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COSTA MESA BUILDING-SAFETY DEPARTMENT FINANCE DEPT.
P. O. BOX 917 COHTA MEBA. GLIFORNIA
CITY OF COSTA MESA
For Applieanf io Fill In Compleiely APPLICATION FOR PERMIT
MAIL
ADDRESS C
CI L�s
ARCHITECT
MESA. CALIFORNIA
TEL.
�-/ � NO.
TEL.
BUILDING
For Office Use Only
HECEIPT NO. P6PMIT NO.
RlC81VED By I DATFA=EC�`/ED� /�/�ATP� 199iED/
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BUILOING � I �I i� A 0-� S�{ /� �/ �
ADORE55 �"'� � JC
COSTA MESA, GALIFORNIA
PIRE � /\�y�
ZONE � TYPE GROUP, J(
APPROV � ^." �� /�� � f
ADDRE65l� �Z- � f�✓1?/ �:)L ✓/�. ZONING
CITY�-�C' S�� � C S". �7L/ ' O PLM1N9 �BUILDINOEW
STATE � / U !G / TEL. �• �_ �j � J� J �.ea�� /
LIC. NO. NO. OHBCHIPT�ON
SIZE , ( I NO. OP BLDOB.
OP LOT i% X J- • NOW on Lor A. P. NO. ��
EXI6TING BLDG (-��7'�'�L'� YARDS EVES
APPROVED ALLOWEO
68TBACN LlNB FRON / � � 10ENT6P L�N6 BT.1
CENTeR On BTrseHi REAR YARD J� FRONT �U FT G L
SI E YARD ILEFT IRIGHT R.SIDE FT.
DESCRIPTION OF WORK ,i ,� _ -
BUIL�ING % ?'!� /Jul
SIZE
z��XJI" ROOMS ~STOF
EXTERIOR WALLt IROOF �
COVERING ���� cC`� COVERING��� r,a
USE OF.@ UILDING ANP WORK TO BE PERFORMED
/Jv PLE �C
APPROVED
BY ��
/ �� �3'�O �
1 HERBBY ACNNOWLCO08 iMAT 1 HAVH RB�D TH19 APPlJGTION THg AMOUM BHOWN UNO6R VALUATION IB FOR THH
ANO BTATB THAT THH ABOVH 18 CORMCT AND AOREB TO COM-
PUPP08C OP 88TABLIBN�NG A PEHMIT FHE ONLY.
PLY WITH ALL CITY OlW�NANCHB AND 6ThT8 LAWB REOUTATINO
eU�LDiNo coNBTAUCTIION. � VALUATION
HIGNATURH OF'�' L�/���� ,� y��� �� ^ �./ '� PERMI7 FEE $ ��! '""- r
PERMITTE // /„( �Yn �i J � a
�� � {' �; •, % s f"� " PLAN CHECK $ � — .
AUTHORIZED AGBNT �/<< ���' �•`� a'< «� _
TOTAL FEE , l� �- � /
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COSTA MESA BUILDiNG-SAFETY DEPARTMENT
P.O. BOX 7200 COSTA MESA. CALIFORNIA 92626
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NAR 13-G9�Myr,�� 302 34•50
APPIICATiON FOR BUILDING PERMIT
For Applicant to Fil1 in Comple[ely
RECEIVEDBV DAT�%CEIVED pATgI55}1gDi
AD1DRE55 ZI��I ^ I�Q« y � /� ��
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OWNER I A.P. NO. "'D — �/ o`
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MAIL BVILDING �/�, / �.CG�✓ �
AODRE55 �QO G �t �+DDRESS �� i.(..P C.. �
CITV t. � ��q NOL GyZ'�(if] TRAC L�OT� �p� BLOCK
CqNSTRUCTION A
LENDER � �+-L
BRANCH
OWNER
ADDRESS
VALUE �
ARCHITECT TEL. S $
OR ENGINEER � N . _,
FIRE �j
A�ORE55 ZONE TVPE GROUP
APPROVED /I� p_I^J_/`
CONTRACTOR UGii:4.��" BV �.� DATE d 9 C7
ADDRESS �
TEL. ZON NO.OF USE OF NEW
CITV NO. P�� BUILDING �-
STATE CITV �'ARDSAPPROVED YAFOSAPPROVED
IIC. NO. LIC. NO. MAIN BUILDING ACCESSORV BVILDING
SIZE NO.OFBLDGS. (FFOMC/LSTREET) /�,, ��
OF LOT NOW ON LOT RONT FT. � � FT. �-'-�'/✓-'
USE OF
EXIS�ING BLDG. 5 E FT. FT. �/
512E OF � NO. OF
NEW BLDG. �� X iZ I ROOMS STOa1E5 L SIDE FT. FT.
