HomeMy WebLinkAbout3161 GIBRALTAR AVE - Building Permits♦
��
.
., ADP���ant to fi11 in all spaces except those within heavv Doraer lines antl zi9n all appropriate
crRY oF cOSTA MESA CONSTRUCTION PERMIT
ProjectAddress ,�16 / Cr/f3R A L?Ah?
Applicant's Mailing Address�Q3� , Mfl-!J.(' /�0� A'V'E
Owner's Name CNA/1 Lr5 cl L/3 QL��Phone 3�6�•S�
Address 3��� �/%A�E��'/i %�V�'
Arch/Eng. License No. �
Address
Contracmr's Na e one'
Add.ess (m� �'�91 � � .
City License No.
UCENSED CONTRHCTOR DECLHRATION
I hereby affivm that I am licensetl untler proJision5 of Charter 9(commencing
with section �000) of Division 3 oi tne BuS�ness antl Profes5ion5 Cotle, antl
my license is in tull force ana eHect.
LI<ense Class� License No:
Date 'Signature
'WORKERS' COMPENSATION DECLARATIPN
i hereby af(irm that I have a cerHficate of consent to selt-insuie or a certiticate
of Workers' Compensation Insurance, or.,d-certifietl copy thereot (Section
3800, Lab. CJ � .
Poliq No. CompanY '
eCertifietl mpy is nereby furnished. �,�
Certifletl copy I5 filetl with the city Bulltlin9 �ivision.
Da[e Appli[an[ - �
E%EMPTION FROM WORKEpS' COMPENSATION DECLARATION
(Thissection neetl mt be completetl it the permitis for one huntlretl ($300) or �
Iess)'.
I certity lha[ in the pertormance Of tbe work !o� wblch this perm�t is i55uetl, I
snall not employ any person in any manner so as to become subject to'the
Workers' Compensation Laws ot Calitornia. ,
Dale � Signature
�NOTICE: If, after making this tleClaratiOn, you shoultl bewme subject to th¢
Workers' Compen5ation provisions ot the'L9bo� Cotle, you musi forthwlth
wmpty with such provi5ions o� this perTit shall be�tleemetl revoketl. �
CONSTRUCTION'LENDING,-AGENCV �• - '��
I hereby afOtm lhat there i5 a ronstruction lentling agency-for Me perfoimanC¢
ot the .work ,-tor which thiz permit, is issuetl ($ec[ion 30W Civ. C.) •
Lentler's Name - - �
Lentler's Atltlress � - � _ �
OWNER BUILDEIt �ECLARATION ' �
I heteby atfirm that I am exempt trom the ContractoYs License Law for the �
tollowing reason (Sec[ion �031.5 Busine55 aNtl Profe55i0nal Cotle: Any city or '
���mrv �.,nicn .eauires a oermR to consiruct. alteq improve, tlemolish w.repair
.to t�ie a siqnea statemen[ 2nai ne/sne is ncen�a v���ua��< <<��= v��•������• ��
the Contractor's License Law (COapter 9(rommencing witM1 Section �000) of
7ivision 3. of the Business antl Prote55ions CotlE) or that he/she, i5 exemPt
'M1e�e(rom antl tlte basis fon[he allegetl exemPtion. Any violation of Sec[ion
7031.5 by any applicant for a permit s�bjeGis the applicanY'to a civil
�penalty of not more Ihan five huntlretl tlollar5 (8500).
