HomeMy WebLinkAbout1853 ELBA CIR - Building Permits CITY OF COSTA MESA
to ' Se BUILDING DIVISION
f ��p$ 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
��•I'�� .8 FOR INSPECTIONS CALL: (714)754-5626
'" ' " 10,
PERMIT NUMBER: B10-00234
PERMIT TYPE B_ROOF2 STATUS: ISSUED
APN: 13942111 DATE ISSUED: 08/10/2010
ISSUED BY: RMD
JOB ADDRESS: x1853-ELBA-CI-CM Suite/Unit:
Vicinity: HOUSE AND GARAGE-ROOF---�
Squares: 2500 Valuation: $4,000.00
SCOPE OF WORK: TEAR OFF EXISTING ROOF MATERIALS,INSTALL 1 LAYER OF 30#FELT ON A 4:12 OR GREATER ROOF
PITCHE AND REROOF WITH 50 YEAR COMP SHINGLES ON AN ATTACHED HOUSE AND GARAGE,APPROX 25
SQUARES.REPAIR AND REPLACE SHEATHING AS NEEDED.COMPLIANCE FORMS ATTACHED TO JOB CARD AND
CITY PERMIT.
OWNER: MOORE,SHEDRICK H TR Address: 1853 ELBA CIR Unit:
PHONE: City/State/Zip: COSTA MESA,CA
APPLICANT: JOHNSON,SCOTT Address: 1260 N HANCOCK Unit: :STE 107
PHONE: 714-777-4040 City/State/Zip: ANAHEIM,CA
CONTRACTOR: MC CORMACK ROOFING AND WINDOW CO License No. 643700
Address: 1260 N HANCOCKUnit: SUITE 107 PHONE: 714-777-4040
City/State/Zip: ANAHEIM,CA - 92807 CELL: 949-347-1400
ARCHITECT: License No. PHONE:
ENGINEER: License No. PHONE:
FEE SUMMARY
Reroof Plan Check: $0.00
Reroof Permit Fee: $97.25
Reinspection Fee: $0.00
Bldg Std Admin Fund $1.00
TOTAL FEES $98.25
HOURS FOR CONSTRUCTION ACTIVITY; EFFECTIVE 3/18/2010 -PER CMMC Sec. 13-279
Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibitied all hours-Sundays and the following Federal holidays
New Years Day, Memorial Day, Independence Day, Labor Day,Thanksgiving Day and Christmas Day
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
CODE N. INSPECTION TYPE DATE INTITIAL$ CODE* INSPECTION TYPE DATE INTITIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa FinalI//� 208 Final Plumbing
200 Final Re-Roof X Bin'/c Rb c""' 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
WORKERS'COMPENSATION DECLARATION: Owner ID verified by driver's license. ❑Yes ❑`No
I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires:
❑ I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed):
compensation, as provided for by section 3700 of the Labor Code, for the
pe ormance of the work for which this permit is issued.
I have and will maintain workers'compensation insurance,as required by
sec 3700 of the Labor Code,for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a
number are: person is required to descend,will be made in connection with work authorized
y )4 5.14. by this permit,and that no building structure,scaffolding,falsework,or demolition
Carrier: W r f or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp
(This section need nnont be mpletedfib perms is valued at ape hundred dollars($100)W less.) 2 Art2 Sec 311 The B,California Administrative Cede).
Policy_Number. lr'( �v'S�` �64'�- G )
❑ As owner-builder, I will not employ anyone to do work which would
❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless
issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California, and agree that if I should
become subject to the workers'compensation provisions of Section 3700 of
Applicant's Signature Date
the Labor Code,14 orthwith comply with these .
provision
e�i �/� e Division of Industrial Safety Permit Number:
Apptt ant's'Slgnature Date
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑Yes ❑No
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. 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
LICENSED CONTRACTORS DECLARATION: 500 pounds.or a volume of 55 gallons,or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is in
full ce and effect. G 7 a registration form for acutely hazardous materials? IDYes ❑ No
C
Class#^" (Section 25533 of the California Health and Safety Code, with some
_v , ' oj - exceptions, requires registration with the Costa Mesa Fire Department by
each business which at any one time has on hand a quantity of acutely
Con ractor'sSlgdature Date 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name: hazardous materials)? 0 Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the
Lender's Address: 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.
Signature Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes ❑No
• I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? ❑Yes ❑No
issuance,also requires the applicant for such permit to file a signed statement
(Section 65850.2 of the ia Government Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors information be furnished on on applications for non-residential building permits).
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 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes ❑No
applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes", the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec.7044,Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? ❑Yes ❑ No
thereon,and who does such work himself or herself or through his or her own
8. (If"yes",attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH
city ordinances regarding Hazardous Materials and Emissions.
LICENSED CONTRACTORS to construct the project(Sec.7044, Business and
Professions Code:The contractors License Law does not apply to an owner of Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
CI I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: 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.
Signa . . e•• •�,:. (s) ��at�/
Signature Date
3057-4e 13/071 �r
And/or AuthW2ed ppucant CDate-:
4 Prescriptive Gentificate of Coinplia,...e: Residential r CF-]R-ALT
Residential Alterations (Page 1 of 5)
ltrr oject,Name: Climate Zone# / #df-stories
Moore I CYVv (o
General Information
-Site Address: / b-5-3 614a Enforcement AgencJ/r,t s, �� Date: 8'lJ t/y, p
Building Type[Single Family 0 Multi Family Circle the Front Orientation:LL '' N,EOW,or degrees r
o U Project Type: 0 Alterations 0 Envelope 0 Fenestration Jtoof 0 HVAC
Conditioned Floor Area(CFA): 7� Replacement or Change Out 0 Duct Replacement 0 Water Heater
NOTE: This Tarin is not to be used/1w Newly Constructer!Buildings ar Additions
:Insolation Values For Opaque Surfaces(for Furring use the Mass and Furring Strips Construction table below)
Assembly Alteration
0 Opening of framed cavity alone—Alterations that involve the opening of the framed cavity of a wall,ceiling, or floor-must install the
mandatory minimum insulation value per§150 for the altered assembly.Fill in Columns A—C and enter mandatory insulation value in Column H.
0 Replacement of entire assembly—Replacement of an entire wall, ceiling,or floor assembly requires the installation of Component
Package-D insulation values in Table 151-C. Fill in Columns A—J. .
Opaque Surface Details For the furred portioned of Mass Walls see Furring Strips Construction Table below.
•
A B I C D E . - F G H - - ' I - f- 3
Proposed
See Note _ Standard Values From JA4 Table
Framing Thickness, Framed Continuous JA4 Proposed
Tag/ Assembly Name Material Spacing, U- JA4 Table Cavity Insulation Assembly Assembly
ID' or Type' and Size' or Other3 factor" _ Numbers R-value R-Value' Cell Values U-factor9
•
.. Now:For furred assemblies.accounting for Continuous Insulation R-value,see Page JA4-3 and Equation 4-/. For calculating fun-ed walls use the Mass and
Furring Consnvction table below.
' 1. For Tog/ID indicate the identification name that matches the building plans.
