ihst I em EXEMVT FROM THE CONTRACTORS LICENSE LAW 1or ihe following reason (Sec. 70�1.5, 8uslneu and Professlons
Code: Any ciry or caunry w�ich requires e pe��t to canstruct, alter, improve, demolish, or repair eny SlrucWre, pnor m its Issuance, alsa requiras the applicant for such pertnit
to Ille e sipnad stetement t�et he or she is Ilcensed pursuant to the proNsions o1 the Conirectors Llcense Lew (Chepter 9(commencing with Section 7000) ot Division 3 of the
Bus�ness end ProleSsions Cade) or ihet he or she Is exempt theretrom Bnd the besis lor the elleged exemptlon. Any vloletion ol Section 7031.5 by any epplicant for e pertnit
sUb�ects the epplicent to a civll penelry ot not more lhen Ove hundred dollers ($500) J:
[I I, es owner ol the properry, or my employees wlih wages es their sole wmpensation, W ILL DO THE WORK, and Ihe siructure Is not intentled ar oNered tor sale (Sec.
7064, Business and Professions Code: T�e Contractors License Law tloes not eppy to an ownet ot properry who 6ulltls or ImD�oves thereon, anC who does such work
himsetl ar herself or Ihraugh his or her own employees, pravidetl Nat such improvemenLs ere nol IntenOed or offered tor sale. If, however, Ihe building or improvement is
sold within one year of wmpletlon, the owner-builGer will have Ne burtlen ol proving that he or she did not build ar im0��'e for purpose of sale.). �
[J I, es owner of the property am EXCWSIVELV CONTRACTNG WRH LICENSED COMRACTORS to consWct the projen (Sec. 7044, Busineu end Professions
Code: Tha contrecmrs Llcense Lew daes not eppty to an owner ot properry who builtls or Improves therean, entl who contrects for such pro�ea with e contractor(s)
license pursuenl to ihe Contredors ticense Laws.).
❑ I em exempt under sec. 8usineu end Professions Cade for ihis reeson:
SiBnature: Date:
pwnar ID vanfied by tlrivers license. ❑ Yes ❑ No Drivefs Licanse No. Expires:
V6��icatbn ot Ow�e�ship by (type ol tlaumant, l.e. - proparty Ux biU w deeE):
DI��SION OF INOUSTRIAL SAFETY PERMR CERTFICATON:
❑ I hereby certify that no excevation iNe (5) or more feet in depth Into which e person Is requlretl to tlescentl, will be made in connection wlth work euthorized by this
permit, antl that no huilding sWCNre, sceHolding, lalsework, or demolltlon or dismantli�g thereot, wlll be more than thlrty-six (38) teet high. (Chap. 32, G�p 2, Art 2, Sec.
341, Ttle B, Calllomle Administrative Cade).
❑ As owner-builder, I will nol employ enyane ta tlo work which would requlre e pertnit trom the Division of Industriel Sefety, es noted ebove, unless such person hes e
pertnit to d0 such work Irom the divisian.
Sipnature: Date:
DI�Ision of Industrial Sefory Permit Number:
CERfIFlCATE OF COMPIIANCE AND AUfHORQA710N OF ENiAV: I ceRity under penalry oi perjury that I have reatl t�ls flpplicelion and siate l�et �he information given is
coRect. I egree to compy wlth ell state laws an0 dy orEinances relating to building construction, end euthoAze representetives of the Ciry of Cosle Mesa to enter upon the
ebP�e-desyfi4ed p�operty for in5pection purposes. I egree not to oaupy or ellow occupancy oi eny building authonzed by this permit until finel inspeclbn.
I nature OI I Owner(s)
i � n,�, .�f—
And/Or utho A plicent
f�]((�E,j, INSVECTONTYPE QdI{ Ii�:S
1g18 Fixed Syslem Flnal Fire PrevenUon
1288 POoI Spa Flnel
200 Flnel Re-Rooi
201 Flnal BIocWReteining Well
202 Final Feclory Flre Placa
203 FinalStgn
204 Final Demditlon
COOE� INSPECTIONTYPE
206 Finel Mechanicel
20B Flnal Plumbing
210 Finai Elecidcel
212 Finel Fire Prevention
220 Final Planning Approvel
222 Flnel Site
250 Flnal Building/Octupenry
Date n/ � -�/
b��" �
Date
PPOJECTAOONE55: 3000 GARFIELD AV
owx"e1lsNnme: LANE, GREGORY S
aooness: LANE, CHERISE
3000 GARFIELD AVE
COSTA MESA,CA 92626
APCHIENGINEEH:
ROONE55:
flEG.NO.:
UNIT:
UNIT:
PEflMITTEE: BRICK ARTISTAY ( 714 ) 841-5643
aooRess: 18357 ENTERPRISE LANE
HUNTINGTON BEACH CA 92648
LICENSEO CONTXACTOB OEClAH11TI0N: 1 �ere�y allirm that I am license� under pmvisions ol C�apler 9(mmmencing vnlA Sec�ion
7IXp) ol �ivsion 3 0l Ihe Business aritl Pw�essionS Cotle. an0 my license is in �ull �orce antl ellecl.
