HomeMy WebLinkAbout1851 ELBA CIR - Building Permits Al
rt CITY OF COSTA MESA
4G9 BUILDING DIVISION
F •_,,,nrs 1 DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER
4• PERMIT 06-01461
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.44
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesaELECTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 1851 ELBA CI Status: ISSUED
Suite No Applied: 12/14/2006
Vicinity: ATTIC AND SIDE YARD Issued: 12/14/2006
Parcel Nuhmber: 13942112
Applicant: INOUYE, WARREN S
Address: 1851 ELBA CIR /13
- Phone: 714-307-8928' ISSUED BY: 1." 13
COSTA MESA,CA " '" Zip 92626
- �; - -
Owner: INOUYE,=WARRENS
Address 1851.ELBA CIR ^ '/
- Phone: 714-307-8928` -' "'
COSTA MESA,CA - Zip: 92626 _
t
v,
Contractor: OWNER-BUILDER
Address /./'
Phone:
Zip:
.-, .License:000000,
� ,`-%, -
- l
SCOPE OF PERMIT
' ELECTRICAL FOR THE INSTALLATION OF A NEW NC UNIT AND RELOCATION OF A FAU TO ATTIC
AREA-FORA SFD: ,
: -REF#:M06-00867
WORK TO INCLUDE:1 RES A/C,PACKAGE AND•1 DISCONNECT FOR FAU..
- FEE SUMMARY
, Quantity Quantity
ISSUE FEE $23.50 - Temp Dist System/Lighting - $0.00 0
Temp service test $000 _ _- - --" Busway/100 ft ,) -" - - $0.00 0 ^- , -
Res.a/c package $54.50 - - • -- Standing Section $0.00 0
New Res(1.2 units) . $0.00 0 Misc Electrical Equipment $18.20 1
New Res(3+units) $0.00 0 Transformers up to 1 kva/kw ' $0.00 0
Pool/Spa . ` $0.00 0 - up to 10 kva/kw $0.00 0 •
Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 ' 0 . ,
Recept Outlets $0.00 0 - -• - up to 100 kva/kw $0.00 0 ,
Switches ' - N �)$0.00 0 ' -' - over 100 kva/kw $0.00 0 •
Non Res APO ��A$0.00 0 Low Voltage Equipment $0.00 0 ,
Res Appy• $0.00 •• 0 . . ' Low Volt Wiring System/Ckt. $0.00 0
Service to 200a v '$0:00: ``-�'0'r, , -Mise.Conduit - $0.00 0 ,,
Service to 10006 . - -,$0.00'. " 0 'Misc.Conductor $0.00 0
Service over 1000a., (, .� $0.00'x, ,'*.0 - " ,Circus(gen or ride) . $0.00 . 0
Motors to 1 hp </: ''$0.00 Ate- 0=,, ' - ,Circus(meth ride or lights) - $0.00 `='/"0
Motors to 10h -
p �� /.$0.00�� 0:' -� Christmas Tree Stand $0.00 0
Motors to 50hp vv $0.00/x"'-' 0 -- - "Fireworks Stand - $0.00. , 0
Motors to 100hp '- $0:00 ,; 0: -Other Electrical Fee $0.00 '
Motors over 100hp $0.00 - 0 - , ,
Communication drops $0.00 0 , ' Investigation Fee $0.00
Sub panel to 200a $0.00- 0 . Plan Check Fee • , $0.00
Pole Light Pkg $0.00'-- - 0 . , Reinspection Fee . $0.00
Sign Circuits $0.00 --- 0 - _ -
Temp Pwr Pole $0.00 0 - - _ . TOTAL CALCULATED FEES $96.20
Intermed Pole $0.00 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
244646(6,00)
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
0 I 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'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(Thi section need not be completed if the permit is valued at one hundred dollars($100)or less.)
certify.that in the performan e of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
L----ealiipensation laws of Califor ia,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these prov' ion, rr
AppTccnt re: 1 yJd6
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37116 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 effect.Lic.# Class k
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I 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.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.).
cLigl as`owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors Lice se La 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 Con rector License Laws.).
❑ I am exempt under s c. Business and Professions Code for this reason:
Signature: - aee
Expires: i--']Art
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
O 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,faisework,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).
O 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 0 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 0 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.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a germit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes IJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes ❑No
(If yes",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(Duality 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 0 No
8 (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 COM UAN 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 com with II state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-describe rope for i pe tion purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
1tit Lybb
//Signatilre Of Legal Owner(s) jj_Date
• And/Or Authorized Applicant Date
CODE# INSPECTION TYPE, DATE INTITIALS CODE# INSPECTION TYPE D)IE INTMAL.S
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical i'-n''A7
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 _
1
110
' 44.4�, • CITY OF COSTA MESA .
