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HomeMy WebLinkAbout1085 GLEN CIR - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 1085 GLEN CI Suite: Vicinity: Parcel Number: 42203145 Zoning: Applicant: NOLTE, FRED Address: 10812 LA BATISTA Phone: FOUNTAIN VALLEY, CA Zip: 92708 Owner: THORNTON, ROBERT A Address SAPORITO, JOHN J $181.25 COSTA MESA, CA - Phone: $0.95 1085 GLEN CIR Zip: 92627 Contractor: NOLTE ROOFING Address: 10812 LA-BATISTA Phone: 714-964-0554 FOUNTAIN VALLEY Zip: 92708 License: 418550 Arch : Address: Eng: Address: ISSUED BY: Status: ISSUED Applied: 06/24/2002 Issued: 06/24/2002 Phone: Phone: Zip: License: License: SCOPE OF PERMIT REMOVE WOOD SHAKES, INSTALL SHEATHING. COVER WITH EAGLELITE CAPISTRANO TILE. NOT TO EXCEED 5.7 LBS ' PER SQ. FT. INCLUDES ATTACHED GARAGE. Plan Check: $0.00 Permit: $181.25 SMIP Res: $0.95 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $182.20 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY Front 0-0 PARKING Existing: 0 NOTES: FEE SUMMARY PLANNING & ZONING Rear 0-0 Left 0-0 Rear 0-0 Left 0-0 Required: 0 Proposed: 0 Calc Valuation: Claim Valuation: Right 0-0 Right 0-0 $9,450.00 $9,450.00 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 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 all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 "� (UW) C DECLARATIONS WORKERS' COMPENSATION DECLARATION: ' I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ❑ I have and will maintain workerscompensation in urance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. M workers' cram at Insurance caro otic number are: r I ,y^� ' , Carrier:y C (1 p y Policy Number: �/wl/� A section need no (Jcoeted i/ the pe if is valued at one hundred dollars ($100) or less.) ❑ I rtiy that in the performance of the wo r which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of C nd a hat if I should become subject to the workers' compensation provislons of Section 371X) ggqf the Labor Code, I shall forthwith comply with these provi ions — .�n Applicant Signature: / Date: WARNING: FAILURE TO SECUR ORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100, , IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION3706 OFTHE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect.-Lic. # Class # O Contractor's Signature: Date: CONSTRUCTION LENDI G AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirn that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ NO Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet Of Compressed gas at standard temperature and pressure). ............................................-............. .................................... ....................................... ............. ............................ -_....................................................................... ............................................... ............ ......................................... ............................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............._.............................. ...................... .... ..............-................................ -.-................................................... ...................................... ................................................ _............. ................................. ............................................. ....................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........._..............................................................................................._.........................................................................................................................................................I................ ........................................................................................... a If en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ............................................................. _............................................................................................................................................................................................................................................................................................................................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes a No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ................_........._............................................................... ................. ................ -............................................ ...................... ......................................... .............. I........... ................ ... .......................................................................................... 6 Will any part of the faciliy, to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If —yes, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ......................................-......................_.......................................................................................... ................................................................. ......... ........................ .......................... ........-........ .................................................................. I................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ........................................ ................. _..............-............................... ................................................................................................................................................................................................................................ B (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I re o comp)yry+ith a state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-d c d pro r ction purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig £bre Ot Legal Owner(S) ` Date And/Or Authorized Applicant Date INSPECTION TYPE D,1& INTMALS CODE# INSPECTION TYPE Ilii jF, I[(TITAL;i 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final �/� 208 Final Plumbing 200 Final Re-Roof —g–DZ"E'9 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy n PROJECT'SNAME: ADDRESS: 1085—GLEN CI UNIT: �� CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 05848`_ AD NAME: OWNER'S THORNTON, ROBERT A 1,085 GLEN CIR PERMIT NO: B 058485 PLAN CHECK NO: 02980-92 S GOVT: N SUPP: N COSTA MESA,CA 92627 CONSTRUCTION TYPE: PERMIT TYPE: STR PURPOSE; OTH ARCNIENE: UNIT: Q F 662-9128 REG.NO.: ADDRESS: JOB DESCRIPTION ADD 2 SKYLIGHTS, ICBO#2469 S T; 800 PERMITTEE: CLAIM VALUE; 800,00 CALC—VALUE: 800,00 GROUP OCC: R-3 / ADDRESS: ROBERT THORNTON (714)662-9128 1085 GLEN CI COMMENTS: NO OTHER WORK PERMITTED % If###%DEI¢##lE#lF#########fE###7(-1E#1 ###E#K�16�1E##########dF#�%�Y.�######�Y:+id(## ##�%##k # �i: �%�it ##-iF �T. �Y## LICENSED CONTRACTOR'OECMLARATION: hereby affirm that am licensed under prroovisio(ns Uf Chapter 9 (commencing with Section 7090) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Z O N I N G R E QU I R E M E N T S A C K $ CITY LIC.: STATE LIC.: CLASS: S E T B Date. Signature: ------------ MAIN BUILDING ----------- --- ACCESSORY BUILDING WORKERS' COMPENSATION DECLARATION: I hereby affirm that l have a certificate of consent to self insure or a candidate of workers' FRNT: FT IN REAR: FT INFRNT: FT IN REAR • FT —1N Compensation Insurance. or a certified copy thereof (Section 3800. Lab. C). LEFT: FT IN RGHT: FT IN LEFT: FT IN RGH T : FT IN POLICY NO.: EXP. DATE: "QMPANY: PARKING REO• PROV: PARCEL: 42203145 7.NE: REF NO: Certified copy is hereby furnished. ❑ certified copy is filed with the city Building Division. PLANNING N TES> > Date: Applicant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This sectio eed not be comp ted if the permit is for one hundred (51901 or less). D E V E L 0, P M E N T S E R V I C E S R E Q U I R E M E a' j S I codify that in the performance of the work for which this permit is i; e I s all not em y any person in any manner so as to become �• subject to the Workers' ComDensalion Laws of California. J/ I //f . ZONING APPROVED BY °'^, DATE:;, Dale: Signature: NOTICE: If. after making this declaration, you should bee e s ect o e workers' Compensation provisions of me Labor BUILDING APPROVED BY DATE �. Code, you must forthwith comply with such provisions Ihis permit shall be deemed revoked CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for v which this permit is issued (Section 3097, Civ. CL APPLICATION ISSUED `BY : DATE • /•Ilb . LENDER: fir ADDRESS:###k7E#lF#!f#iF1(####iF#Se##XEi6##i4 ib##iE##•####iF#3E##14##3f###ii##if iE iEIf#%###3F#lE#ie#iE'x�r i(; 1E##i4###)e. Y..