ciTruc.://Q�p sTnTeuc.:454722 ciass: C�29
a /{
ro,�. -/-! f-GGL( 2 slBnawr;�,�!-u±� //r/ . —
WOHREflS' COMPENSATION OELNBRTION: I �ere�y athrm ��al I �ave a tertitita�e ol ton5eni 1 i4insure or a cenilicale ol workeri
Comoensation Insurance. or a cenilietl caoY �hereol (Section 3800. Lab. C).
PO�ICY NO.: E7(P. OFTE:
COMPFNY:
� Cendiea caDY �s nereoy furnisneU. ❑ Cenitie0 cooY �s IileA wilh the ciry Building Division.
Odt¢: AppliCdnl:
EXEMPTION FNOM WOflNENS'COMPENSPTION OECIAflATION: (Thissedian neetl nolUecom0letetlitthe De�milislorone huntlreG�$100�orIMS�.
I cer�ity Ihat in Ihe De�formance ol Ihe work for which Ihis permil is issued, I s�all not employ any person m any � ner so as �0 6ecome
sublecl to Ne Workers' Compensalion law5 0l Calibmia.// /�J�
ffytp'. �/ ���% SipnaWre�-�/o ^��L—�'f� ,�E( �7
NOTILE: II, a�iet making �his dedaralion. y0u S�ONU ecomb e 5u0�ec� to ��e Workers' Co i nsation pmvisions ol ihe LaOor
Catle. you musl �arlhwiih comply wi�h such provlsiais or I�is Oermi� 6�all be deemed r ketl.
CONSTNUCTION LENOING RGENCY: I here0y aifirm Ihal ��ere is a cons�mction lentling ency �or �he Detlormance o� Ne work lor
which IhiS permn is i55u¢0 (SetliOn 3097, Civ. C�. '
LEN�EH: �
FODNESS:
OWNEB BUILDEB OECLABRtION: 1 �ere0y allirm �na� I am exempi imm t�e Contractors' Sta�e Licenu Law lor the lollovnng reawn
(Section 7031.5 Business anU Pmlessional CoOe'. Any ciry ol county w�ic� reQuires a permlt to constmCl, alrer, improve, demolisn, or
rePair any simcWre. O�ior to it5 i55uance, also repuires lhe applicant for such permi� �o lile a signetl statement tlu� he/she is licensetl
pUR�dlli�O�hC pf0YIL005 O�IIIC CAItlfdCIOR Siate License Law�Cha0�er9�commencing vnN Sectian 7000�ofDivision 3 ofthe Busineu
and Pmlessions CoOe� or ihal �e/she is e�empl lherelmm and ihe basis for ihe allegetl exemD�ion. Any violation ol Section 7031.5 by
any apvlicant far a permil sueiects ihe appiicanl lo a civil penalty ol nol more ihan Irve nundre0 doilars (351101.
I, as awner ol Ihe O�openy or my employees wii� waAes as Iheir sole com0ensation, will Oo ihe wofk, antl I�e
❑ stmttureis nolinleneeG orofle�etl Iorsale�5ection 70E4, BusineSs an0 PrafeSSionalCOAe: The CAntractors' Stale License Law
tices nol apply Io an owner al a D�openy wta DuilJs or improves ihereon, antl who tloes such work himseli/�erseli or I�roup�
his o� Aer own em0�oyees, DmviOed tha� suc� impmvemenis are no1 intentletl ar oflereE for sale. If. �owever IOe �vilding or
impmvemeni is sold wilhin one year ol compleiion. I�e owner will have Ihe bur0en ol pmving he/she Oitl not huild o� im0�ave
lor ine purpOse ol Satel.