� I, as owner ot the Droperty�..s-.uS�._ ""—""'��" "�"'
'- will tlo the wark, antl tM1e struc[ure a not intentletl or offeretl '
for sale (Section ]046, Business and ProfF55ional Code: The Gontractor's
License'Law tloes not apply to an owner of'a Property who builtls or improves
tM1ereon; antl who tloes such work himself/beRelt.or [hrough his or her awn �
employees. Providetl that such improvement5 are nOt Intentletl or otteretl for �
5ale. If, howev¢r, the builtlin9 or improveme�t I5 soltl within one year ot com-
pletion,'the owner wilP have.the burtlen of proviog he/she ditl not builtl or�im-
p�ove for the purpo5e of sale). :
❑ I, as owner ot the properTy, am extlusivF�Y cont�actinq with IicenSetl wn-
[IdCIOf5I0 COIISf(UCI [M1¢ pIOjECI (S2CL1011 IO44. BUSIIIQSS dOG P(Of25510lIS COd2:
.Th¢ Contractor's License Law tloes not apply to an owner of property who �
builtls or imD�oves thereon, antl'who conVacts tor Such projects with a con-
hactor(sl O<ense pursuant to [he Contractor's Liwnse Law). I am aware that
proof of their WOrkeCs Compensation insu�ance shoultl be provitletl to me.
❑ 1 am exempt untler Section B. & P. C. for this reason
Date �I Owner
I hereby certify tpat I have reatl Ihis appli�ation�antl state tM1at the above
information is wrrect. 1 agree to comply wiYh all city antl county ordinances
antl siate laws relating to builtlinq construct�on, antl hereby authorize repre-
sentatives of this city to enter upon tM1e above-mentioned property for
inspection pur oses. / �
Si9nature Oate
Drivers' License or'S5 � � �
CMF OB65-4fi, rev. 10/84 White - Builtling; Canary - APplicant; Pink - Acwunting;
TYPE OF CONSTRUCTION. LJ NEW I�1 AOD CJ ALTERATON LJ REPAI R �
❑ CONVERSION ❑ DEMOLISH ❑ OTHER � A P # —
DESCRIPT�ON OP WORK/USE OF BLDG. �g%�O COVER
� � S Main Building:
TVPE OF PERMIT GRADING ❑ FOUNDATION STRUCTURAL T Front
❑ TENANT ❑ ELECTRIGAI. ❑ PLVMBING ❑ MECHANICAL B Reaf
❑ OTHER %{
PROJECT DESCRIPTION Sq. FT. � oCCua,crvCV�€�� C Right �
CONSTRVCTIONTVPE -�Cp VAWATION$ � ZCOO 5 Left I
ZONE � GRADING CU.YDS. ACRES p�ng. Ref. $/-
Remaiks: � ' � �, ' . � Planning Notes:
ar Sink •
ackflow Preventer �
ackflow Irrigation
athtubs � . �
larifiers .
IShN25hEf � �
rinking Fountains
loor Drains
Floor Sinks �
Gas Seryice � .'Outlets '
Interceptors, - �
Kitchen Sink ' -
Lavarories "
P-Trap �
Roof Drains �
' -. i
.Reinspection Fea � � $15
Boiler
Duct- UnderGround
Duct - Structural
Duct-Ventilating ,
ExhaustSystem ❑ MWtiple❑
FirepUFacc BIL ICBO # ^
Heating System & Ducting
❑4100,000 BTU � 100,000 BT�
peinspectian Fee I $15
ServiceSink ' ' �
Sewer Cap �
Sewer Connection �
So1ar Collecmrs _ .. �
Solar Pipin9� '
Solar Tank
Swimming Pool w/Spa
Urinal �
Water Closet ' ,
Water Heater '
Water Service . ' ` � '
Issue Fee �
0
EES
Automatic Washer
Construction Pole
Cooking Unit
�1� -Q6�I .r7�U%/S: 2one
^Q��P}��Accessory Building: . .
Dryers'�Gas ❑Electric �
� Fan
F.A�.U. •
Fixtures ' '
� Device Boxes � �
Outlets ' '
Switch¢s
Garbage Disposal •
� Generator 00.5 KW 05-15 k
0
Hood or TYP¢I; ❑
Canopy Type II ❑ �
Refrigera[ion System
❑0-100,000 BTU 0100,000 Bl
System Repair/Alteration
Fire Dampers
Registers � '
Issue Fee
$ 3
FEES
$ 3
Perking Req./Provided
0
ELECTRICAL , �
Transformer ❑ 75-50;KW
❑ 50+ KW
Meter ❑up to 700amps
- - Meter �over 100 amps -
Su6 Panel ^
Motors OO-1 HP �1%'-'8 �
Inc.Solar 09-15 HP �16-15+
Microwave '
� Pole Light .
