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HomeMy WebLinkAbout1099 GLEN CIR - Building PermitsW / SEPgRFOR gTE PE " APPRO�A� y I yEgT"IVO, Et TRIC41 PCE to'JlRrD PC- -4t E` -qC( CTI ay RfiOc `Nob u E E 0 e C P e 0 pe r'. ,e c e / SEPgRFOR gTE PE " APPRO�A� y I yEgT"IVO, Et TRIC41 PCE to'JlRrD PC- -4t E` -qC( CTI ay RfiOc `Nob u E E 0 O C c I\ qj C. I LP . yvJ SoE vIsW Cup,T 10 T) GIF-?,) G R 6y2,- S55 �l 41 �° X0-4,0 9JR 4 O A 4 Cp ,ems, I L4 ro 2x( RPS ------------ NEi ti P� Vt 1� �SJIt'Ov` c�1� 101,1 c IA, � (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.caUILDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 1099 GLEN CI Status: ISSUED Suite: Applied: 06/28/2001 Vicinity: Issued: 06/28/2001 Parcel Number: 42203152 Zoning: Applicant: COFFEY, BRIAN Address: Phone: 949-722-8846 Zip: Owner: SELBY, KARIN KAY Address 1099 GLEN CIR Phone: COSTA MESA, CA Zip: 92627 Contractor: THE ROOFING SPECIALISTS Address: 2428 NEWPORT BLVD #5 Arch : Address: Phone: (949)722-8846 COSTA MESA,CA Zip: 92672 License: 734068 Phone: Eng: Address: ISSUED BY: Phone: Zip: License: License: SCOPE OF PERMIT TEAR OFF SHAKE, INSTALL SHEATHING, APPLY 40 YEAR COMP AND ALL RELATED FLASHING. FEE SUMMARY Plan Check: $0.00 Calc Valuation: 84,675.00 Permit: $111.25 Claim Valuation: $4,675.00 SMIP Res: $0.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $111.75 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY Front 0-0 PARKING Existing: 0 NOTES: PLANNING & ZONING Rear 0-0 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 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 2446-46 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following dedarations: ❑ 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 workers' Compersoldon insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: "I I, Carrier: Policy Number: (This section need not be completed it the permit is valued atone hundred dollars ($100) or less.) ❑ 1 certify that in the perfornc mae owork for 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 Califomf th9la, El egreo that if I should become subject to the workers' Compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these ision, Applicant Signature: Date: WARNING: FAILURE TO SECURE WOE COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5100,000), IN AD TIO TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby 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 affect. LIC. tl Class e Contractor's Signature: Date: CONSTRUCTION LENDING AGENC : ❑ 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 affirm 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 ($500).): ❑ 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. It, 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 contractor(s) license pursuant to the Contractors License Laws.). ❑ I 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: ❑ I 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). ...........................__........................_..............._............................... .......................................................................................................................... .............................................................. ....................................................................I............. ....... 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 teat of compressed gas at standard temperature and pressure). ........................ ..................................................................... _...................................................... .................. ........ ... ...... ......... ..... ................... ................................................. .......