I.as owneroll�e D�operty.am eeclusivel9 conlractinA w��hlicensetl comracmrs�o tonsiructthe D�ole��l,Section 7044. Business
❑ antl Pm�essions Code: ihe Contraciws' State Liceree Law dces iro� appry to an owner of pmperty wlw OunAs ar imo�oves tnerean
antl who conVacls lar suth pmle��s wit� a[oniracioqs�license pursuan� ro Ihe Contra[tors' Siate License Law�.l am aware
Ihal O�ool ot Iheir Worker's Compensation insurance 5�ou10 be pmvitled to me.
� 1 am ewempl un0er Seclion: B. 8 P. C.
br �his reasOn',
Daie: Ownec
I eo nereby cenily ihai I am aware ol anA un0erstand the repuiremenis ol Califomia Heal�h and Safety Cotle Sections 2550.5, 25533, an0
25534 antl Ihat I or any Iuiure UuilOmg occupanl wiil/vnll not (ci¢le one) need to tomply wilh said staie codes and I�e r¢Quiremenl5 for a
permn lor consimclian or modilica�ion Imm t�e Air �ualiiy Management �istric�. ReSiAential constmciion apDlicalions are exempi �mm
Ihese pmvisians.
Date: Av�licant:
I �ereby teriily Iha� I Aave r¢aa I�is ap0litaiion antl 51a1e I�al lhe abOve inlOrmalion i5 Corret�. I agree t0 comply wilh all Cify antl COunly
ortlinances zntl Slalelawsreldtinpto �uiltling confilmdion antl hereby aulhorizerepresenlatives o�this cilyio enlerupOnthe above�mentioned
'. pmperly br inspeclion puipases. �� / � ��
Drive�'s License ar Sacial Securily p:
�6eL46 Wbite-BUAEing�, Green-Cotle Enbwemem: Canary-Applicanl; Pink-Revenue: GoltlenroG-Assessor
CITY OF COSTA MESA — BUILDING PERMIT PERM NO; B 059990
PERMIT NO: B 059990 PLAN CHECK NO: 04494-92 S GOVT; N SUPP; N
CONSTRUCTION TYPE; V—N PERMIT TYPE: STR PURPOSE; OTH
JOB DESCRIPTION ; 150LN FT OF CZTY STD BLOCK WALL SQ FT: 150
CLAIM VALUE; 3,800.00 CALC—VALUE: 3,000.00 GROUP OCC: R-3 /
COMMENTS: LEFT-65LF REAR 75LF lOLF ON RIGHT SIDE ABUTTING REAR PROPERTY
**r*�e�rrx��r��t*�r�t�r�r***�r�**�r�r*r***�r�r*�r�e*��**�r�r*x*�t�t*****x�*��r�r�r**�t**�x�r*�t�r**�r*�t��e�r*�r
Z O N I N G R E Q U I R E M E N T S
S E T B A C K S
------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING ---------
FRNT: FT IN REAR: FT IN FRNT: 15 FT IN REAR: FT IN
LEFT: FT IN RGHT; FT IN LEFT; FT IN RGHT; FT IN
PARKING REQ• PROV; PARCEL: 14113436 ZNE: R1 REF NO:
PLANNING N(STES� REARI(65BL70CLFji6L10�LFEON�RTTSIDEPL�NABUTTINGSREAR�pL?LF),
if iE iE 1k iF 1f iF 1F �f �f iF iE iE iF if ik if iF ik 1ElF iF iE 3F iE �)E ik iE 3E �E it�F It �E it 1F1F i! If it �E iE iE iE �1E ik iE if Ik if �f �F1Flf K iE �E 1E af if iF if if iE 3F iF �F iF if 16 iE iF iE iF �f i! IF IE iE
D E V E L O P M E N T S E R V I C E S R E(J U I R E M E N-T-S
ZONING APPROVED BY : (�.�.l�I�— `� DATE: ' �.f l / 1'
HUILDING APPROVED BY ; ' R—E�i DATE: ." (G' (' �Iy
APPLICATION ISSUED HY• - i�rF������� DATE:,� l�'.,l L�
1kMikMkiFklEik�FiEiflfiEik�fifikiflkiFlF�iF�i ifkikikif�fkififk . kif
iFikiEitik�FiFiklflE�flfiFiFiklFiFikkiliffFkiEfl3titiFil�EitiFikiEfElEiF k�fkiFit�kikitlfltifitklfiF�FiFiEiFiEitlF�FjFiliFlFiEk��kiElFiFikitifiFikitriF
LEGALI2ATION;N F E E S U M M A R Y STRUCTURAL;'SEGMENT:Y
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
PERMIT 59.00 ' � ,50,
: SMIP/NON—RES
ISSOE FEE 35.10 ,, ,
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECR TOTAL PAID !� DUE
TOTALS----> 54.50 0.00 35.10 89.60 98.10 `," —8.50
REVENUE DIVISION TOTALS--> COLLECTED; , 98,10 OVER/SHORT: "� 8.50
HLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
54.00 ' .50 �;: 35.10
�f if it if i! iF k iF M if ik k if iF if if iF k ft k fE if ff !f if if if 1f if �k M ik iFiF k if it if !F i! ik iF k If k if If k iF i! if ff if kif if iE ik if iE iF iFiE iE iF k k �F iF�f �k 1f iF i! iF iF if 1f �f
I N D I V I D U A,li F E E B R E A K D O W N ,
TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST
SFR 150 RES—CONCRETE BLOCK WALL . / FT, 20,00 3,000,00
END OF FEES
/ �
., '�I !`.1.