2.Indicate the Assembly Name or type:Roof/Ceiling, Walls,Floors, Slabs, Crawl Space,Doors and etc...Indicate the Frame type and Size:For
Wood, Metal, Metal Buildings,Mass,enter 2x4, 2x6, or etc...see.1A4 for other possible frame type assemblies.
3. Enter the thickness for mass in inches or Spacing between framing members enter; 16"or 24"OC;or Other for all other assembly description
such as Concrete Sandwich Panel, Spandrel Panel,Logs,Straw Bale Panel and etc....
4. Based an the Climate Zone;enter the Standard U-factor from Table 151-B, C or D for each different assembly Name or type.
5.Enter the Table number that closely resembles the proposed assembly.
6. Enter the R-value that is being installed in the wall cavity or between the framing;otherwise, enter "0".
7. Enter the Continuous Insulation R-value for the proposed assembly;otherwise, enter "0".
• 8.Enter the row and column of the U-factor value based on Column F Table Number and enter the Assembly U-factor in Column J
9.The Proposed Assembly U-factor. Column J,must be equal to or less than the Standard U-factor in Column E to comply.
Furring Strips Construction Table for Mass Walls Only
A I B I C D i E F G 1-1 I J K L M
Proposed Properties of Masonry and Concrete Added Interior or Exterior Insulation
Walls From Reference in Furring Space from Reference
• Joint A pendia Table 4.3.5,4.3.6.4.3.7 Joint Appendix Table 4.3.13
ISI _
�� ` o n' �,
Assembly 2' j o c` 2 F u c a,^., m "'-., Final
` .- y J <. _
' Mass Name or JA4 Table v oro E R o i a V _ ` = Assembly
Thickness' Type' j Number' 5 j ,� t w = r- Lt = ter e : ani r U-factor Ga Comment
I _ _ ,
l . I I
Registration Number: Registration Date/Time: HERS Provider:
2008 Residential Compliance Forms' August 2009
Prescriptive Certificate of Compliance: Residential • • CF YR-ALT
Residential Alterations r_____ ,, (Page,3 of 5)
I ojecCName? ,p Climate Zone# '#of-Sfories
// Goi e Art?' 2702-1ROOFING PRODUCTS(COOL ROOFS)§151(12 0
When the area of exterior roof surface to be replaced exceeds more than 50%of the existing roof area,or more than 1,000 ft', whichever is
less,the new roofing area toast meet the roofing product "Cool Roof'requirements of§152(b)IHi,152(6)1Hii,or l52(b)1Hiii.
Check applicable alternative or exception below if the roof alteration is exempt from the roofing product "Cool Roof'requirements. Note:If any
rSone of the alternatives or exception below is checked, the Aged Solar Reflectance and Thermal Emittance requirements for roofing products in
§118(i)are not applicable.Do not fill table below.
D Cool Roofs Not Required in Climate Zones 1-12, 14,and 16 with a Low Sloped. Less or 2:12 pitch.
Cool Roofs Not Required in Climate Zones I through 9 and 16 with a Steep-Sloped Roofs(pitch greater than 2:12)and product unit weight less
/than 51b/ft2.
.Alternatives to§152(b)1Hi and§152(b)Hii,Steep-slope roof(pitch>2:12)
J❑ Insulation with a thermal resistance of at least 0.85 hrft2.°F/Btu or at least a 3/4 inch air-space is added to the roof deck
over an attic;or
❑ Existing ducts in the attic are insulated and sealed according to§151(010;or
.❑ In climate zones 10,12 and 13,with 1 112.of free ventilation area of attic ventilation for every 150&of attic floor area,and
where at least 30 percent of the free ventilation area is within 2 feet vertical distance of the roof ridge;or
❑ Building has at least R-30 ceiling insulation;or
❑ Building has radiant hairier in the attic meeting the requirements of§151(02;or
❑ Building has no ducts in the attic;or
❑ In climate zones 10, 11,13 and 14,R-3 or greater roof deck insulation above vented attic.
Exception to§152(b)1Hiii,Low-slope roof(pitch 52:12)
❑ Building has no ducts in the attic.
Other Exceptions
0 Roofing area covered by building integrated;photovoltaic panels and solar thermal panels are exempt from the below Cool Roof criteria.
.Cl Roof constructions that have thermal mass over the roof membrane with at least 25 Ib/ft2 is exempt from the below Cool Roof criteria.
- Note:If no CRRC-1 label is available,this compliance method cannot be used,use the Performance Approach to show compliance,otherwise,
Check the applicable box below if Exempt from the Roofing Products"Cool Roof"Requirement:
Roof Slope Product Weight Product Aged Solar Thermal
CRRC Product ID Number < 2:12 >2:12 < 51b/ft2 > 5Ib/ft2 Type2 Reflectance" Emittance SRI5
O 0 0 0 ❑4
0 0 0 0 ❑4
r
O 0 0 0 ❑4 .
O 0 0 0 ❑4
O 0 0 0 ❑4
I. The CRRC Product ID Number can be obtained from the Cool Roof Rating Council's Rated Product Directory at www.coolroo(tors/products/search.php
2, Indicate the type of product is being used for the rooftop,i.e.single-ply roof asphalt roof metal roof etc.
3. If the Aged Reflectance is not available in.the Cool Roof Rating Council's Rated Product Directory then use the Initial Reflectance value from the same
directory and use the equation(0.2+0.7(flthutat-0.2)to obtain a calculated aged value. Where p is the Initial Solar Reflectance.
4. Check box if the Aged Reflectance is a calculated value using the equation above.
5, Calculate the SRI value by using the SRI- Worksheet at hon:/hvww.enerev.ca.gov/Iitle24/and enter the resulting value in the SRI Colurnn above and attach atopy of
the SRI-Worksheet to the CF-I R.
To apply Liquid Field Applied Coatings,the coating must be applied across the entire roof surface and meet the dry mil thickness or coverage
recommended by the coatings manufacturer and meet minimum performance requirements listed in§118(i)4. Select the applicable coating:
O Aluminum-Pigmented Asphalt Roof Coating 0 Cement-Based Roof Coating 0 Other
Registration Number: Registration Date/Time: HERS Provider:
2008 Residential Compliance Forms • August 2009
Prescriptive Certificate of Compliance: Residential CR-IR-ALT
Residential Alterations n (Page 5 of 5)
Pr:ojecLNamtVe:,, 1 ) W On�j CLQ n - 00 // I Clinattr nt� i;
"tit_
f1/ %
HERS VERIFICATION SUMMARY The enforcement agenet•should pm•special attention to the HERS Measures specified III this
checklist below. A completed and signed CF-41(Form for all the measures specified shall be submitted to the building inspector before final
inspection.
Duct Sealing & Testing HERS verification is required,for this measure.
❑YES 0 NO 1'ES:In Climate Zones 2 and 9-16,if more than 40 linear feet of new or replacement ducts are installed in unconditioned
space,the ducts are to be sealed per§152(b)1Dii and the newly installed ducts are to be insulated per §151(1)10.
0 EXCEPTION: Existing duct systems that are extended, which are constructed, insulated or sealed with asbestos.
0 YES ❑ NO YES:In Climate Zones 2 and 9-16,if the existing space-conditioning system(HVAC equipment and ducting)is replaced;the
ducts are to be sealed per§152(b)1 Di.