__.................................................................................................. 3 Does or will theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes EDNo (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. ................................................................................................................................... .......................... .................... ..................................................................................................................................................................................... ......_............. 4 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 appemit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ 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 facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If ryes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...................................... -.............. _................. _......................................... ........................................................ ........... ....................................................................... ................................................ ..................................... ...................................... - 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? [I Yes ❑ No I ..................................................................... _......................................... .......................................................................................................................................................................................................................................................................... 8 (If ryes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: 1 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 agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nature Of Legal Owner(s) Date rd/Or Authorized Applicant Date CODE P. INSPECTION TYPE FAIE INTRIALS CODE INSPECTION TYPE PATE INTRIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 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 PATIO COVER DETAIL 6/1/67 �STATE--j--__� SIZE SPACING SPAT OVERHANG 1 O"RAFTERS: ;E 2 STATE LE NGTH -ate SLOPED FOR DRAIN vwnM V. SPAN Blocking 4' °/i MAXI �- BEAM 3/16 X 2" -T -ST POST -BEAM .CONNECTION POST 3/g x 5'Logs 32°k —� Predrill Ledger 'H� Predrill Existing '/4-3 Deep JOIST HANGER or other approved methods of support a tie. ALL LUMBER DOUGLAS FIR CONSIRUCT/ON' GRADE I% L-! )W SIZE f SHOW SPACING SHOW LOCATION ON REVERSE SIDE. -� SLOPE TO DRAITJ— i��. - o. 6 DROP PATIO FLOOR �— PUDDLED SAND FILL " Remove Grass And Weeds Down To Notural Grade 1 CONCRETE MIX 1:3:4 MAXIMUM WATER CONTENT POST ANCHOR _ .�...� 7i GALLONS PER SACK CEMENT. For Pipe Post. Embed �12� Provide 26 Go G.I. Flashing At Wood Floor Const. Pipe In Footing. Provide Flange Or Weld Plate Screwed Or Boiled To Frame. CMF 00012-46 (BU 40) TYPICAL JOIST ANCHOR CONTINUOUS LEDGER NOTE: USE REVERSE SIDE FOR PLOa` q. No N'O4&2 �Ozo�&� �\e NOTE: FOR PROPOSED OR FUTURE ROOM;;O,R°�(l�tPATIO WALLS ARE TO BE BUILT. USE NOS��20°��YA� ONLY. WIDER RAFTER SIZE MAY BE INEDED FOR SPACING ONLY. FOR PROPOSED OR FUTURE ROOM OR WHERE PATIO WALLS ARE TO BE BUILT SUBMIT COMPLETE HOusE AND ADDITION PLANS COSTA MESA BUILDING DEPT. 77 FAIR DRIVE 834-5273 NO I RAFTER - CHART FOR OPEN EGG CRATE FOR SOLID,`,�SHEAT HING.a ALUMINUM OR PLASTIC SHINGLES 'OR?,BUILTcroU • ROOF COVERING ROOFING. ti Vf MAXIMUM SPAN SIZE SPACING MAXIMUMy.'SRA7' 17' 0 2x 6 12'% r �A 15,411 -IA -1 16 0" 2'x6` Ifi% 13''3 oa 15, 0 " 2'x 6' 24 % 10 ' '11 04 12' 0" 2"x 4" 12% 9�I. 10" 0" 1 2'x 4". 