• BUILDING DIVISION
>f<r,;irmilacria ; DEVELOPMENT SERVICES DEPARTMENT RMIT NUMBER
F 1 �
JPERMIT M06-00837
teb
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
MECHANICAL PERMIT
Job Address: 1851 ELBA CI Status: ISSUED
Suite No Applied: 12/14/2006
Issued: 12/14/2006
Vicinity: ATTIC AND SIDE YARD
Parcel Number: 13942112
Applicant INOUYE, WARREN S ISSUED ev: C)
Address: 1851 ELBA CIR . - :
%. Phone: 714-307-8928
COSTA MESA;CA _
i Zip: 92626 ' , ,�
i �. - ,
,�/, ,
Owner: / INOUYE;WARREN S./ -
Address: . 1851 ELBA CIR' - nnn" S
' - Z96-307-8928
' COSTA MESA,CA Zip:ip: 922626 `Q
re)
Contractor: OWNER=BUILDER
Address:/ // " .-
Phone:
Zip:
' License:000000'
SCOPE OF PERMIT
' MECHANICAL PERMIT TO RELOCATE AND CHANGE OUT FAU TO ATTIC AREA AND INSTALL A
, NEW NC UNIT FOR A SFD.
• REF#:E06-01461
' WORK TO INCLUDE: 1 INST FAU> 100 K BTU AND 1 COMPRESSOR 3 TO 5 HP/500K BTU.
FEE SUMMARY - '
•
, Quantity Quantity
ISSUE FEE $23.50 , - Repair/Alt Absorbtion Unit $0.00 0
Inst FAU<100 k BTU $0.00 _0,-- -_- - =" _ _ Repair/Alt Refrigeration Unit • $0.00 0
Inst FAU>100 k.BTU, - $18.20:.4:1 .. --. ,- . _ I Ventillation;System - $0.00 0
Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0
Inst/-Rep.Recess Wall Htr $0.00 0 Commercial Incinerator - ' $0.00 0
Refrig Sys<100 k BTU $0.00 0 Domestic,lncinerator $0.00 0
•
Refrig-Sys>100 k BTU 80.00 0 Compressors/Absorption Systems
Gas Piping $0.00 0 Up to 3 hp/100 k BTU $0.00 0
Factory Fireplace. $0.00 0 - 3 To 15 hp/500 k BTU $27.15 1
Hood w/Mech Exaust \< $0.00 0 15 To 30 hp/1,000 k BTU $0.00 0
VAV Box \\ $0.00 0 - - 30 To 50 hp/1,750 k BTU $0.00 0
Vent Fan/Single Dod $0.00 c-.0., Over 50 hp/Over 1,750 BTU $0.00 0
Appliance ' ,'$0.90 0 Boilers
Fire Dampers . $0.00; 0 Up to 3 hp $0.00 0
Smoke Dampers'' . - $0.00, 0, 3 To 15 hp - ' $0.00 0
Inst or Relocate Appl Vent'' I $0.00' 0- _ ' 15 to 30 hp
Air Handlers< 10000cfniV `/'( $0.00,. 0 -- - '- 30 to 50 hp ' - $0.00 0
Air Handlers> 10000dm I . $0.00 0. Over 50hp $0.00 0
Floor Furnace $0.00 ' 0 - Other Mechanical Fee
Floor or Suspend Heater . $0.00 0 , Investigation Fee - $0.00
Plan Check Fee $0.00
Reinspection Fee $0.00
TOTAL CALCULATED FEES $68.85
COMMENTS/SPECIAL CONDITIONS
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 applied 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(6/00)
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
O I 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.
O I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carder: Policy Number:
(This/action need pot be completed if he permit is valued at one hundred dollars($100)or less.)
t
--- 'compensation
certify that in the performance o the w rk 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 Call mia, nd a ee that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
S---comply with these provisio .
�12J/'-I+],/Q (,
Applicant,Signature:<r Date;;
WARNING:FAILURE-TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DO.LARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060E 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 effect.Lic.# Class#
Contractor's Signature: Dale:
CONSTRUCTION LENDING AGENCY:
❑ I 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).):
O 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
old 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 end 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 Cont ctor License Laws.).
f �❑
lam exempt under se . Business and Professions Code for this reason:
-Signature: (-Date: LP 10
Owner ID verified by driver's license. des 0 No Drjver's.LlCenSe No.
\? -(-}--'`..>. E.2pires: Z1/2oLo
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 then thirty-six(36)feet high.(Chap.3.2,Grp 2.Art 2,Sec.
341,Title 8,California Administrative Code).