% LEGALIZATION:N —J•' E E S U +. M A R Y STRUCTURAL SEGMENT: Y Gull BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors' Slate License Law for the following reason BLDG PMT PLUMBING ELECT�3C ArECHANIC FIRE SMIP/RES GRADING (Section 7031.5 Business and Professional Code'. Any city of county which requires a permit to construct, alter, improve, demolish, or e repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed PERMIT 21•00 1, J 0 pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7D00) of Division 3 of the Business SMIP /NON—RES and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by PLAN 33.65 + any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500). ISSUE FEE £ I, as owner of me property or my employees with wages as their sole compensation, will do the work, and the BUILDING—DIV—> PERMIT ISSUE PLAN= CONSTRUCTION AND PLANNING - POO' SPA x - APPROVALS Permit - Date Inspector APPROVALS Permit # - Date Inspector A. Temporary Electrical Service or Pate 52. Pool &Equipment Location 1)40 2. Soil Pipe-Undrgrnd. r` V 53. Steel Reinforcement ~( ( v . 3. Electrical Condu.1t,Uti1ity-Undrgrnd. 54. Forms d 4..Electriaal Conduit-Undrgrnd. �L 55. Electrical Bondingfen V 5. Steel Reinforcement - - - 56. Rough Plumbing & Pressure Test r r 6. Electrical UFER_Grnd. 57. APPROVAL TO COVER-GUNITE 7: Footings - 58. Electrical Conduit-Undrgrnd. o 8. Foundation J �} r 59. Gas Pipe, 0 Undrgrnd., Test ai 9. Water Pipe-Undrgrnd. 25/ 1-1 60. Backwash Lines, P -Trap, 0 Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK l �• '�/� 11. Pro party Sewer Cine& House Connection 62. Backwash & Receptor -Final 12, Sewer Cap - 63. Heater & Vent -Final �n 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final r i 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 ElectricalrT Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS: 'Permit # r - 20. Rough Factory Fireplace.:. ¢. - _ r 21. Ducts, in Structure ,, ,, z ` :.� 'ti _ .- 1 70. Underground Hydro 22. Duct!;; Ventilating_.: I ^� - < .''r- ? 71. Product Piping 0 Gas El Oil _ •�, 23. Gas Pipe-fioug�&Test 72. UndergroundFlut,6:-, C._ 24. Roof:Fra.ning� _ . • 1.s;> R 73. Undergmd.:Storage Tank 0Gas 0Of1' 25. Roof;Sheething- � •' �>` ti j4. 'Overhead Hydro �-' - c) •: 26. T -Bar Ceiling (Structural) & Monocoat - 75. Dry Chemical e 27. Frame and Flashing: - (p f/�` 76. Dry Standpipe i 28. Lathing &;Siding �•; -- y 77. FIXED SYSTEM FINAL y 29. Insulation 78. -FIRE PREY. FINAL- - 30. Drywall Nailing HEALTH DEPT.,REQUIREMENT 31. Plaster Brown -Coat 79. 'FINAL INSPECTION -- - 32. Electrical Power MeiersFinal 80. FOOD CERTIFICATE ISSUED r 33. Final l Iectrlc 34. Final Heating '& Air Conditioriing = Notes'. 35. .Final Gas Pipe -Test - •• l 36. Hood or Canopy 37. Final -Factory Fireplace 38: Final Plumbing_ -- 39. Water Service -Final 40. Gas Service -Final '41. Solar Domestic -Final _ -• --- 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation ---{_ 46. Handicap Regulations ' 47. FINAI_STRUCTURE &BUILDING �j L10y / I 48. FINAL PLANNING 49. Electric Release to Edison - 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date CITY OF COSTA MESA BUILDING DIVISION OWNER -BUILDER VERIFICATION A city or county, which is required to give notice pursuant to Section 19830, shall attach to such notice, and, as a condition precedent to issuing a building permit, require the completion and require the return of, an owner -builder verification. Attention Property Owner: An 'owner -builder' building permit has been applied for in your name and bearing your signature. Please complete and return this information in the envelope provided at your earliest opportunity to avoid unnecessary delay in processing and issuing your building permit. No building permit will be issued until this verification is received. 1. I personally plan to provide the major labor and materials for construction of the pro- posed property improvement. .�Yes ❑ No 2. 1 (have/have not) A�, 4(5- signed an application for a building permit for the proposed work. 3. 1 have contracted with the following person (firm) to provide the proposed construction: Name Address City Phone ( ) Contractor's Lic. No. 4. 1 plan to provide portions of the work, but I have hired the following person to coordinate, supervise and provide the major work: Name Address City Phone ( ) Contractor's Lic. No. 5. 1 will provide some of the work but I have contracted (hired) the following persons to pro- vide the work indicated: Name Address Phone Type of Work I hereby affirm that I have received a copy of the information set forth in Section 19830 of the State of California Health and Safety a and have completed the above information to the best of my per- sonal knowledge, in c li this State law. Signed: Date: -z— Name: Name: (Printed or Typed) C.D.L. # or S.S. # 754-5273 1042-46 I I OF COSTA MESA REQUEST FOR OC TRACT NO. 9zP-5 LOT NO. / ADDRESS /D �J ( 2 /eAf lam/ Qc /Lc ANCY DATE • o 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 . r accepted by the City of Costa Mesa. The undersigned, by executing this agreement, acknowledges that (he -she -they) (was or 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 approved. The City assumes no liability for the enforcement of the conditions necessary for approval other than those conditions protected by surety bond. The undersigned agrees to indemnify and hold the City harmless from any claim resulting in damage or personal injury to the undersigned by reason of the aforementioned uncompleted condlr+— RECEIVED CITY OF COSTA MESA PLA"! W4r', 77PT. AUG 2 4 1977 AM. PM 718,9110111112111213141516 UWNtK y UAlt 12-7_76 JOB ADDRESS 10 5 Glen Circle BUILDING PERMIT NO. 42758 C' FAL CONTRACTOR J. Ray Construction Co DESCRIPTION of WORK Res w/att. Gar. t . 