❑ YES 0 NO YES:In Climate Zones 2 and 9-16,if the existing HVAC equipment is replaced(including the replacement of the air handler,
outdoor condensing unit of a split system,cooling or heating coil,or the furnace heat exchanger)the ducts are to be
sealed pet §152(b)1E.
❑ EXCEPTION:Duct systems that are documented to have been previously sealed confirmed through HERS
verification iu accordance with procedures in the Reference Residential Appendix RA3.
0 EXCEPTION:Duct systems with less than 40 linear feet in unconditioned space.
❑ EXCEPTION: Existing duct systems constructed,insulated or sealed with asbestos,
Refrigerant Charge- Split System HERS verification is required for this measure.
❑ YES 0 NO YES:In Climate Zones 2 and S-I5,when the existing HVAC equipment is replaced(including the replacement of the air
handler,outdoor condensing unit of a split system A/C or heat pump,cooling or heating coil; or the furnace heat
_ exchanger)a refrigerant charge measurement shall be verified per§152(b)lF.
•
Central Fan Integrated (CFI)Ventilation System and Fan Watt Draw
The ventilation requirements of 5150(o)do not apply to existing residential homes.
Ducted Split Systems-Air Conditioners and Heat Pumps: Airflow HERS verification is required for this measure.
❑YES 0 NO YES:In Climate Zones 10 through 15,when the existing space-conditioning system(H VAC equipment and ducting)is
replaced,the airflow and fall watt draw shall be verified per§152(b)1 Ci to meet the requirements of&l51(f)7B.
Documentation Author's Declaration Statement
• I certify that this Certificate of Compliance documentation is accurate and complete
Name:
„Ci 0 ' csO )" y)S at/ Signature
Companyfit
Cot e eVU It:„ _ L 0 7 / J/ Dater tD
QVI /'—
Address: q 1 .11 if Applicable❑ CEA or O CEPE
1 Z p 6 C-]Ct lj G o G J4 / d e (Certification#!):
City/State/Zip: f l • n„ ,.., /lb 7 Phone:
Responsible Lluilding Designer's Declaration Statement
• I am eligible under Division;of the California Business and Professions Code to accept responsibility for the building design identified on
this Certificate of Compliance.
• I certify that the energy features and performance specifications for the building design identified on this Certificate of Compliance conform
to the requirements of Title 24,Parts 1 and 6 of the California Code of Regulations.
• The building design features identified on this Certificate of Compliance are consistent with the information provided to document this
building design on the other applicable compliance forms,worksheets,calculations,plans and specifications submitted to the enforcement
agency for approval with this hitilding permit application.
Name: Signature.
Company: Date:
Address: License.
ay/Smut/Zip: I Phone:
Far assistance ar questions regarding the Energy Standards, contact the Energy Hotline at:3-800-772-3300.
Registration Number Registration Dote/Time: HERS Provider:
200f.;Residential Compliance Fonts' August 201)9
. 04,5 /4Af;i7 wcr Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
•CITY OF CDSTA MESA CONSTRUCTION PERMIT PEF�pIToOa,S—S� TRACT NO. LOT NO. UNIT NO.
PEM
DDVV ' 8294 5/21 /87
'Project Address 137 Y��.� �e�.'`�/ I 14.50 TL
//f�1� . ��u�� Ft--- TYPE OF CONSTRUCTION U NEW U ADO U ALTERATION LI REPAIR
Applicants Mailing Address !! ooze- er114 , ❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P.# Zone
Owner's Name �u!.v ��()�-�L� Phone�T/"
Address IS", e.L42" L.A r_h __ DESCRIPTION OF WORK/USE OF BLDG.
S Main Building: AccessoryBuilding:
Arch/Eng. License No. TYPE OF PERMIT ❑ GRADING ❑ FOUNDATION�jIJ STRUCTURAL E Front o
Address ' 11 •p c� / ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING yam' MECHANICAL B Rear - N
Contractor's Name c tA. 4 P1' ��o�. Phone54 -16,3 ❑ 'OTHER A I
��//p1 / PROJECT DESCRIPTION SQ. FT. OCCUPANCY C Right N
Address lmailingl_4- 52 U�� �, K
CityLicense No. ' O 7r?� _7E CONSTRUCTION TYPE VALUATIONS s Left R
ZONE GRADI NG CU.YDS. ACRES R
LICENSED CONTRACTOR DECLARATION Ping. Ref.# Parking Req./Provided • E
I hereby affirm that I am licensed under provisions of Chartei 9 (commencing Remarks: ,/ ADO • GNI Planning Notes: Q
.I's with section 7000) of Division 3 of the Business and Professions Code, and RECEIVED MAY 2 0 1R
.\,• , my license is in fu or, .nd e fect. /! �..=�� T
�: License Class- .. icense N4. - $
fjlS' C ( ear 1 PLUMBING FEES
Date —r Signature
WORKERS' COMPENSATION DECLARATION • Bar Sink Showers
� •
' I hereby affirm that I have a certificate of consent to self-insure or a certificate ELECTRICAL FEES
f Workers' Compensation Insurance, or a certified copy thereof (Section Backflow Preventer Service Sink -
p )000, Lab.„ )ge.71 - Automatic Washer - .Transformer 0 15-50 KW
•
C♦ Policy No.{'�—1 Company 3v.-(tias 4140. Backflow Irrigation Sewer Ca 0 50+KW
ertified copy is hereby furnished. p Construction Pole Sub.
Daefed copy is fi-( with the city ByiR . .-.__.o3i�^ Bathtubs Sewer Connection
''7 L/, ( �G` M— Cooking Unit Meter Our)to 100 amps
Da e 1� •�7 Applicant —
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Clarifiers Solar Collectors Dishwasher Meter Cover 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 •
t -
shall not employ any person in any manner so as to become subject to the Drinking Fountains Solar Tank Fan
Workers' Compensation Laws of California. Motors 00-1 HP 01'A-8 •
Date Signature ' Floor Drains SwimmingPool w S a -
NOT.ICE:If,after making this declaration,you should become subject to the _ / P F.A.U. Inc.Solar 09-15 HP 016-15+
Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks Urinal Fixtures
comply 'with such provisions or this permit shall be deemed revoked. Microwave
CONSTRUCTION LENDING AGENCY ' Gas Service Outlets Water Closet
I hereby affirm that there is a construction lending agency for the performance Device Boxes Pole'Light
of the work for which this permit is issued (Section 3097 Civ. C.) Interceptors Water Heater Outlets
Lender's Name ' Range
Lender's Address Kitchen Sink Water Service •
Switches Sign
OWNER BUILDER DECLARATION
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 Disposal ;Standing Sections
county which requires a permit to construct,alter,improve,demolish or repair P—Trap Laundry y Tra s Generator ❑05 KW❑5.15 KW
any structure, prior to its issuance, also requires the applicant for such permit - Trash Compactor
to file a signed statement that he/she is licensed pursuant to the provisions 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 -
`herefrom and the basis for the alleged exemption. Any violation of Section '
031.5 by any applicant for a permit subjects the applicant to a civil
• enalty of not more than five hundred dollars($500).