O 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? 0 Yes 0 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? 0 Yes 0 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 then 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 Calitomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of en RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 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 appermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes u No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes ❑No
(if"yes",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? ❑Yes ❑No
8 (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 C MP ANCE 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 mply 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-des ibed p arty or inspection purposes.I agree not to occupy or allow occupancy of any building authorizer\by this.permit until final inspection.
LSignature Of.Legal Owner(s) --Date
And/Or Authorized Applicant Date
CODE 0 INSPECTION TYeg PALE 1NTTALS CODE r INSPECTION TYPE PAI INth
UI1AL
1616 Fixed System Final Fire Prevention 206 Final Mechanical 0137
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 _
V 1 Ca Ci e tta APPROVED 14 "
CITY OF COSTA MESA
PLANNING DIVISION
SUBJECT TO BLDG. DEPT. REG.
NOTE: ADDITIONS, DELETIONS,
OR CORRECTIONS SHALL BE
APPROVED BY THE PLANNING DIV.
l �(M�, Z
DATE:I C /y/0.
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I
F CITY OF COSTA MESA
BUILDING DIVISION
H _ �..1' DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER
t• PERMIT P06-01041
00
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.RL JsJMBING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 1851 ELBA CI -- Status: ISSUED
Suite No Applied: 12/14/2006
Issued: 12/14/2006
Vicinity: ATTIC SPACE
Parcel Nunmber: 13942112
Applicant INOUYE, WARREN S
Address: 1851 ELBA CIR - ISSUED BY: ��
- ' ' Phone: 714-307-8928
COSTA MESA,CA' v'' - Zip: 92626 . - _
Owner: INOUYE,-WARREN-S _
Address A1851 ELBA OIR _- _ - - ;
1.11/2/� A \, / - - - Phone: 714-307-8928 - - - - - -/ COSTA MESA.-CA ' Zip: 92626 -
. ' .
Contractor. OWNER BUILDER i., �,:y�
Agdress:i ' TT Q
•
/ //✓ Phone: r - -
•
,'; - Zip:
'•License: 000000
SCOPE OF PERMIT
PLUMBING PERMIT TO RELOCATE AND CHANGE OUT FAU TO ATTIC AND AREA FOR A SFD. ,
REF#:M06-0837 -
WORK TOINCLUDE:1 GAS'(1-4 OUTLETS). -, - -
' c FEE SUMMARY
AMT QTY AMT QTY ' ' AMT QTY
ISSUE FEE $23.50 - . LaundryTub/Washer., • $0.00•. 0 .' • . Sump Pump $0.00 0
Backflow irrigation ' $0.00 0 '„ Landscap&Irrigation - -'$0.00; / 0 -. - Swimming Pool , $0.00 0
Backflow Preventer $0.00 0 -- - P-Trap -• - ' '$0.00 0 Trap Primer $0.00 0
Bathtub $0.00 0 Pressure Regulator $0.00 ; 0 Urinal - $0.00 0
Clarifier System $0.00 0. Process Piping(per 10 ft) •'$0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0
Connect(Ice,Sodi,etc) •'. , $0.00 0 Receptors : $0.00; '0 Vacuum Brkr Bkflow(5+) $0.00 0
Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin ' $0.00 0
Dishwasher ' $0.00 0 Sewer Cap for Demo: • $0.00 0 Wash Basin Set $0.00 0
Drain,Floor $0.00 0 Sewer Conned . $0.00 0 Waste and Vent System $0.00 0
Drain,Rainwater \$0.00 0 Sewer Private Line :$0.00 . 0 Water Closet(Toilet) ' $0.00 0
Drain,Roof,.'. $0.00" 0 , . Shower . " $0.00 '0 Water Heater/vent $0.00 0
Drinking Fountain $0.00 . 0 ' Sink,bar $0.00 • 0 Water Piping(Inst or Rep.) $0.00 0
Expansion Tank'- ,$0.00 0; Sink,commercial $0.00 0 Water Re-pipe - $0.00 0
Gas Earthquake Valve $0.00,, `-0c y_ Sink,Floor ' - $0.00 ‘ 0 / Water Service $0.00 0
Gas(1-4 outlets)," `'$6.15, - 1 ',„;:.:,:•K,',:),Sink,kitchen -$0.00 -0 - Water Softener , - $0.00 0
Gas(Over 4 outlets) \.A $0.00/ . .0 Sink,service/mop• - - -$0.00, 0 - OTHER - $0.00
Gas Repipe .'N- $0.00' O;-'v " Spa_-(pnvate). - _ $0:00 0 , VIOLATION $0.00
Gas Service $0.00 ' '0 .-„,,Spa(public) $0.00 0 PLAN CHECK , $0.00
Interceptors(Grease,Oil)' $0.00. '0; , ' . ' 'REINSPECTION $0.00 0
Interceptors(Sand Auto) $0.00 0 - , ' ' - /
_- . . ,- . TOTAL CALCULATED FEES: $29.65
--COMMENTS/SPECIAL CONDITIONS
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(600)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and wit 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.