Range .
I Reinspection Fee � � 515 '
DEVELOPMENT SERVICES REQUIR
Zoning Approved By
Building Approvad B�
��
FEES
Standing Sections • '
Trash Compactor
, ; i
luue Fee $ 3
dT �i�.. __ ���
�/`'i P y Date'�
�`�_,�__Date
�
Z
O
N
1
N
G
R
E
Q
M
T
S
� SUMM RY O FEES ;,� A
BUILDING PERMIT $ � SMIP � $ ��
PLAN CHECK $' 2 Sr O3 pERM1T
PLUMBING , $ �SSUANCE , $ .
PLAN CHECK 25% $ ENERGY P.C. $ '
ELECTRICAL • $ � GRADING S �
PLAN CHECK 50% $ MICROFILM $
MECHANICAL , $ TOTAL FEE $ � ,03
PLAN CHECK �25% $ _ '
� CONSTRUCTION AND PLANNING - P�� 6` SPP'
-1 Date Inspector Date Inspector
APPROVALS Permit # APPROVALS Permit #
� 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 - - 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, O Undrgrnd.,�Test
9. Water Pipe�Undrgrnd. 60. Backwash Lines. P-Trap, � Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
17. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final -
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrica6Conduit 66. Solar System-Final
76. 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. Rough Factory Fireplace APPROVALS Permit #
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping OGas ❑Oil
23. Gas Pipe-Rou9h & Test� 72. Underground Flush
24. Roof Framing �� 73. Undergrnd. Storage Tank O Gas ❑ Oil
25. Roof Sheathing � . 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding � 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing :� HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat , 79. FINAL INSPECTION
32. Electrical Power Meter-Final . 80. FOOD CERTIFICATE ISSUED
33. Final Electric � Notes:
34. Final Heating & Air Conditioning
35. Final Gas Pipe-Test �
36. Hood or Canopy .
37. Final Factory Fireplace �
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final
41. Solar pomestic-Final .
42. Backflow Preventer ,
43. Backflow Irrigation
44. Landscape Irrigation System �
45. Sound Attenuation . �
46. Handicap Regulations
47. FINALSTRUCTURE&BUILDING �f ��
48. Special Requirements Completed
49. Electric Release to Edison �
50. Gas Release to Southem California Gas Co ` • i'
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 proposed
property improvemen/t1. 18f� Yes ❑ No
2. I(havelhave not) y`-«"L signed an application for a building permit for the
proposed work.
3. I have contracted with the following person (firm) to provide the proposed construction:
Name —
Address —
Phone ( 1
Contractor's Lic.
City
4. I plan to provide portions of the work, but I have hired the following person to coordinate,
supervise and provide the major work:
Name
Address
Phone (
City
ConVactor's Lic. No
5 I will provide some of the work but I have contracted (hired) the following persons to provide
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 Code and have completed the above information to the best of my
personal knowledgeq, in compliance with this State law.
Signed: l-�J ✓�Y✓� . Date: � � �
Name: GFfA/h LC S .) ?/� ON�
(Printed or Typed)
C.D.L. #or s.s. #
CMF 1042-46 754-5273
A,
'' V
.