LJ I, as owner of the property or my employees with wages as their sole Reinspection Fee I $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'sMECHANICAL 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 Hood or Type I ❑ DEVELOPMENT SERVICES REQUIREMENTS:
employees, provided that such Improvements are not intended or offered for Boiler ZoningApproved ByDate
sale. If, however, the building or improvement is sold within one year of com- Canopy Type II ❑ pp
pletion, the owner will have the burden of proving he/she did not build or im- Duct-Under Ground Building Approved By Date
prove for the purpose of sale). W❑ 1, as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System Application Issued By ®-- Dat
tractors to construct the project (Section 7044,Business and Professions Code: �kyy
The Contractor's License Law does not apply to an owner of property who i Duct-Ventilating 1 X0-100,000 BTU 0100,000 BTU -7 93 SUMMARY OF FEES
builds or improves thereon, and who contracts for such projects with a con- l
tractor(s) license pursua bt to the Contractor's License Law). I am aware that Exhaust System ❑ Multiple 0 System Repair/Alteration BUILDING PERMIT $ - SMIP $ _
proof of their Worker's Compensation insurance should be provided to me. PLAN CHECK $ PERMIT .7�j
❑ I am exempt under Section B. & P.C.for this reason Firepl/Fact.Bit. ICBG# Fire Dampers E $
' PLUMBING $ -
Date Owner _ _ He ting System& Ducting Registers PLAN CHECK 25% $ ENERGY P.C. $
I hereby certify that I have read this application and state that the above i0.100,000 BTU 0100,000 BTL( m GRADING $
information is correct. I agree to comply with all city and county ordinances JI I JI 4 _"l ELECTRICAL $
and stale laws relating to building cons action, and hereby authorize repre- PLAN CHECK 50% § MICROFILM $
sentatives of this city to en.-r upo he above-mentioned property for /�
•
inspection • ••�. --5y t7 tG TOTAL FEE $ (—TI
Signature Q bLL�_ Date J_ MECHANICAL $ ' /�
Drivers' License or SS# Reinspection Fee $15 Issue Fee $ 3 PLAN CHECK 25% $
a
CMF 0865-46,rev. 10/84 White - Building; Canary -Applicant; Pink -Accounting; Goldenrod - Assessor
CONSTRUCTION AND PLANNING POO. _SPA
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 UF ER Grnd. 57. APPROVAL TO COVER-GUNITE
-7. Footings 58. Electrical Conduit-Undrgrnd.
8: Foundation 59. Gas Pipe, 0 Undrgrnd.,Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap,0 Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
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 - 68. APPROVED FOR PLASTERING
r
•
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 0 Gas 0 Oil
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:
34. Final Heating & Air Conditioning 644/87 Len
35. Final Gas Pipe-Test
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final ry;
41. Solar Domestic-Final
}
rs
42. Backflow Preventer
43. Backflow Irrigation
,t,
(-1
44. Landscape Irrigation Systertt,r
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUCLDING
48. Special Requirements Completed
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co •
51. CERTIFICATE OF OCCUPANCY
No. Date
Applicant to fill In all spaces except those within heavy border lines and sign all appropriate declarations.
Cl1 Y OF COSTA MESA CONSTRUCTION PERMIT PERMIT NO. TRACT NO. LOT NO. UNIT NO. 0641 6/Z:./ .7 I' . '
/,P5' 34CR
e ,SZi - , c[c 6 L-2o 13
• Project Address 1.147:01)
YI
77„7,6-e. TYPE OF CONSTRUCTION LI NEW LADD L I ALTERATION U REPAIR
Applicant's Mailing Address 0_ cin, 7 El CONVERSION ❑ DEMOLISH 0 OTHER A.P..86 Zone
Owner's Name/�S y • ,OQI�C Phona� n�.� % DESCRIPTION OF WORK/USE OF BLDG.
Address _4.7 -5OMr --II S Main Building: Accessory Building:
Arch/Eng. License No. TYPE OF PERMITry XC GRADING E FOUNDATION U STRUCTURAL E Front ZO
Address •
TENANT ELECTRICAL 0 PLUMBING 0 MECHANICAL B Rear N •
Contractor's Name �/v Phone 0 C Right N
Address(mailing) PROJECT DESCRIPTION SQ. FT. OCCUPANCY K G
CONSTRUCTION TYPE VALUATIONS ._ _ S Left
City License No. ZONE GRADING CU.YDS. ACRES R
LICENSED CONTRACTOR DECLARATION Ping. Ref.# Parking Req./Provided E
I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: Planning Notes: Q
with section 7000) of Division 3 of the Business and Professions Code,and M
my license is in full force and effect. T
License Class License No. S
Date Signature .
PLUMBING FEES
WORKERS'COMPENSATION DECLARATION Bar Sink Showers
I hereby affirm that I have a certificate of consent to self-Insure or a certificate ELECTRICAL FEES
of Workers' Compensation Insurance, or a certified copy thereof (Section Backflow Preventer Service Sink -
3800, Lab. C.) • _ Automatic Washer Transformer ❑ 15-50 KW
Policy No. Company Backflow Irrigation Sewer Cap - - - Construction Pole Sub. 0 50+KW
8 Certified copy is hereby furnished. -
Certified copy is filed with the city Building Division. Bathtubs Sewer Connection Cooking Unit Meter ❑up to 100 amps
Date Applicant— Clarifiers
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION - Solar Collectors Dishwasher Meter Dover 100 amps
(This section need not be completed if the permit is for one hundred ($100)or •
Dishwasher �i
less). Solar Piping Dryers ❑Gas ❑Electric Sub Panel)
I certify that in the performance of the work for which this permit is Issued, I — — - / ` r. C Do
shall not employ any person in any mann c me subject to the Drinking Fountains Solar Tank Fan •
Worker5kyCCo$p¢nsat�n...aws of Calif nia. - Motors 00-1 HP ❑1'h-8
Date/f�---/c, —/� / Signature c- Floor Drains Swimming Pool w/Spa F.A,U.