24° NOTE: FOR PROPOSED OR FUTURE ROOM;;O,R°�(l�tPATIO WALLS ARE TO BE BUILT. USE NOS��20°��YA� ONLY. WIDER RAFTER SIZE MAY BE INEDED FOR SPACING ONLY. FOR PROPOSED OR FUTURE ROOM OR WHERE PATIO WALLS ARE TO BE BUILT SUBMIT COMPLETE HOusE AND ADDITION PLANS COSTA MESA BUILDING DEPT. 77 FAIR DRIVE 834-5273 J y 9 TRACT NO. //,91OS IAT N0, j % ADDRESS /.O g 7j V C. OF COSTA MESA REQUEST FOR OCC .NCY DATE3 / % 7 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) c✓ci.r 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 condition. RECEIVED CITY OF COSTA MESA PLANNIF!G 4FPT. SVP 2 3977 AM TIEIAMAJ211121314A6 . '`.CITY OF„� FrW1ESA PARK FEES Fee Payment Receipt Project Address l('t—1//UIZ bLOu\ A. P. No. Building Permit No.42%�� 427(ptp - N° 230 MAIL^ mN Park Area Owner's Name TOW W Mailing Address 8 8 �� C • M . FEE Single Family a No. of Units 2 @ $455.20 = Multiple Family ”' No. of Units @ $321.32 = natuung Department /2-2 I * 10, Q24.80 Total Fee U T? a0 City Or4 nance�72- - r •• City Ordinance 72-45 *•• City R"oiutl0p-74424 White- Planning; Canary - Planning; Pink - Finance; Goldenrod - APPIlcant CMF 0174.28 CITY OF COSTA MESA PARK FEES Fee Payment Receipt Project Address Building Permit No. N2 199 Owner's Name kUU6pffiftll'�.� Mailing Address AR 4 l%� ST. F p`q IKAV A FEE Single Family * No. of Units 14a @ $455.20 = 7 3• a� Multiple Family ** No. of Units @ S321.32 = Total Fee ris�3. •:.� ..ening Department Applicant's Signature " City Ordinance 7x4"4 `��/ City Ortlina nc 72• / '"• City ReSolut&n 124 White . Planning; Canary - Planning; Pink - Finance; Goldenrod - Applicant CMF 0174.26 OWNER AP No. 115-661--29 LOT 9 TRACT 9105 DATE 19-7— SUBCONTRACTOR' I 9-7— GAS SUBCONTRACTOR'I Dote Number Si nature WATER (�f6= 5 "'x,76 Plumbin ROUGH PLUMBING .'2Z• HO PROP. SWR. LINE ❑ HOUSE CON. 179 SPRINKLING SYSTEM OF MISCELLANEOUS ROUGH HEATING AND AIR CONDITIONING TEMPORARY SERVICE OR POLE UNDERGROUND 0 POWER E] ROUGH WIRING G4+Z.L'� Heatin an Vent. TRENCHES FORMS STEEL REINF. G FLOOR SYSTEM Q g,2A- LATHING — IN X OUT PLASTER, BROWN COAT STRUCTURAL, KINAL iG. VENT., REFRIG. AND A.C., FINAL O+ I LING. FINAL AND GAS TEST rV ELECTRIC, FINAL BUILDING, FINAL +f 9105 P,,,u ., a' 1556 COSTA MESA BUILDING -SAFETY DEPARTMENT P.1O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely —Use Ink Only APCTION FOR STRUCTURAL PERMIT REC BV O E E pJUE � BUILDING ADDRESS OWNER R & W Development A.P. NO. I S' ER f MAIL 1HH E. 17th'St. ADDRESS NG ADDRBUILDIE S ��� C CITY Costa Mesa, -Ca. NO`.642-4210 /�{s TRACTLIA//S LOT CLOENDER�IO`gal • Fed. Savings &Loan P' D AL AIR PBRANCH MOVING E 5670 Wilshire Blvd. PADDRESS OWNER W �j�Q.Y IYIARCHITECT Los Angeles, Ca. 90036 S W WrT AIr,LU$ DMA Assoc. Tey31-216 OR ENGINEERDMA ADDRESS 17621 Irvine B1vd,Tustin,Ca IFIRE ZONE rt PE GROUP `j CONTRACTOR J. Ray Construction CO. APPROVED BV DATE ADDRESS188 E. 17th St • TEL /. "f —421 C I,TV Costa Mesa, Ca. NO. E /'"r% c1- NO. OF/J G. BUILDING USE OF EW A CTY LIC. NSTAO. 126426 LIC. No. ARDS APPROVED VMAIIN BUILDING YARDS APPROVED ACCESSORY BUILDING SIZE OF LOT 3J .O2 X 12H NO.OF BLDGS. NOW ON LOT o (FROM C/ REE RONT 23 FT. FT. USE OF EXISTING BLDG. o R. SIDE FT, FT Separate permits are required for electric, plumbing and heating work. L. SIDE 5 FT. FT. REAR (0 FT. FT. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. MAIN BLDGS. BET. MAIN & ACCESS. BLDGS. . Single Family Dwelling W/ VAR. �h rJF,r ''77// �j C.U.P. sy+Z`_/}7_// DATE APPROVED (�J Attached Double Garage APPROVEDBY JOLD FOR SPECIAL KGUIR!:"!�°#e,4; 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 I em properly licensed as a contractor under the State of California Business and Professions Code, Division 3, Chapter 9, 'and th s h Iicensas era In fuforce end effect, or I tons of theS of California Business am exempfroW.dl end Professionson 3, C 9. Signature of Permittee ' ,+ s' �SO. FT. i O THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: VALUATION $ 4. 