115-661-29 LOT 16 TRACT 9105 FIRE ZONE VALUES 33600.00 INSPECTIONS Si nature Date 11TYPE V GROUP I & S ZONE R2—CP GAIL SUBCONTRACTOR M 5 GAS Date Number1 Si nature WATER 6•• Plumbin ROUGN PLUMBING r22• 1 O PROP. SWR. LINE ❑ HOUSE CON. M•ZS• / SPRINKLING SYSTEM Y166Eh4AI1fiBtlG I ROUGH HEATING AND AIR CONDI G� ,%7 TEMPORARY SERVICE OR POLE UNDERGROUND ❑ POWER ROUGH WIRING eatina nnd ent. TRENCHES FORMS STEEL REINF. FLOOR SYSTEM BOND BEAM STEEL REINFORCE SHEATHING FRAME AND FLASHING c LATHING — IN OUT ER, BROWN COAT S _TURAL, FINAL HEATING, VENT., REFRIG. AND A.C., FINAL PLUMBING, FINAL AND GAS TEST ELECTRIC, FINAL , BUILDING, FINAL .Z .7) 9105 rzsr� t :.K. 'sI6 -_ CFO ****71 j 'COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 A f P�KATION FOR STRUCTURAL PERMIT C. o. rsppus.aua w rw w a,mnpscscsy — aix sun vmy BV O TE CEIVE DATE IS��I/JEJ[�'. CBUILDING '© ADDRESS �J L-�� 1' M(. OWNER R & W Development P R . 4^ MAIL 188 E. 17th St. G SS io86 CiTz. ADDRESS CITY Costa Mesa, Ca. NO`.642-4RACT / �7 LOT /(� BLOCK Tn CONSTRUCTION Cal Fed. Savings & LoA D A T R I PENDER BRANCH 5670 Wilshire Blvd.ADDRESS LOS Angeles, Ca. 90036 W — EIraPME1l1T /a -,T �ALu$�V ARCHITECT DMA Assoc. TEL731-216 S OR ENGINEER N 17621 Irvine B1vd,Tustin,Ca. FIRE ADDRESS ZONEVPE�GROUP CONTRACTOR J. Ray Construction CO. APPROVED BY DATE i ADDRESS 188 E. 17th St. TEL Costa Mesa, Ca. ��``lIE NO. OF USE OF NEW r�L' PLANS 2 BUILDING CITY NQ.642-421 STATE CITY YARDS APPROVED YARDS APPROVED LIC. 126426 LIC. NO. MAIN BUILDING ACCESSORY BUILDING 512E LOGS X 103 OLOT OOF MAC/ (FOM TEE�I/OOB40.94 LOT WN FT FT. USE OF EXISTING BLDG. O R. SIDE 4 FT FT. Separate permits are required for L. SIDE ' v FT.'Cl FT. electric, plumbing and heating work. a�XR FT. USE OF BUILDING AND WORK TO,BE PERFORMED DISTANCE BET. BET. MAIN & MAIN BLDGS. ACCESS. BLOCS. Single Family Dwelling W/ VAR UR#DATE APPROVED Attached Double Garage APPROVED(;/ - 1 AvDATEh I hereby acknowledge that I have read this application and state that the above Information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person In violation of the workman's compensation laws of the State of California. SQ. I hereby certify that I am properly licensed as a contractor under FT. the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that s licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from t pr vi ' n5 of the State California Business VALUATION PERMIT FEE $ and Professions de i ion 3, C er 66 Signature of Permittee Q PLAN CHECK $ A /✓� $ f/(/- TAX $ Author ed Agent TOTAL PAID $ '� • 49 1a� COSTA MESA BUILD NG -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in CRmpletely — Use Ink Only BUILDING ADDRESS OWNER MAIL ADDRESS TEL. CITY NO. CONSTRUCTION LENDER BRANCH ADDRESS ARCHITECT TEL. OR ENGINEER ADDRESS CONTRACTOR ADDRESS TEL. CITY NO. STATE CITY LIC. NO. LIC. NO. SIZE NO. OF BLDGS. OF LOT NOW ON LOT USE OF EXISTING BLDG. Separate permits are required for electric, plumbing and heating work. USE OF BUILDING AND WORK TO BE PERFORMED 1 hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that 1 am properly licensed as a contractor under the State of California Business and Professions Cod., Division 3, Chapter 9, and that such licenses are in full force and effect, or 1 am exempt from the provisions of the State of California Business and Professions Code, Division 3, Chapter 9. Signature of Permittee Authorized Agent FFti! 'f('—1-lpire,.-QG 2(}q 7st * u }413 9.00 APPLICATION FOR STRUCTURAL PERMIT RECEIVED BY I DATE RECEIVED nATF MC 11F1 BUILDING ADDRESS FIRE ZONE APPROVED LOT DATE BLOCK ZONE NO. OF USE OF NEW SQ. FT. PLANS BUILDING YARDS APPROVED YARDS APPRO' MAIN BUILDING ACCESSORY BUI VAR,* DATE C.U.P.+ APPROVED APPROVED n m SQ. FT. my THE AMOUNT SHOWN UNDER VALUATION IS FOR m THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: VALUATION PERMIT FEE $ / m O N m PLAN CHECK $ n TAX $ u. U TOTAL PAID $ /