NOTICE:If,after making this declaration,you should become subject to the Inc.InoSolar 9.15 HP 016-15+
Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks Urinal Fixtures
comply with such provisions or this permit shall be deemed revoked. Microwave
CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet
I hereby affirm that there Is a construction lending agency for the performance - Device Boxes Pole Light
of the work for which this permit is issued (Section 3097 Civ. C.) Interceptors Water Heater
Lender's Name Outlets Range
Lender's Address Kitchen Sink Water Service Switches Sign
OWNER BUILDER DECLARATION
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 Disposal Standing Sections
county which requires a permit to construct,alter,Improve,demolish or repair P-Trap
any structure, prior to its issuance, also requires the applicant for such permit Laundry Trays Generator 00.5 KW 05-15 KW Trash Compactor
to file a Signed statement that he/she is licensed pursuant to the provisions of 7400f Drains
the Contractor's License Law (Chapter 9 (commencing with Section 7000) of _ Z(VE rO
Division 3 of the Business and Professions Code) or that he/she is exempt S.7Oq
. therefrom and the basis for the alleged exemption. Any violation of Section COA/J� ��C'd�
A
7031.5 by any applicant for a permit subjects the applicant to a civil - �_ "•Y`�^ _
to Ity of not more than five hundred dollars($500). •
ZO I, as owner of the property or my employees with wages as their sole Reinspection Fee I $15 Issue Fee S 3
compensation, will do the work,and the structure is not intended or offered MECHANICAL - Reinspection Fee I $15 Issue Fee $ 3
for sale (Section 7044, Business and Professional Code: The Contractor's 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 are not intended or offered for Boiler Hood or Type 1 ❑
sale. If, however, the building or improvement Is sold within one year of Com- Canopy Type II ❑ Zoning Approved By Date
pletlon, the owner will have the burden of proving he/she did not build or im- Duct-Under Ground Building Approved By Date
prove for the purpose of sale). - /(y/t/7 / 4 /v 1❑ I. as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System Application Issued By - / Date / ` O
tractors to construct the project (Section 7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who Duct-Ventilating 00100,000 BTU 0100,000 BTU
builds or Improves thereon,and who contracts for such projects with aeon- —
$UMMARV OF FEES
tractor(s) license pursuant to the Contractor's License Law). I am aware that Exhaust System 0 Multiple❑ System Repair/Alteration BUILDING PERMIT $ - SMIP $
proof of their Worker's Compensation insurance should be provided to me. PLAN CHECK $ _ PERMIT
❑ lam exempt under Section B.& P.C.for this reason Firepl/Fact.Blt. ICBG# Fire Dampers ISSUANCE$ $
Date ,I!/�Ylir Owner t.....aiim7ats Heating System&Ducting Registers PLAN CHECK 25% $ ENERGY P.C. $
I hereby certifythat I have read this application and state that the above 00-100,000 BTU 0100,000 BTL /3.o
information is crrect. I agree to comply with all city and county ordinances ELECTRICAL $ V GRADING $
and state laws relating to building construction, and hereby authorize repre- MICROFILM $
sentatives of this cit to enter upon the above-mentioned property for • PLAN CHECK 50% $
inspection r0o5¢S. - Ii
Signature � Data C.-74:27 MECHANICAL $ TOTAL FEE $ I
S•Ou
Drivers' License or SS# Reinspection Fee $15 Issue Fee $ 3 PLAN CHECK 25%- $
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. 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 UF ER Grnd. 57. APPROVAL TO COVE R-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, 0 Undrgrnd.,Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, ❑ Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
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 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 0 Gas 0 Oil
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:
34. Final Heating Air Conditioni? ,''meg/ J.C.
35. Final Gas'Prpe-Test
36. Hood or Canopy
37. Final Factory Fireplace
•
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final
41. Solar Domestic-Final
42. Backflow Preventer
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations
47. 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
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
PER N TRACT NO. LOT NO. UNIT NO.
CITY OF COSTA SA CONSTRUCTION PERMIT 4779 2/00/00 5e00 TL
?xss EL a i2c 9aceara 3 s ii ib
Project nt's Mailingt 11U ADD U ALTERATION U REPAIR
Applicant's Address//////��1���l1153 I.0 !-110CLxA..� TYPE OF CONSTRUCTION ❑ NEW
Owner's Name Y,Re Phone5y5:( y ❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P,# Zone
DESCRIPTION OF WORK/USE OF BLDG.
Address Me S Main Building: Accessory Building:
E Z
Arch/Eng. License No. TYPE OF PERMIT U GRADING ❑ FOUNDATION U STRUCTURAL T Front 0
Address 0 I, ❑ TENANT 0 ELECTRICAL 0 PLUMBING 0 MECHANICAL OTHER A Rear N
eT/
Contractor's NamE Er�2 S DL/)m13/AXt.Pl,gnr.09r9-3�9p C Right GN
gg3Y
Address(mailing) 5`33 ,vis) L1re vL-10 Q1...+ heiin PROJECT DESCRIPTION SQ. FT. OCCUPANCY
C O N ST RUCTION TYPE VALUATIONS S Left
City License No. `7 666 ZONE GRADING CU.YDS. ACRES R
LICENSED CONTRACTOR DECLARATION Ping. Ref.# Parking Req./Provided E
. Q
I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: Planning Notes: r�r� M
with tectlon 7000) of Dlvislon 3 of the Business and Professions Code,and R T
mY license is in lull force a of i r) 0( /7 D FEB - 1 S
'� Licens5/[1las �- Li en LQS/ ���5
Date /6Y-1 7 Signature t' / .0 ui�i PLUMBING FEES
WORKERS'COMPENSATION DECLARATION Bar Sink Showers ELECTRICAL FEES
l I hereby affirm that I have a certificate of consent to self-Insure or a certificate
I Workers' Compensation Insurance, or a certified copy thereof (Section Backflow Preventer Service Sink
800, Lab. C.) ////J� Automatic Washer Transformer ❑ 15-50 KW
\ Policy No. O��`yt/ Company EaUL� �1�1s Backflow Irrigation Sewer Cap Construction Pole Sub. 0 50+ KW
Policy
copy is hereby furnished.
Certifiecl,copy i filed with the city a w
9 'si Bathtubs Sewer Connection Cooking Unit Meter ❑up to 100 amps
r'
Date /o -r` Applicant di .ri.a../cm u a
EXEMPTION FROM WORKERS'COMPENSATION 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 00-1 HP 011/2-8
Workers' Compensation Laws of California. `_
Date Signature -- -- Floor Drains Swimming Pool vv/Spa F.A.U. Inc.Solar 09.15 HP 016-15+
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 Fixtures
comply with such provisions or this permit shall be deemed revoked. •
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 v 9
of the work for which this permit is issued (Section 3097-'Civ. C.) / -
Interceptors / Water Heater a COOutlets Range
Lender's Name — -i
Lender's Address Kitchen Sink Water Service - Switches
OWNER BUILDER DECLARATION - Sign
I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash
Garbage Disposal Standing Sections
following reason (Section 7031.5 Business and Professional 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 P-Trap Laundry Trays Generator 005 KW ❑5-15 KW Trash Compactor
to file a signed statement that he/she Is licensed pursuant to the provisions of Roof Drains
the Contractor's License Law(Chapter 9(commencing with Sections7000)of
Division 3 of the Business and Professions Code) or that he/she Is exempt
. herefrom and the basis for the alleged exemption. Any violation of Section
031.5 by any applicant for a permit subjects the applicant to a civil
,enalty of not more than five hundred dollars($500).