EXTERIOR WALL ROOF
COVERING .Sfd4 COVERING u +- � REAR FT. FT.
USE OF BUILDING AND WORK TO BE PERFOflMED ' DISTANCE BET. eET. MAIN & �
MAIN BLDGS. ACCESS. BLDGS.' J
{7. �D6T . VAR. # DATE
ITi� � �A� .pvc� � y-. yQ C.U.P.3y. APPROVED
APP E _�`�
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I hereby acknowledge that I have reetl this application antl state
that the above intormation is correct antl agree to comply with � C/'T� _
oll Inws regulating builtlinB constructian, antl I shall not employ '� ••u�� �
any person in violetion of the wOrkman's compensation laws ot
the Sta�e ot Californie. '
I hareby certify t�at I am properly licensed ee a contracior untler SQ. FT.
the State Df California Business anC Professlons Cotla, Divislcn 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR
Chapter 9, antl that such licenses ara in full force antl eifact, or I THE PURP05E OF E5TABLISHING A PERMIT FEE ONLV:
om exampt from the Orovisions ot Ne Scexe o( Celtfornie eusiness VALUATION
antl PrOtesSions Cotle, Division 3, Chepter 9. �1�• illl
/ �-/ ^^ PEFMIT FEE $ Of /� C/
Pa�imittee�f �� ��` �""°-CL"�`���^- � ���'y I�— p�p,N CHECK $ �
��
Authorizetl Agent
TOTAL FEE $ �
� � • ~ 2983G
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COSTA MESA BUILDING-SAFETV DEPARTMENT
�� 3 P.O. BOX iZ00 COSTA MESA, CALIFORNIA 92626
� APPLICATION FOR BUILDING PERMIT
�0]r Fo/ Applicant to Fill in Completely
df� RECEI ED BV DATE RECEIVED D TE ISSUE
BUILDING ['/ I �_ //_ (�Q �..%.��
ADDRE55 � I Z �'I /-lCQ.. �
OWNER ��/¢' ; �l tr Uw A.P. NO. �l
MAIL � ADIDRIE S �
Z ADORESS 9a� �I'fl� t .r!
wa U 1 TEL.
CITY OS'/a /,L NO. R C
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a m LENDER
J � BRANCH
J N OWNER ,
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J Q ARCHITECT Q�� ,e � TEL. S
OR ENGINEER �`7
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JO CONTRACTOR WN��^ B�'
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KAR 73-69�FIS�OO 301 0*****5.0�
w w TEL. ZONE � NO.OF
z� CITV NO. ��
w � STATE CITV YARDS APPROVED
y� LIC. NO. LIC. NO. MAIN BUILDING
� � SIZE ( �/ � ND.OF BL > (FROM C/L STREE'
OFLOT �Q l� NOWONLO FROM � FT.
USE OF
EXISTING BIOG. G0.✓' S1 FT
� SIZE OF NO. OF
Z NEWBLDG. ROOMS STOFIES L.SIDE FT.
U EXTERIOR WA�L ROOF
COVERING �%'«o COVERING LG�^'✓� REAR FT.
J USE OF BVIIDING AND WORK TO BE PERFORMED DISTANCE BET.
a MAIN BLDGS.
a
Q VAR. aW
� o..,d..t�' �. Fos oc�,i�� �� z c.u.P.�w
F APPRO
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VI hereby ecknowletl0e t�at I hove reatl this apPlieation entl stata (S
� thot the nbova i�formation is correc[ entl apree [o comply wI[h
� ull laws reBulatinB builtlinB consttuction, antl I shell not employ �+{pLD POR
r eny person In vlolation o( the workman's compenmtian laws of
(q Me S[ate of Celi�ornia. [:C�C�v
zI hereby cartify Nat I am pro0a�ly licensetl as a contractor untler SQ. FT.
th¢ State of Califomia Bvstnasa antl Profeuions Cotla, Oivisicn 3, THE AMOUNT S.
Chepter 9, entl that such licenws era in full force ontl effoct, or 1 THE PURVOSE OF
am exampt irom the provlsiona of the State ot Califomla Busineas VALUATION
entl Profnssions Gatla, Divislon 3, Chaptar 9.
SIB�at�ra of o � �
Parmittee ��^�^ � . / ��` 5 �
Auihorizatl Agent
USE OF NI
BUILDING
VARDS
ACCESSC
'J
DATE
APPROVED
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VALUATION IS FOR �
A PERMIT FEE ONLY: m
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