O I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
ITy.section need not be completed if the permit is valued at one hundred dollars($100)or less.)
— l.certify.that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
C ',Compensation laws of Ca fo ia,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply withthese p vlsi ns Lu' 4/'b 1
-Applicant SIggoature: L-+-✓ z I� Date:',:`.= "
CI WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
111 THOUSAND DOLIARE($100,000),IN ADDITION 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 end effect.Lic.# Class#
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3091,Civil Coda).
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.If,however,the building or improvement is
old 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.).
� 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 purs ant to the Contractors License Laws.)
❑ I
ere.exereun er sec. Business and Professions Code for this reason: ` I�
Signatuie::. ••✓�� 'Nate"1%) 14JO 1-
Owner ID verified by driver's license. es 0 No DriverCel:cense No;
Verification of Ownership by(type of document,i.e.-property tax bill or deed): fp )
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).
O 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:
I 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? 0 Yes 0 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? 0 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.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this Replication akEermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes LI No
(Section 65950.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
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"yes",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? ❑Yes 0 No
8 (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 COMPLIANC 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 a stat 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 in ctio pu miss.I agree not occupy or allow occupancy of any building authorized by this permit until final inspection.
� .. ILA 41047-
SignatureO1,LegalOwner(s) 'Date • - .
And/Or Authorized Applicant Date
CODE# ItlSEEOIlOITYPE _ PATE INITIALS CODE# INSPECTION TYPE PBS€ INTRIAL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing �Z-S—07 O
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 — -
� CITY OFCOSTA MESA
4 it/ 111t6C BUILDING DIVISION
�- DEVELOPMENT SERVICES DEPARTMENT PER UMBER
1. 1 . PERMIT
-`W''o`m"/�111
�p B05-01144
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 1851 ELBA CI Status: ISSUED
Suite: Applied: 07/11/2005
Vicinity: ROOF Issued: 07/11/2005
Primary Occ: R3 Type of Construction: V-N
Parcel Number: 13942112 Zoning: R1
4114)
Applicant: KEVIN CROWLEY ISSUED BY:
Address: 1016 E FIRST ST
Phone: (714)836-1966
SANTA ANA,CA , Zip: 92701 ,
Owner: INOUYE:WARREN S
Address 1851 ELBACIR,
Phone:
COSTA MESA,CA Zip: 92626
Contractor: GREATER PACIFIC ROOFING
Address: 1016 E FIRST ST
Phone: (714)836-1966
SANTA-ANA,CA
Zip: 92701 - License: 621368
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT,
TEAR OFF EXISTING SHEATHING AND SHAKE ROOF, INSTALL 50 YEAR CLASS-A ELK SHINGLES OVER ASTM 30LB FELT ON ATTACHED
HOUSE AND GARAGE.
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $6,995.00
Permit: $139.25 Claim Valuation: $6,995.00
SMIP Res: $0.70
SMIP Com: $0.00
Other $0.00 _ , •
Inspection: $0.00
Total: $139.95
PLANNING &ZONING
SETBACKS -
MAIN STRUCTURE-Front s 0-0 Rear 0-0 Left 0-0 Right - 0-0
ACCESSORY FronU 0-0 Rear - 0-0 Left 0-0 - Right . 0-0
PARKING Existing: 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
fora 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(WOO)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations: '
❑ I 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
4„..- - ork for which this permit Is issued.
.pq I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
y workers'compensation Insurance carrier and policy number are:
Cerner / IPoli y-NOmber:`arIOS'CC°("7S/775
(Thie'section need not be completed if t e permit is valued at one hundred dollars($100)or less.)