❑ I, as owner of the property or my employees with wages as their sole Reinspection Fee I $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 Boiler Hood or Type I 0 DEVELOPMENT SERVICES REQUIREMENTS:
employees, provided that such Improvements are not intended or offered for yp ZoningApproved By • Date
sale. If, however, the building or Improvement is sold within one year of com- Canopy Type II 0 pp
p tette r h owner willhave the burden of proving he/she did not build or im- Duct-Under Ground Building Approved By Date
LI i, for
to
Cho purpose of sale). e,,.._
Ias owner of the property,am exclusively contracting with licensed con- Duct-Structural Refrigeration System Application Issued By Dat
,
tractors to construct the project (Section 7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who Duct-Ventilating 00-100,000 BTU 0100,000 BTU SUMMARY OF FEES
builds or Improves thereon,and who contracts for such projects with a con-
tractor(s) license pursuant to the Contractor's License Law). I am aware that Exhaust System 0 Multiple 0 System Repair/Alteration BUI LDING PERMIT $ SMIP $
proof of their Worker's Compensation Insurance should be provided to me. CHECK $ -_ ^ MIT
PLA (�( PER
C I am exempt under Section B.& P.C.for this reason Firepl/Fact.Bit. ICBG# Fire Dampers PLAN MBING $ J ISSUANCE S
Date Owner Heating System & Ducting Registers PLAN CHECK 25% 5 ENERGY P.C. $
I hereby certify that I have read this application and state that the above 00-100,000 BTU 0100,000 BTL ELECTRICAL $ GRADING $
Information Is correct. I agree to comply with all city and county ordinances -
and state laws relating to building construction, and hereby authorize repre-
sentatives of this city to enter upon the above-mentioned proper or
inspection purpos
7Date Reinspection Fee $15 Issue Fee $ 3 PLAN CHECK 25% $ •
CMF 0865.46,rev. 10/84 White - Building: Canary - Applicant; Pink - Accounting; Goldenrod - Assessor
CONSTRUCTION ANDPLANNING POOL& SPA
APPROVALS Permit# Date Inspector APPROVALS Permit Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. ! 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms •.t•
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Press rre Test
6. Electrical UFER Gr,iid-: 57. APPROVAL TO COVERI-OtJNITE
7. Footings '• - 58. Electrical Conduit-Undrgmd.
8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines,P-Trap, Cl: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 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 0 Gas 0 Oil
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:
34. Final Heating & Air Conditioning
35. Final Gas Pipe-Test
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing 2/ff(/ Z �
39. Water Service-Final 7
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
H . . LAWMASTER & CO. , . NC .
7940 MAIN STREET — STANiON, CALIFORNIA 64CMS-028AZN-002
828-8040
XXXXX
Field Data on Test Specimens Core _Concrete_ ._—_Gunite—__Grout1Moi tar
Pr°lett _.`Dr4_5hedrickj oarr _ — Perna No._23318
Project
Location 1.05J__ElbtiaKcla, _ o§Sa_Mesa,_Calif-.__
Contractor Architect
Anthony Pools
Location in StructureBond beam Engineer T. I. Larson
Date Moulded 1/14/65 No of Specimens 3
Slump / Specimens Marked 1 2 3
Specified Strength at 28 days 2000 P.S.I. Mix Designation 1 - 4 1/2
Age to be tested days days days_ _days
READY MIX PLANT Job Mix AGGREGATE SOURCEGeo Binns Corona
Weather Condition Warm I Yd. 1 akyd. Batch
Cement Monolith Type II Cement, lbs. 150 sks
Admix None Sand 40 ton
Specimens made by Mel Norton #4
Data by Charles Camp #3
Delivered by #2
Date Delivered #
REMARKS: Water, Gals.
4t Le,
FOR LABORATORY USE ONLY _�
Lab. No. 5418 _54-1.9_._ 5420_ - 1 _ - _ _
7 Day Test 28 Day Test - Day Test I Day Test
Date of Test 1/21 2/11 w _�
Specimen Dimensions 5.57 X 12 _5.12.5 X 11 a5 ---46. _�ear a
1 1`� i
Area 24.35 20...63 - - __ I �etyFtc
Ultimate Load - 62,500 51,000 _ Bfy�n� CeP[esa it;
/ `v\
Lbs. per sq. in. 2,568 t 2,761 _ _ I- 41- _
H/D Corrected _
(11400J en 'IA Tc'—is-
CITY OF COSTA MESA
CALIFORNIA P.O. BOX 1200
FROM THE OFFICE OF TEE PLANNING DEPARTMENT
Dr. Shedrick Moore September 24, 1965
1853 Elba Circle
Costa Mesa, California
Dear Pool Owner:
The Costa Mesa Planning Department has been notified of the completion
of your swimming pool.
So that your pool will be a safe one and for the purpose of advising
you of your responsibility regarding the requirements of the Costa Mesa
Municipal Code, we quote Section 9298.9:
1. No swimming pool shall be constructed closer than five (5)
feet to any property lines, measured from water line of pool.
2. No swimming pool shall be constructed under any electric power
lines or on any electric power easement.
3. No swimming pool shall be constructed unless the yard
surrounding such pool is completely enclosed by a fence
six (6) feet in height and have a self-closing and
locking type gate or gates.
This courtesy letter is directed to you so that you will be aware of
our ordinances and can make a complete safety check of your pool area.
Sincerely yours, (1
William L. Dunn
Director of Planning
I 8253 •,v,/.F•,PnCOSTR.T,n- ,,,, ,:n,na
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 917 COSTA MESA. CALIFORNIA
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING •
D
ADESS / 15-3 /,...:tier.-1(72,17- --4---1(72,17- --4---1/�Ai
COSTA MESA. CALIFORNIA For Office Use Only
A�.,,� `}�yJ //L) RECEIPT NO. PEI�py}���,1/�15�3
OWNER ////U I-574e2?'T `-� n I I 1 VLL7
MAIL / ///N t E, L/F' RecEly 1" BY I 71727121:„2„,...., MVE'LB 3 1962
ADDRESS NS.3 / O B l
CITY /./ 5 7?' ///t3,9 NOL. //n� pcY ADILDING
DRESS
LFT / / ,+5�((� /N ADDRESS
ORARCHITE EEER� Cc, IS�CTr/!/ /0�//WL�"336/ COSTA MESA. CALIFORNIA
ADDHeSS/T7f el 77-1-09 /Y/Jm FIRE /�
/ ZONE TYPE Y GROUy •
CONTRACTOR S r//L/. 6-7115% /(..c i APPROVED DATE
ADDRESS /'� 3 �/Noz'e,J /✓? ZONING 2 ./')
//,/� //y/J
1 I NO.OF 2.../.... I USE OF N ,ji1 GV n ,
CITY ( '1'�i{� /i' ,IG
3 c _ PLANSBUILDING V J p-1
STATE n� 07 NO. //G /S DESCRIPTION -�j o /,J
LIC.NO. OJ 40T WV /C g3�/
SIZE x NO. OF SLOGS......-----
NOW
OF LOT /�i� I NOW ON LOT A.P.NO.
^
USE OF YARDS EVES
EXISTING BLDGC APPROVED ALLOWED
SETBACK LINE FROM 3, / / (CENTER LINE ST.)
CENTER OF STREET c5 ,J REAR YARD od9 FRONT '3 nFT. IN.
SIDE YARD I LEFT q I RIGHT 7 R.SIDE 9 FT. IN.
DESCRIPTION OF WORK (y
II R L.SIDE U FT. IN. (/
NEV I,k II ALTERATION I (III ADDITION I REAR l!J FT. 1 QIN. 1 ,�
REPAIR I II MOVING I II DEMOLISH 'I/ APPRO •VED I�/ � DATE I"'/7.�
BUILDING �J G� RNO. OF OOMS 7 STORIES I4 L //�� 1111!!!! 4/) iT
SIZE7
EXTERIOR WAL ROOF _
COVERING L�jY l" COVERING f/A
USE OF BUILDING AND WORK TO BE PERFORMED
LOW Sc- . ✓/r M./W 62 / Ce /1
lel I-1 �..1c -.23 93 15-6,..._ 5/7 a .