5S-o
�
i
�
'r
— ` -
7otAL t3AGK Yf+r-,D
zS � �� =�30 0� sq � r
�D
z7-o
i ,�
/
/> L
I � nEw
BAGh �l/�,�iG ( � PA'7f0 GO�lE�
j i 70TAL A v, sn =sso.rs sa � r
� _ _� U�
�
L �
I
C_89 f a Mesa Butldfng pt.
o nAa�� r`1.��a
es r s719
TH6SE P1AN5 MUS� 8E ON JOB TIME:,
F�il(E NO CHAN6FS WIiHpUT p.I�OR APPROVAL'
OE DEP�:
dFiE 1SSUAMCE OR GRANfING OF A pERMIi OR APPROVAL :
OE PIAaS AND SPECIfICAT10NS SHALL NOi BE CONSTRUED �
TO BE A PERMIi FOR, OR AN APPROVAL OF, ANY VIOUITION I
OF ANY OF THfi� pRpU1SI0NS OF THIS CODE NO PERMIT PRE.
SUM�NG TO GIVE AUTHORITY TO VIOIATE OR CANCEL iHE �
PROYISIONS OF THIS CODE Sl;ALL BE VALID, IXCEpT IfV, SO �
FAR AS,THE WORK OR USE WHICH Ii AUTHORIZES IS U,1W�11(; '
THE �SSUM7CE OF A PERM17 BASED UPON PLAN$ AND �
SDECIFlCATIONS SHALL NOi PREVENT iHE BUILDINC OFFICIAL' �
FROM 1NEREAFTER REQUIRING THE CORRECTIOY OF ERROR$
IN SAID PLANS qryD SPECIFICATIONS OR FROM PpEVENi1NG I
BUILDING OpERqTIONS BEIfVG CARRIED Of! THEREUNDFR WH�1 �
IN VIOlAT10ry OE jH�S CODE OR Of. ANy OjHEf� QgD�y�Cp.
OF TH� C�
.I�
I U� O —t�
z �', O
� _
� �Rc��,e��
��11' Of COSiA MESA
PLANNING DEPT.
�1ECT i0 BGDG. DEPi. REp,
�
�
�
I
�
O� �LANNINO
F�,vrv r srT� �LAI�i
�� 31Gr riF�AL;,sfZ
C c S i p %�j E',5 C. �/^� .
Gl.�1NE1� CNA�.'-:r; ,) T(�oyj
?1�?-SU6-SFG��
g�CIS=12o
_
: ,- , . .
' _ _.,� �_____ _ STRUCTURAL APPROVA .VLY
-- /-.... _. ..
_— = SEPARATE PERMITS ARE RE�UIRED
_ - -�— — — FOR ELECTRICAL, PLUR181NG.
-- - - -- ----- — HEATING. VENTILATING AND
— — REFRIGERATION WORK
4x� - z�-- _ � Peretrei� #��
TYP. � l�+rricE
�� X �� v 80 _ ` I THIS NUMBER MUST ACCOMPANY
, I ALL INSPECTION RE�UESTS
I i!G_SX 5;��
2
6, rs� qo -�.5 xr�3t.s_i!
�` . I � 'I� .�
_�� Z�?' �
� �
I
50
I rYP.
r
�,s; r
v /_
��4 = �' Sca.Lt
r0rp� �.�,�p � 356.:2Ssq1=�
WEST EIEVATION
)
- FOH BUIlO!NGS WHEflE PEflSONS ARE TO BE
EMPlOYED. WE SUGGEST THAT THE STATE Of- �- —
CALIFORNIA OIVISION OF INDUSTfl1AL SAFETY
BE CONSULTEO FOR AOOITIONAL
HEQUINEMENTS.
24 To ` � .
�ex�sT�NU ��
anF��y � _,
_,
2x� � lED(�Ef�
' � �__
c=
4x6 ao�s� �tiauC,ER
Q�8x5`� �A(� bo�zg
3 V(o" p.C.. CSTAC�ERED�
�
� STJCGO I
+' ! I
LONNEL��pN TO
CX�S1lN(r WAL`
�x8
---__ 4x6 ..�_.-
x8
Kq-
F��Z- DEA�"\ CotaNE�T�Ot�
1�� - 1 xn.�
4xQ PosT
'rbST
SADp�E
�o��- :5 ;; --�-
�
.' � �` _ iZ'
I-..�.�
�
,�- l 2 "---,�'
Foo7 � N�
OWNER Simq,g'FtLArm T at�m rn DATE 3-26—$j
JOBADDRESS 3].(�l Glb2'31},2T AVE. BUILDINGPERMITNO. #Jy']S7
GENERALCONTRACTOROT+R72T B].(IT`. VALUE $ �.0,909�00
i 140 BLOCK rancr 2353 Res, w/att. �ar.