❑ I certify that in the perform of the work 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 C omia d agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these pro cions. '- ' c
Ap tg : , C-�%/J G6C�`'/ SDete:---- _ >- /I-GCS
WARNING:FAILURE TO SECURE WORKERS'COMPENSATI COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER=CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDmON 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 affjrm,that.l:am.licensed under provi ns of Chapter 9(commencing with Section 7000)of Division 3 of.the.Business and Professions Code,and my license Is in full
force-and -Hc'# he�Z t`j CClass-i cf 9
-4c;n 9tgnalurer, - . - //7 r 7 /// [Date — �Y/S
CONSTRUCTION LENDING AGENCY: G�u��
9 I 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).
Lenders 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.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 properly 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. 0 Yes 0 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? 0 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? 0 Yes 0 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 Califomia 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 an 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 a ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? IU Yes j�No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safely 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 prescnbed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (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 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 propert ' inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Ap ature Of Le:/Owner(s) Date
AC_/ 7—//7I
si.OcAtidlorized,• ..li :nt tate Vit'
ODE I INSPECTION TYPE PAIL MEDALS LODE E INSPECTION TYPE DAM BOW
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 1'---22" a r a 210 Final Electrical
201 Final BIock/Retalning 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
_ '1.1?13, CITY OF COSTA MESA •
w. �. BUILDING DIVISION - t
F r 'now ;I DEVELOPMENT SERVICES DEPARTMENT
UMU
PERMIT PERMITERMIT NUMBER
ER
(714)754-5273 • Fax(714)754-4856 BUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 1851 ELBA CI Status: ISSUED
Suite: Applied: 06/15/1998
Vicinity: Issued: 06/15/1998
Parcel Nunmber: 13942112 Zoning: R1 R1
Applicant: INOUYE, WARREN S
Address: 1851 ELBA CIR
Phone:
COSTA MESA,CA Zip: :92626 -
Owner: INOUYE, WARREN S
Address 1851 ELBA CIR
Phone:
COSTA MESA,CA Zip: 92626 - -
Contractor: JERRY &ASSOCIATES
Address: 508 N.NEWPORT BL •
Phone: 645-2422
N.B.CA., Zip: 92663N
License: 2187
Arch/Eng:
Address: •
Phone:
•
Zip: •
License:
SCOPE OF PERMIT
CONSTRUCT 52 LINEAL FEET OF 6 FT HIGH BLOCK RETAINING WALL INSIDE OF LEFT PROPERTY LINE. WALL HEIGHT MEASURED FROM
PROPERTY GRADE
FEE SUMMARY
Plan Check: $64.84 Calc Valuation: 84,160.00
Permit: $99.75 Claimed Valuation: Soon
SMIP Res: $0.50
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $165.09
PLANNING & ZONING
SETBACKS •
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right. 0-0
PARKING Existing: 0 Required: 0 Proposed: 0
NOTES: •
EXP`R op
lb
DATE
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
DECLARATIONS
WORKERS'COMPENSATION DECLARATION: _
J
I PerePj amN under penalty of perjury one of the following declarations: .
❑ I 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 hive and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
MyWorkers'compensation Insurance carder and policy number are:
Cartier: Policy Number.
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
❑ I certify that In the performance of the work 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 California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions.
Applicant Signature: Date:
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED
THOUSAND OOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEYS 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.Lk.a Class a
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I 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).
Lenders Name: Lenders 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.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 contractor(s)
Iicens: •ursuan loth:Contractors License Laws.).
r• un• r s: .(r„�_ Business and Professions Code for this reason:
..ignature: A 1
Expires: 1 a.)
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? 0 Yes 0 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? 0 Yes 0 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.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes 0 No
(Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If yes',the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 If a permit from the South Coast Air Duality 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 0 No
8 (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 COMPUANCE 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 al ste a laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property f r ins
ctk purposes.I agree not to occupy or allow occupancy of any building authorized b this p�it until final Inspection.
ure Of Legal Own r(s) _!` Date
And/Or Authorized Applicant Date
CODES INSPEI_SPECI0dNTYPE DATE EIMIALS MEI INSPECTION TYPE DATE MEALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1268 Pool Spa Final 20B 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
2446-46
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
CITY OF,COSTA MIS cSI CO RUCTION PERMIT PER T NO. TRACT NO. LOT NO. 'UNIT NO.
�t3a� oS' 6917 9/17/BJ 5pC1 TL
Project Address Mailing J [[ �x L rte/ ,
Applicant's Address "l, f'///IW!/ TYPE OF CONSTRUCTION ❑ NEW ❑ ADD L I ALTERATION LJ REPAIR
1 s/tif ,lis , /. Phone � SZ5 ❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P.# I Zone
Owner's Name 1 I / (/IA•Mi I'^YI^V/y OV V DESCRIPTION OF WORK/USE OF BLDG.