I HEREBY AC NOW LEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN VALUATION IS FOR THE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CON. PURPOSE OP ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING
BUILDING CONSSTRUSON. VALUATION '�j
SIGNATURE Or ,y^ �� `�J- PERMIT FEE $ �/J
PERMITTEE. ---=„1 PAc1 a.�ct..-GA-CGGK -�'/ti�LL.L!/. �j h N
AUTHORIZED AGENT ,/`.CcC.Ii� /� , S /33�DJ PLAN CHECK $ &/01.D).5./
Q,�.� `r
TOTAL FEE jQ
2
FEE RECEIVED
r ' - • ?3313 DEC 14 1964
•cosTA-MESA BUILDING-SAFETY DEPARTMENT FINANCE DEPT.
P.O.BOX BIT COSTA MESA,CALIFORNIA
CITY OF COSTA MESA
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT • BUILDING
For Office Use Only
BUILDING
ADDRESS 1853 ELBA CIR R[C[IPT NO, PERMIT NO. a '
COSTA MESA. CALIFORNIA ,-,, 33 e
gq��
OWNER
DR SHEDRICK MOORS RED[Y .Y /, RE/[7�b Dj ey c. ,/
BUILDING
MAIL BUILDIADDRESS 1853 ELBA CIRCLE
ADDRESS 1853 ELBA CI•R
COSTA MESA 541- 6056 FIRE
CITY ZONE E GROUP
APPROVED /'//�/. /
ARCHITECT TEL. BY /� DATE Y 7}/ K
OR ENGINEER T T,AR SnN NO. A!.'/,I1 ✓+Y\/
5871 FIRESTONE ZONING
AL .55 ZO [ I NO.OF ( USE OF NEW f K
CONTRACTOR ANTHONY POOLS ( -I PLANSLOL BUILDING
4 4341
5871 FIRESTONE BLVD. AL
DESCRIPTION
ADDRESS
SO GATE A.P.NO. 13 ej ( / /
CITY
/ `" Ai"- /
STATE 190179 TEL. NONOTE: SOIDE EAVE REAR POVERHANG SHALL BE LESS THAN
L/C.NO. l L�.
EAVES
SIZE 3j' )/ X J 1 ,QL� j. '1}��r({�TLO(lti� NO.OP BLOCS. ALLOWED (U.B.C.REQUIREMENT)
OF LOT USE OF I) 1 .114 1, RE S AND rat
ON LOT YARDS APPROVED YARDS APPROVED
EXISTING BLDG. MAIN BUILDING ACCESSORY BUILDING
(FROM C/L STREET)
SETBACK
CENTER FINE STREETI FROM
1717 E REAR YAR 26191 FRONT Fr. f / FT./l• ,
1
SIDE YARD LEFT RIGHT R.BIDE PT. r G FT.
DESCRIPTION OF WORK L.SIDE FT. 17 FT.
NE" _x__ ALTERATION ADDITION REAR FT. 9 FT.
DISTANCE BET. BET.MAIN @
REP..aH MOVING DEMOLISH MAIN BLOGS. ACCESS.BLDGS.
BUILDING NO.OF VAR.# DATE
SIZE 480 ROOMS STORIES C.U.P.# APPROVED
EXTERIOR WALLROOF APPROVED / /
COVERING Ici
,./{' `
COVERING • BY ,JTE >-� L
USE OF BUILDING AND WORK TO BE PERFORMED HOL FOR SPED EQUIREMENTS
SWIM POOL PRIVATE
C.C. ( Jg 4 4.l. j (T-I9
CO
U
BQ.FT. F
O
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THX F
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. G
PLY WITH ALL CITY O ANCES AND STATE ULATING / VALUATION
BUILDING CONBTR ION
PERMIT FEE $ /I CI -'--. H0
SIGNATURE
isr,
PERMITTEE «IiJg.I _ O
S PLAN CHECK $ �P o
/ AUTHORIZED ADEN //
2400.00 TOTAL PEE $ / P —
2Tg73 CITY OF COSTA MESA
•.COSTA MESA BUILDING-SAFETY DEPARTMENT APR 27 1965
P.O.BOX 317 COSTA MESA,CALIFORNIA
Otti
For Applicant to Fill In Completely @A3PP@!C• I U:� OR P MIT •
TYPE OR PRINT riot
- IL"I
BUILDING 1853 a CSA Cilei« For Office Use Only
ADDRESS RECEIPT NO. PRRO.
cCOST/A/ MESA./� CALIFORNIA D;J .”.013
OWNER S (/'''/4 . M 43 a/�I\a p R)[eq)y9D By OwT7REcrVEDic- </f as
25894 JUL 11-66 00 45503*****5.00
••'COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 - COSTA MESA, CALIFORNIA 92626
For Applicant to Fill In Completely APPLICATION FOR PERMIT
I TYPE OR PRINT BUILDING
BUILDING For Office Use Only
ADDRESS ( B STS te.j3A C(RCCE-
RtenrrNo. � I�-�
COSTA MESA. CALIFORNIA /{ 2JUL76.1'
OWNER RIC[IytD iY TpA1B R65!_t0'. /DATE//-D
Sdi,
V MAIL /Q BUILDING
ADDRESS 1 "}'y�I 3 �L64 CIe CLQ ADDRESS
CITY C o 5771 71 4 N0.5gc-667 FIRE ///TYPE GROUP • /
ARCHITECT TEL . APPROVED %� g (J 1>
'NGINEER NO. BY / DATE r
ZONING 1(L7
ADDRESS
ZONE-. f11 1 I NO.OF BUOF NEW
/� K PLAID • BUILDING
• CONTRACTOR 0 L kis - 6u I 1---PT
LEGAL P • 3`j I
ADDRESS DESCRIPTION
CITY A.P.NO. l 3 7 - I Z/- 1l
NOTE: NO[AVE OVERHANG SHALL BE LESS THAN
STATE TEL. : SO•TO SIDE&REAR P.L.
LIC.NO. NQ.
'. Sl" VES
I LOT to//g Xv� I NO.OF SLOGS. / ALLOWED (U.B.C.REQUIREMENT)
NOW ON LOT YARDS APPROVED YARDS APPROVED
USE OF /la/14 . MAIN BUILDING ACCESSORY BUILDING
EXISTING BLDG.
SETBACK LINE FROM
-, CENTER OF=MAT REAR YA[_LD �/ rat"• PT.
I
SIDE YARD I LEFT I RIGHT • R.HIDE FT. FT.
'`' DESCRIPTION OF WORK L.SIDE J W/121*. PT.
i`,
✓ REAR PT. PT.
TERATI•N ADDITI•N
it
■ •�■ MEW
Q
• REPAIR MO IN,
ACCESS.BLDGB.