GROUP I& J TVPE V ZONE RI.� FIRE DISTRICT Jl'j9Q '
INSPECTIONS I DATE SUBCONTRACTOR PERMITSIS'5UED
DATE I NUMBER
Foundation Forms and Grade to Garage � ��
Rough Framing � J �O _ �
Plumbing, Rough to Slab IU W�LS � �i T
. . .'1'1_ �('�_. I@,t,i.,r, .!- .Srn.. �5' �.4 % ✓
Plumhinn. Rauah Cmm�le}o n9( �i .4%GS=.ii �
Pole
S
Heating, Final _� � � ..1�/�� )
vsewer, Nouse r Sewer, St. jy! � S :/7'S7
Septic Tank or Cesspool
� �g, In� Out� ��— ' _
P..._.ering lm �"�
Plumbing,Final,FiXturesComplete�i�((�S ��j�-S7
Plumbing, Fin,al Gas Test ��r %y�CS r� S - /� '�
� ' � � ,G c u , ,
Wiring, Final In' �,��
OccupancY Y�'f (� „ii1� �'f,y.,17_ —
FONM 210 3M 10�^vi
. �: � �¢ 7:�0
�uOSTA MESA BUILDING DEPARTMENT
- P. O. BO% 31�
COSTA MESA, CALIFORNIA
FOR APPLICANT TO FILL IN
MAIL
ADDRE55
ARC"'TECT
OR INEER
7�
GOSTA MESA. CALIFORNIA
TEL. Vre
NO. _
LIC.
NO.
ADDRE55 11L.1 J Vl� ,]C V Gt"1 —LV o tlut G1
5�1��2'1�` Yid CITV LIC./ p
CONTRACTOR ]��n(j'uQ NO.CI� V
12L} So. Peverly TE�r�stvy��
ADORE55 �,^o Anveles al NO. �ZiVG
LEGAL LOT „
oescnivnoN NO. ���(] BL�CK TRP.CT r
A.P. NO.
SIZE NO.OF BLDGS.
OF LOT � n HOW ON LOT;jn
USE OF .
EXISTING BLDG.
SETB4CK LINE FROM r
CEuiF.a OF 91AEEi �O � REAR YARD ��j �
N�
REPAiR
BUILDING
size 1
E%TERIOR WA
COVERING
USE OF NEW
RIGHT � 1 LEFT � I
DESCRIPTION OF WORK
3� ALTERATION ADDITION
MOVING DEMOLISH
2Q5 NO.OF
ROOMS � STORIES 1
, �S1;UCC0 �noF CQMAOS1tlOri
FEE RECEIVED
'1ti,G,..,6,����� 9�.
FINANCE DEPT.
APPLG�A�1��T�'��PERMIT
BUILDING
FOR OFFIGE USE ONLY
COSTA MESA. CALIFORNIA
APPROVED
9Y pqTE
CORRECTIONS
I HEPEBV •CNNOWLEDGE TMnT I H�ve rv[�o in s�v Li iiprv nrvp
ST�TE TNST THE 100VE IS CONfiECT �N� 4GREE TO COMPL WITM wLL
CITV ORDININCE$ M1ND $TATE L�WS REGULATING BUILDING CONSTRVC�
iior+. VALUATION
SIGNATURE OF PERMiT FEE S 2L�QlJ
PERMITTEE �'
n 5 /O �O�'� PLAN CHEGK 5 13�Q0
Al)THORI]Ff] 4GFNT1(//VLLA4W��j�% � / TOTAL FEE 5�%�oo ��
OWNER JAMES, Glen DATE
� AP
� v
�;
\GAS
PROP. SWR. L
ROUGH HEPTING ANO AI
UNOERGROUN� �1 POWER
_y
STRUCTURAL, FI
H' vG, VENT.