r .
. /'
i t
� CONSTRUCTION AND PLANNING POO� SPA
Date Inspector Date inspector
` APPROVALS Permit # APPROVALS Permit # •
�
t. Temporary Electrical Service or Pole 52. Pool & Equipment Location �� -
<-
2. Soil Pipe-Undrgrnd. , _ 53. Steel ReinforcemenC •
tTi�M�
� 9.`�.S'EI2ct�ical CondGi't=,F�fifitY-Undrgrnd. ,` � 54. Forms �•%
:: 4:� EleaVical Condutt-Undrgrnd. �� 55. Electrical Bonding
'� 5.` S��Reinforc�ir 56. Rough Plumbing & Pressure Test 5
tf, t..',L
!ri4�r..'Electrical UF6R;fi�d. r_ 57. APPROVAL TO COVER�GUNITE �
�i
�'�`^F�o�o�ngs �,?; .� � � 58. Electrical Conduit-Undrgmd. ,� -x
`t�. F,{aundation Y�`�. `� �� 1 !� ' � � 59. Gas Pipe, O Undrgmd., Test ,� �•"
� 9. WBter Pipe-Undrgrnd. , � 60. Backwash Lines, P�7rap, O Undrgrnd. L��
10. Structurel Floor �ystem . 61. APPROVAL TO DECK •'
,.
71. Property Sewer Lirte& Hans,e'Connection %, 62. Backwash & Receptor•Final
12. Sev�r Cap 1, �/,. 63. Heater & Vent-Final /.•:�
i
13. Roof Drains i ,, i� 64. Plumbing SYstem � Final ;�,�"�
r
14. Rough Plumbiy � .�� �� 65. Electrical�Finai �
15. Rough Electri�al�Conduii � 66. Solar SVstem�Final
16. Rough Electric�lJiring 67. Fencing & Access ApProval
17. Rough WiringSjgn 68. APPROVED FOR PLASTERING
18. Rough Electric�l•T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
79. Rough Heating & Air Conditioning ' FIRE DEPT. REQUIREMENT
_ . C Q'rSi- X /F z� O`
20;GRo� h F3CSOlY F',�rEpIBCe I�'S.?1 eL'? # �7 C?� x APPROVA'L•'S`�CPerotit #>< �. m
�^ -' x rr r - -� ? x x ' " V E.:'- r-�
S x 1:� �. x� n. �-. ^'7 x.,.' . . S C`Q -�1 x ST7
21,�u�ls,in�Str��lct�j�T �.... ��,_, x S ;i --M x,70. tlndergrogn@ Hjqlro R
22. Duos, VLntllatibqx i CJS � � S Qx �. =77, producTRping �6as Q'Oil
� r n. _v -
23CGa�ip��-.Ra h &' 7est � x � '` � "" '� - '- � � fi C.a
� +.. i 'vS �:n r E 0= x- �Z• Undergrbyn�J F�u�-,; ;c N,
24�.�,Rocif FEaming ;r� x � F- F-� M? O � �_*, 73� Under9rn�i. Sto � Tank�O Gasr O 9'il
� m � : < -
25. Ro Sl�athin `n :s N �c ;T7 rq v Ux x' �'- v .-+-,0 x
� � 9 '� .h �<y .� r ;� ] ;� � ,. 74� Qver.�i¢ed HydroJ' ;i
26;vT�Bqr Ceiling (Stru¢tural) $y�AaaocoaYo *� tt+ G7 ci;x a: 75':'� Dry Ciiemical -� �-' G[4
27°iFra ea,nd FlasFiin" D` `�* � CA �` ` ^ '' T ,.">F '� 5 �n �.7
a.• � w •� :.cco; x r: � >+ s:� � 76J Dry Stanc�.Pe ,� x
, - � . � �. . ,
',�28:JLae}�ing$ Sidin�t � �-±sy� c;[; R F ••x x 77- FIXED SY9TEtu1:61NAL< O
,- -
�'29. Insula[idn ��� `� S"' ��� � x� `� 78: FIRE PREV. FIfV(�L x> z x
S .� ♦. J' ' . /
�:{30. Drywal��NaiSng��: O'��� . t < - -k1EALT@ijDEPT<kiEQlll ` MENT
��31. Plaster �}o�Q COp�`. S, � sr,n z � ' ` t 79 FINAL IAt$�ECTEDN *`� � ;s
�
=V32t; ElectriGai Potver Met��Finah ' 6: v -. `�- �� 80,^FOOD CE T�� �f6�TE ISS EO C �
�33SFir�l E[Fctr' .=,x ,Y i ay� � =`� ' k ' Noies ��j �r � e �!L/L3�YL �
�, �
�34�.Fin�l Hqy�ting&`�i`g Pditipr�n,g �^C x J' ��: �; -� �.��T S 3�� �.