DATE
BUILDING NO.OF
• SIZE ROOMS STORIES
APPROVED
s• OEIWALL IO `I• / '
—//--6.COVERING COVERING LDATE
USE OF BUILDING AND WORK r*pp BE PERFORMED / Po
pA�o Cov��e ( 7Wo 1�dcif
'd 07
70 Fe, S. ,Ai . r.,CA.O
SQ.PT.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IB FOR THE j
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CON. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING
VALUATION
BUILDING CONSTRUCT W
SIGNATURE OF O/ PERMIT FEE
PERMITTEE v11 w `fJ� Co
`' - AD
E _. W
AUTHORIZED AGENT /\
.. . ... ,,. w TOTAL FEE $ t.----
PAIL` ..t{.=5.^C
"5-7/ccsn002735 u*
32000
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Completely
RECEIVED QY DATE RECEIVED DATE ISSUED
BUILDING SBDDRESS/O EG BA C �CG� 0��
6p -�7S/--7U -1�31 Q= 7
'L �,s A.P. NO./3/J�!! If PY 8&Q
OWNER a Aft/ MOO/FS
MAIL �,,,r BUILDING / g!3 'Lein}_ /� r. a�
ADDRESS SAME ADDRESS �`1) „yf 6 l��
W W ,A ��.. ^�I TEL.b — p� A u
0-U CITY 0957 ,r/�Sr4 NO.6,6'71/ TRACT T✓ LOT/J BLOCK
ZZ
Q CONSTRUCTION NEW ADD ALTER REPAIR MOVING DEMOI ISH
ON LENDER ,SacLf _ /
a m C
J r BRANCH '
J N OWNER S . ,
Q ADDRESS
a VALUE
ARCHITECT TEL. USE $
J N OR ENGINEER -SGLr
NO. _
U FIRE
Z Q ZONEGROUP W 2 ADDRESS TYPE--r.
`
W Z /� � ��j BYPROVED �/I// DATE 26
J U CONTRACTOR QCAIAIGre /' \�_ / 6 7a
CC Z � A
W cc ADDRESS ZON NO.OF USE OF NEW/L6-y-„,,,jam ,
Z-. CITY NO.TE —/ PLANS B .14-D N �t _ /
Wt...
STATE CITY YARDS APPROVED YARDS APPROVED �',M•/
to K LIC.NO. LIC.NO. MAIN BUILDING ACCESSORY BUILDING
DU SIZE yy��yy��IIOF (FROM C/L STREET) //•''��-f��-�-f//��. �'�/'`a� (/ "��/f
OF LOT 3 ���/��� Q�' 1JOW ON LOTC FRONT FT. C ( w7c"j
USE OF 337/
EXISTING BLDG. R.SIOF FT. r9 / FT.
I— SIZE OF NO.OF
Z NEW BLDG. ROOMS STORIES L.SIDE FT. SFT.
VEXTERIOR WALL ROOF /
_ COVERING COVERING REAR �” / �3 FT.
USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
_MAIN BLDGS. ACCESS. BLDGS.
O �S'7f CED ZA-7774C-epof cn v7t CC.UU P.#p� �) APPROVED
F/'E/ b� 6 `2- S�7D
IA �rI L.�SC4G �OU C✓/'ut/'t_>'l�I'Ir� Ry [ E
0 A/PoVW) PDCL—
UI hereby acknowledge that I have read this application and state
D that the above information is correct and agree to comply with
CC all laws regulating building construction, and I shall not employ
I— any person in violation of the workman's compensation laws of
N the State of California. co
zI hereby certify that I am properly licensed as a contractor under SO. FT. O
the State of California Business and Professions Code. Division 3. THE AMOUNT SHOWN UNDER VALUATION IS FOR
Chapter 9, end 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 CC
VALUATION
and Professions Co., •' 'Bion 3.Chapter 9. / m
00 PERMIT FEE S C7 ' D O N
Signature of // _ co
Permittee �i $ 6 00 PLAN CHECK $ E
`o
Authorized Agent �yy u
TOTAL FEE $ r t/[/
• 4G266 -
6542 6/23/78 54e50 TU
• COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 �L
AIt A- ION FOR STRUCTURAL PERMIT
For Applicant to Fill in Completely —Use Ink Only YV711�
('� �/�)7, (/��� `,ss RE ED V DATE RECEIVED O,BTE jSSUBU �
ADDRESS
LDING OWNER
/ Vc.� —T'�•� �lJw
OS
MITN
/�ll� 1 tq tr Go '- A.P. N 3 _ PERMIT NO.
OWNER , _l I(y—��" l,lf �r BUILDING/� �
ADDRESS 0MAIL C0 ..�— `-�'(J3 s ADDRE S /J&S � CLQ able
CITY �2 ry TE�yC�µ_ r � /� NO.ITRACT`7t 3 /E LOT/NG BLOCK
CONSTRUCTIONN - G NEW ADD ALTER REPAIR MOVING DEMOLISH
LENDER -{� 1[
BRANCH �" y� r/1 rr (�
OWNER M 1tem1-tr VV•v
ADDRESS
ARCHITECT TEL. V$F � L VALU$ 56614 ,..,...-
ARCHITECT
OR ENGINEER NO. FIRE ,
$/{y/y. J(�
ZONE VPE' %GROUP
ADDRESS �j ( � /^/ ��j / ��(t��s/{�'
CONTRACTOR 1 " 2 `' 2 1J_S BVPROV ED DATE �J"L(/
ADDRESS 4/o s+ et c_/,,,,--0 . .5t. •
pq�µ�/E 1
CITY � ,/C/Y"e' NO.TE ��J�1 2K 1 PLAnta BUILDING f per ,, j�
F STATE {� �t .{�� CITY YARDS APPROVED APPROV ED
gLIC. NO. L/ O-2 �,) LIC.NO. G/SI MAIN BUILDING ClAC SORV BUILDING
W SIZE LLL NO.OF BLDGS r]� (FROM C/L -J ET)
Om OF LOT NOW ON LOT FRONT �� / / sFT.
Q USE OF ////
EXISTING BLDG. R SIDE (7 ire . i SL FT.
El)
I-.
Separate permits are required for L.SIDE S FT. FT.
C electric,plumbing and heating work. REAR ./ FT. 3 FT.
14 USE OF IWILDING ANA WORK TOffiE PERFMRMED • t DISTANCE BET. BET.MAIN&
, 0 ill-- o C (✓V /� C!/r.'�lop ?'1 ON MAIN BLOCS. ACCESS.BLDGS.
IN.a 4— 13 ATN /VIA 2 ' C.U.P.# APPROVEDV�
} ROVtC DATE`C/ /
Y /
wl
Ei
ta
0 I hereby acknowledge that I have read this application and state n
G4 that the above information is correct and agree to comply with m
A. all laws regulating building construction, and I shell not employ
i
Z any person in violation of the workman's compensation laws of _ m
W the State of California. . ///
I hereby certify that I am properly licensed as a contractor under V E SO. FT. of
the State of California Business and Professions Code, Division 3, T AMOUNT SHOWN UNDER VALUATION IS FOR m
Chapter 9, and that such licenses ere in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: e
am exempt from the provisions of the State of California Business 3�•= y
VALUATION PERMIT FEE $
and Professions Code,Division 3,Chapter 9. 0. v u+
m
PLAN CHECK $ 1e
Signature of �� /Art
2
Permit-tea Iee i i frr $ . j� SCJ u.
TAX $
_sai
Authorized AgentV
0 ., TOTAL PAID $ .5-0