0, ©$Q PERMIT FEE $ PLAN CHECK $ TAX $ Authorrxed Agent TOTAL PATO $ • r C. COSTA MESA BUIL ING-SAFETY DEPARTMENT .P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 r mom For Applicant to Fill in Completely — Use Ink Only BUILDING I /i// / . J i s OWNER CITY TEL. NO. CONSTRUCTION LENDER REAR FT. BRANCH RMIT NO. ADDRESS BET. MAIN & ACCESS. SLOGS. ARCHITECT OR ENGINEER TEL. NO. ADDRESS CONTRACTOR r V ADDRESS m CITY TEL NO. STATE LIC. NO. CITY LIC. NO. SIZE OF LOT NO. OF SLOGS. I NOW ON LOT USE OF P cl29.2 [ APPLICATION FOR STRUCTURAL PERMIT RECEIVED BY I DATEIRECEIVEVII.TE ISSUED REAR FT. FT. RMIT NO. A.P. NO. BET. MAIN & ACCESS. SLOGS. THE AMOUNT SHOWN UNDER VALUATION IS FOR BUILDING DATE APPROVED ADDRESS /O PERMIT FEE $ V TRAC m PLAN CHECK $ BLOCK W ADD AL R TAX $ OWNE14 TOTAL PAID $ Olt SE 'FIRE V R ZONE TYPE _GROUP APPROVED BY DATE ZONE PLANS I BUILDING USE OF NEW ' YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING (FROM C/L STREET) Separate permits are required for electric, plumbing and heating work. L. SIDE FT. FT. REAR FT. FT. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. MAIN BLDGS. BET. MAIN & ACCESS. SLOGS. THE AMOUNT SHOWN UNDER VALUATION IS FOR VAR.+ C.U.P.# DATE APPROVED APPROVED PERMIT FEE $ 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. I hereby certify that I am properly licensed as a contractor under the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are In full force and effect, or I am exempt from the provisions of the State of California Business and Professions Code, Division 3, Chapter 9. Signature of Permittee Authorized Agent n m i SQ. FT. N THE AMOUNT SHOWN UNDER VALUATION IS FOR m THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: VALUATION PERMIT FEE $ V m PLAN CHECK $ ^ �s 0 LL f TAX $ U TOTAL PAID $ OWNER Herber OB ADDRESS 1099 G ;GENERAL CONTRACTOR Owner - AP -No. 422-031-52 LOT SECTIONS 5 GAS ATER ROUGH PLUMBING DROP. SWR. LINE E HOUSE CON. SPRINKLING SYSTEM MISCELLANEOUS ROUGH HEATING AND AIR CONDITIONING TEMPORARY SERVICE OR POLE UNDERGROUND POWER ROUGH WIRING TRENCHES FORMS STEEL REIN F. FLOOR SYSTEM BOND BEAM STEEL REINFORCE SHEATHING FRAME AND FLASHING LATHING - IN D OUT n PLASTER, BROWN COAT ST-' TURAL, FINAL 1 IG, VENT., REFRIG. AND A.C., FINAL PLUMBING, FINAL AND GAS TEST n ELECTRIC, FINAL DATE SUBCONTRACTOR PM PM r a W 0 O 9i a Z W C_ COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For. Applicant to Fill in Completely — Use Ink Only 6369 4/09/79 7850 Tia APPLICATION FOR STRUCTURAL PERMIT - RECEIVED By PERMIT BbLDINGADIDRESS (] G C'N /- A.P. NO. ZZ vi OWNER OR L /fir BUILDING /S(j� ADDRESS :2; 7 TENANT C r L /J Er�s UNIT MAILING / SPACE NO. ADDRESS /PN TR.N9/O� LOT BLK. CITY (- O S- TA /C'�i cl NOL b NEW ADD ALTER REPAIR MOVING DEMOLISH CONSTRUCTION LENDER BRANCH I OWNER Q U ADDRESS VALU ARCHITECT r TEL. USE 4�170 OR ENGINEER /— N 0. � ADDRESS ZONE TYPE GRO SE PPROV ED C DATE eV / CONTRACTOR Y (' ADDRESS TEL. CITY NO. STATE CITY APPROVED SETBACKS LIC. NO. LIC. NO. (FROM C/L STR ET SIZE NO. OF BLDGS OF LOT NOW ON LOTFRONT USE OF/fir. EXISTING BLDG. T (A 9 fy Separate permits are required for L. SIDE / FT electric, plumbing and heating work: REAR jeffleO FT. VS ING9ND WOflK TO BE PERFORMED PLANNING ACTION DATE APPROVED APPROVZ& . W1•/ _ 9► 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. I hereby certify that I am properly licensed as a contractor under SO. FT. the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from the provisions of the State of California Business VALUATION �/�7 PERMIT FEE $ and Professions Code, Division 3, Chapter 9. �v PLAN CHECK $ Signature of / PermitteeJ/V_) TAX $ or t Authorized Agent Date TOTAL PAID $