P, lING, FINP
BUILDING PERMIT N0. =
SUBCON7RACTOR
4�.�it�j49 au� �9-�t�"„—Sh00 sa� �**�*¢5.00
��' COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
Z .
o- U
ZQ
O v~i
am
J �
<
❑.
m
J Q
U N
2a
W �
p, W
WZ
J Q
m Z
J �
W w
O=
Z F-
w �
N �
� �
H
Z
a
U
�
a
0
H
N
z
�
F
U
�
�
F
N
Z
APPLICATION FOR BUILDING PERMIT
ForApplicant to Fillin Completely RECEIVE BV �ATE PECEIVED DATE, ISSUED
BUILOING �� /.-� � � /,' /1
ADDRESS 31G/ G�ea.�.�r,a¢ A�r_- i i
,�/ /�� /� `_// PERMIT NO.
OWNER (GN %AM/�S A.P.NO � � ✓ E�
MAIL /J BUILDING / /j� ��
ADORES531(,/�y7//S/lA�r9fl /'�✓4�. ADDRESS ��(O� � t/L�(�,`LGu('
CITV
COS�A /%icSA. No`.SyG1gG TRAC LOT� / BLOCK
CONSTRUCTION W ADD A P
LENDEP
BRANCH
OWNER
AODRESS p�� VALUE � RO
ARCHITECT TEI. S C..G � �g
OR ENGINEEF N .
FIRE
ADDFESS ZONE TVPE �1 GROUP
APPROVED / _ �I
WNTRACTOR �CJMk/L • sv � DAT % /
ADOFESS
ZO —/ NO.OF USE OF NEW •
TEL. p�,qry$ � BUILDING
CITV NO.
STATE CITV YAROSAPPROVED VARDSAPPROVED
LIC. NO. IIC. NO. MAIN BUILDING ACCESSORV BUILDING
SIZE NO.OF BLDGS. (FROM C/L STREET)
OF LOT NOW ON LOT FRONT F. FT.
USE OF
EXISTING B�DG. � T. FT.
SIZE OF NO. OF ♦
NEW BLOG. ROOMS STOFIES L. SIOE FT.
EXTERIOR WALL ROOF
COVERING COVERING REAR FT. FT.
USE OF eUILDING AND WORK TO BE PERFORMED DISTANCE ET. BET. MAIN &
MAIN BLDGS. ACCESS. BLOGS.
� /J VAF. � DATE
r�"� ��G�• C.U.P.# ROVED
� APPROVED ' i
I hereby acknowletlge that I have reatl ihis application antl stete
that the above information is torrect antl agree to comply wi[h
oll laws regulating builtlin9 construction, and I shall no[ amploy
any person in vialation ot the workman's compensa[ion laws of
che State of Cnlifomia. m
e
I hereby certify that I am prOp¢rly licensetl as a coniracior untler $Q. FT. O
the State of Celifornia Business entl Professions Cotla, Divisicn 3, THE AMOUNT SHOWN UNDER VA�VATION IS FOR �
Chapter 9, antl that such licenws ara In full forca entl atfact, or 1 THE PUAPOSE OF ESTABLISHING A PERMIT FEE ON�v: o
am exempt from [he provisions of Ne Stata of CellfOrnia Business �
VALVATION
antl Professions Cotle, Divisi n 3, hapter 9. m
PEFiMIT FEE $ a-O �
�q 7
Si9nature of ��p �% (.�V m
Perm(ttee $ �I � •�, p�qN CHECK $ `_ E
V1 `o
Authorized ant �-�' � LL
TOTAL FEE $