Address S Main Building: Accessory Building:
E Z
Arch/Eng. License No. TYPE OF PERMIT LI GRADING L<l FOUNDATION ❑ STRUCTURAL T Front 0
Address A • A 8,5-111)10--C:
J(� D� ❑ TOENANT ❑ ELECTRICAL .IY7-'I PLUMBING ❑ MECHANICAL HER i B Rear N
Contractor's Nam - 4 • Pho e r C Right N
./ PROJECT DESCRIPTION SQ. FT. OCCUPANCY G
Address(mailing) /"l aa em 7� C 1 K
-/-.� CONSTRUCTION TYPE VALUATIONS _ $ Left
City License No. ZONE- GRADING CU.YDS. ACRESE
LICENSED CONTRACTOR DECLARATION Ping. Ref.# rr'�s Parking{ ( Req./Provided l{
I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: Planning Notes:• '♦CCE�V LiJ MAR 1 �"�� M
with section 7000) of Division 3 of the Business and Professions Code, and _ 1
my license is in full for --a r effect. T
' License lass - • ice se o. I 1 1 •
S
Q� Date _ - , - •• signature �'d,4 .. Ar ':, PLUMBING FEES ,
�'[IA
WORKERS' COMPENSATION DEC VIaN ' Bar Sink Showers
I hereby affirm that I have a certificate of consent to self-insure or a certificate ELECTRICAL FEES
workers' Compensation Insurance, or a certified copy thereof (Section •
Backflow Preventer Service Sink
), Lab. C.) 2 q q �-}� /}1tAutomatic Washer Transformer 0 15-50 KW
( Icy No. "1� k 'J4 -U9 Company ✓Ibl� -1-n a\ Backflow Irrigation Sewer Cap0 50+ KW
ertif ietl copy is hereby furnished.
DOn$LrdCtlOn POI¢Sub.
TJ Certi tlmi,Dy j.'s sled with the city ing n Bathtubs Sewer Connection Cooking Unit Meter ❑up to 100 amps
(� -
Date 0 tY) Applicant /t `�
EXEMPTION FROM WORKERS'CO P SATION DECLARATION Clarifiers Solar Collectors Dishwasher Meter Dover 100 amps
(This section need not be completed if the permit Is for one hundred ($100)or
less). Dishwasher Solar Piping Dryers ❑Gas ❑Electric Sub Panel
I certify that in the performance of the work for which this permit is issued, I -
shall not employ any person in any manner so as to become subject to the Drinking Fountains Solar Tank Fan Motors DO-1 HP ❑1'h-8
Workers' Compensation Laws of California. `_
Date Signature Floor Drains' Swimming Pool w/Spa F.A.U. Inc.Solar ❑9-15 HP ❑16.15+
NOTICE: If,after making this declaration, you should become subject to the
Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks ' Urinal
comply with such provisions or this permit shall be deemed revoked. Fi%Lures Microwave
CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet Device Boxes Pole Light
I hereby affirm that there is a construction lending agency for the performance %,. / 9
of the work for which this permit is issued (Section 3097. Civ. C.) Interceptors 1 Water Heater y�L�'f�� Outlets
Lender's Name / Range
Lender's Address Kitchen Sink Water Service 'a- QO Switches • Sign
OWNER BUILDER DECLARATION I
I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash
following reason (Section 7031.5 Business and Professional Code: Any city or Garbage DisposalStanding Sections
county which requires a permit to construct,alter,improve,demolish or repair P-Trap LaundryTrays
any structure, prior to its issuance, also requires the applicant for such permit Y Generator ❑0-5 KW❑5-15 KW Trash Compactor
to file a signed statement that he/she is licensed pursuant to the p,rovisions of ,
Roof Drains
the Contractor's License Law(Chapter 9(commencing with Section-7000)of
Division 3 of the Business and Professions Code) or that he/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
,)enalty of not more than five hundred dollars($500).
O I, as owner of the property or my employees with wages as their sole Reinspection Fee $15 Issue Fee $ 3
compensation, will do the work, and the structure is not intended or offered — - Reinspection Fee I $15 Issue Fee $ 3
for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES
License'Law does not apply to an owner of a property who builds or improves
thereon, and who does such work himself/herself or through his or her own DEVELOPMENT SERVICES REQUIREMENTS:
employees, provided that such improvements aro not intended or offered for Boiler Hood or Type I 0
sale. If, however, the building or improvement is sold within one year of cum- Canopy Type II 0 Zoning Approved By Date
pe the owner will have the burden of proving he/she did not build or im- Duct-Under Ground Building Approved By Date
prove t
for the purpose of sale). e-� 7L/L/—"t/�4L
❑ t as owner the property,roject exclusively sinesscontracting with licensedionode- Duct-Structural Refrigeration System Application Issued By , Dat
•
tractors tactorsconstruct the project (Section 7044, tos Business and Prof property
Code: - - -The s Contractor's License Law does not ato an owner je iswih who Duct-Ventilating ❑0.100,000 BTU 0100,000 BTU SUMMARY OF FEES
builds or improves thereon,and who contracts for such projects with acon-
tractor(s) license pursuant to the Contractor's License Law). I am aware that Exhaust System 0 Multiple 0 System Repair/Alteration BUILDING PERMIT $ SMIP $
proof of their Worker's Compensation insurance should be provided to me. - PLAN CHECK $ PERMIT
❑ I am exempt under Section B.& P.C.for this reason Firepl/Fact.Bit. ICBO# Fire Dampers PLUMBING $ ISSUANCE $
Date OwnerRegistersPLAN CHECK 25% $ ENERGY P.C. $
I hereby certify that I have read this application and state that the abovejI .'. ...i1fA'.1tcti.usnuGRADING $
information is correct. I agree to comply with all city and county ordinances ELECTRICAL $ -
and state laws relating to building construction, and hereby authorize repre-
sentatives
of i c' y to enter pon e above-mentioned property for /J
Inspection p e . //� .�_ &_p'6 - - MECHANICAL $ TOTAL FEE $ l)
DSirivers' (/7/
.