�35y'h�F irfai Gas Pi¢e-T�ct� �'� ' T ` . K `.` Y t %! � � �r i ♦ �/C G•_c�i_c_O�(
:{_r_t ' , �.c
."C ' �.n Q x :I : r . x �* '• � /-F :Tl
�r36. Ho'od oc�CanOPY,-yy: ,^., I"r - r!', �: C: t. T C"� l� >
- -��� ��_�.��_� z �.7��
"''37:•FinTa� F¢�ctarv FeZe'IAee � St� •-�S .x T. * < . �i� < <, .
-..�£ � K x x i7
-�38aFirle) Pkqmbin9 :Ji� N i.. ., w Kn :c � h.'�.'� � x i,A i ,'_
:�39�Wat2r Setvice�Fi3ak � � � �^ 'o�'�� �*' Y '+' � . Z�uO M :C Cr ,
:V d � v I J c'CI.* Y. i% CC \ r,
^ '4 C�. '�( V [CI �: K f - • +[ ! .
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�50�Gas;Release to Sou�hem Califos�ja Gas Co '; � _ ( ; r; � _ - , ,� n�J « ` .
:,51. CERTIFICATE O�OCCUPA � � � � _ �- „� ,_� ,, , , �
No._ . _ Date
�or�68 TRACT !12 2
. � �,�. ��
. �
.-- "
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 977 C08TA MBBA. CALIRORNIA
Fo� Applicani fo Fill In Complefely
TYPE OR PRINT ��/���'
COSTA MESA. CALIFORNIA
K B�. K DEVELOBMENT C
SIZE
OF LOT � R
USE OF
EXISTING BI.DG
88T9ACK LIN¢ PHOM
JC I
y—
NONE
��
�t�❑
TEL.
FEE. RECEIVED
� SEP 27 t961'
FINANCE DEPT.
CITY Of COSTA MESA
APPLICATION FOR PERMIT
BUILDING
For Offiee Use Only
INC.
Rec vee er
,�
,...,.-. BUILDING
NO. OP BLD68.
� n
RIGHi 7 �
OF WORK
BUILDING '1 NO. OF
81ZE � 4Z SQ . FT .ROOMS STOF
EXTLRIOR WALL ROOF
COVERING STUCCO COVERING ROCK
UHE OP BUILDING AND WORK TO BE PERFORMED
SINGLE FAMILY RESIDENCE AND ATT
GARAGE
aecerveo
COSTA MESA. CALIFORNIA
ZONING
ZONE // � I PLANB G I BUILDINO e y/!�G :
�
� 1 ./ �\
�eaw� �'" 6� O T/1 � Z.i Z.
DEBGHIPTION
��,
1 IC[NT6R LINe Bi.l �� f
_ FRONT
R. SIDE /�
L. SIDE �
..�... Z� �
APPROVED L�
1 HEREBY ACI(NOWLED6G TXAT 1 NAVE READ TXI9 APPLIWTION 1HE AMOUNT BHOWN UNU6R VALUATION 19 ROR THe
AND BTAT! THAT THe ABOVE I6 GORP6CT AND AGRHE TO COM- pURP09E OF EBTABLIBHING A PERMIT FEE ONLv.
vLY WITH wLL c1iY OROINANCEe AHD 6TATE IAWB Pl6ULATINO
auumxo coNsrnurnoN. VALUATION
81GNATURE OF /�� �S�/ � PERMIT FEE $ � ���
PERMITfE w `�
� S PLAN CHECK A //i S`
�AUTHORIZEO AGENT