CMF 0865-46,rev. 10/84 White - Building; Canary - Applicant; Pink -Accounting: Goldenrod - Assessor
CONSTRUCTION AND PLANNING POOL &SPA
APPROVALS Permit# Date Inspector APPROVALS Permit # Date Inspector
1. Temporary4Electrical Service or Pole 52. Pool & Equipment Location
2.t Soil Pipe-Undrgrnd. - 53. Steel Reinforcement i•'
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical UF ER Grrid: 57. APPROVAL TO COVER-GYNITE
7. Footings 58. Electrical Conduit-Undrgrnd:•
8. Foundatiori • 59. Gas Pipe, 0 Undrgrnd.,Testi
9. Water PipOndrgrnd. 60. Backwash Lines, P-Trap, Oj Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK - J
11. 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 Electrical-Conduit - 66. Solar System-Final
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign , ,17 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 01 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 0 Gas OOil
23. Gas Pipe-Rough &Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 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:4/Z /rt Lee-roma• L
34. Final Heating & Air Conditioning
35. Final Gas Pipe-Test
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing c'/yf$t [W
39. Water Service-Final �'f
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. FINAL STRUCTURE & BUILDING
48. Special Requirements Completed
49. Electric Release to Edison
•
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
18252
r..I, cosrr . .N . . . .._--
COSTA MESA BUILDING-SAFETY DEPARTMENT .,ry.73-f. fl!OST , 9cn ***1'1250
P. 0. BOX 517 COSTA MESA. CALIFORNIA
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT
BUILDING)XS/ 7:1-pe-a- �e�<�� BUILDING
ADDRESS COSTA MESA. CALIFORNIA For Office Use Only
y I RECEIPT NO. I "rA 2
OWNER T/�%✓ � ��t�J 0714 II(!I4J
MAIL ��� /`J A� ,�/�J RECEN}D BY DATA RECEIVED VoATB ISSUED
ADDRESS �1,. „fr a3'4e Y�rC////� // // {�� r/('j--6 DI NOV Z J 1DL
6c / 1 g- NTEO�J :7, ADILDING
DRESS
CITY ADDRESS
ARCHITECT E CLo./Jy1 j3�j COSTA MESA. CALIFORNIA
OR ENGINE�EyRJ�/�J / ��y WA9Mpto '/ J�I
lb
ADDRESS%/ /s`� l 2n-c-, /f//-fir` �mC'//IJ FIRE
ZONE TYPE • GROUP /
CONTRACTOR( J//JJy.� 6/Y6% (_2, APPROVED DATE ��p
ADDRESS/4 CI �.4N/.P8.4 (/�6 ZONING ��,�ee11,�.(�Gy"'—/ /
////////JJ��� " /'/_ // .77?
O `/ I NO.OF USE OF NEWS'�I/A.(�{ f
CITY gics T11 /?J/��r/ 2 C� O(' , J PL/AN9 BUILDINGo (�/ I. /I H
STC.COO. �,,�//9/ /�l/� TNO. �D J/S EGSCCC11RRRIPTIOIIN e./.1 r I�- /3%/ 1.-
SIZE
OF LOT SO 1, Ino. OF BLOCS..�� Q
,{ /�' NOW ON LOT A.P.NO. /) 'O Ln ^/��
USE OF _ YARDS EVES
EXISTING BLDG APPROVED ALLOWED
CENTER OPI NSTE TE M � (( / / (CENTER LINE ST.)SETBACK O FT. IN.
V v REAR YARDS
SIDE YARD I LEFT /0/ I RIGHT / / R.SIDE 7 FT. IN,
DESCRIPTION OF WORK' ir�fla-fit;
\ L.SIDE o FT.
NEW I r II ALTERATION I II ADDITION I REAR /'OFT. / IN./ 411,
REPAIR I II MOVING II DEMOLISH II / BYPROVED N / „J/ () DATE II-- 19.-6 \,
/
BUILDING r/ RNO. OF OOMS 7
SIZE STORIES -// ! LLL------
EXTERIOR WA ROOF
COVERING c f9 CO I COVERING e57 a0e-0 -
USE OF BUILDING AND WORK TO BE �PERFORMED�/� �7
�J�Z10 CG..c c /I, Pzsc L. _ .2-3 45
ct/7 /&A- oR _a02577v-- -670 a'
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN ER VALUATION IS FOR THE
AND STATE THAT THE ASQVE IS CORRECT AND AGREE TO COM. PURPOSE OF ETABLI RING A PERMIT FEE ONLY.
PLY WITH ALL CITY 0 [RANGES AND TATE LAWS REGULATING
BUILDING CONSTRU oN 1 / VALUATION
SIGNATURE O`er- / PERMIT FEE $ 25-------
PERM ITTEF / /y; / '7 _ o
$03/ PLAN CHECK $ J_ w'
AUTHORIZED AGENT// . 2l A /LOG%°"'/ / It
F
TOTAL FEE - - .5 0
y 21406 FEE RECEIVED
re
'COSTA MESA BUILDING-SAFETY DEPARTMENT JAN•16. 1984 - . Q •
o.O.BOX 317 COSTA MESA.CALIFORNIA FINANCE DEPT.
For Applicant to Fill In Completely APPLICA W ®bfty® IrMESA
au ILDIN
TYPE OR PRINT BUILDING
}r }- I ,.I For Office Use Only
ADDRESS f q SI EL I1 n l x •
RECEIPT NO. �E44UU(DU-
2 RNIZE"
COSTA MESA, CALIFORNIA
1 I' Cy / / RECEIVED EY DATE RIMED/ElyDATE ISSSUED/�
OWNER IN . . N� I he L/ /—/ ' /—/(9 /9
MAIL / BUILDING
ADDRESS i ,y/ FL$.7 r . FIRE
ADDRESS
^^ TEL.. ZONE TYPE Y GROUP
CITY Or CP) PS. NO,5y(.r4 [°
ARCHITECT TEL_ APPROVED 0 /I
OR ENGINEER NO. BY I DATE Av
WING 0 arm
ADDRESS
�jJ��j� /� �//[ ZONE NO.OF USE OF NEW n 4 ,. 449--
CONTRACTOR 061/// L A- s' /L! /� l�' PLANS "��- BUILDING �^ ,� /
LEGAL //l r ) 7'2-YCgJa`��L/i',
ADDRESS EGCRIPTION e__4,' J I
CITY A.P.NO. f 3 9- lj '/-/
NOTE: NO EAVE OVERHANG SHALL BE LESS THAN
STATE TEP Sr TO SIDE 9 REAR P.L
LIG.NO. NO.
,/ EAVES
SIZE _0 X 7-.107 I NO.of BUDGE. / ALLOWED (U.B.C.REQUIREMENT/
OF LOT
5
NOW ON LOT
USE OF �J , YARDS APPROVED YARDS APPROVED
/ MAIN BUILDING ACCESSORY BUILDING
EXISTING BLDG. �.-L-icC
_ (FROM C/L STREET)
SETBACK LINE FROM FRONT .,c.
CENTER OP STREET /�' /�� REAR YARD
SIDE YARD/ LEFT y .fin `p�.._0...-5,9�°// I RIGHT lL/- ' R.SIDE LFT. •I Pr.
DESCRIPTION OF WORK L.SIDE /0 FT. FT.
NEW ALTERATION ADDITION .;...• REAR /J' ‘Ff' FT.
DISTANCE BET. ACS. @
REPAIR MOVING DEMOLISH MAIN AINBL
BLDGB. ACCESS.SLOGS.
LDOB.
BUILDING ` NO.OP VAR.* DATE
SIZE �.� LC' ROOMS STORIES C.U.P.# APPROVED
EXTERIOR WALL 777___ I ROOF APPRpyGD� 0
COVERING COVERING ,LA NX. BY ( t • DATE — . ' V•"
USE OF BUILDING AND WORK TO BE PERF^-MED /^n-
C?--t/( N
Gi th y-- SQ.FT.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE 5
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. o
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING VALUATION /(� I�1
BUILDING CONSTRUCTION. PERMIT FEE .9 y7 --✓Ly-
SIGNATURE OF
. 4 @Qr.LeZ _ _
PERMITTEE •
$ PLAN CHECK $_ D
/
AUTHORIZED AGENT
N ��//�J Q TOTAL REE
1 / /4