HomeMy WebLinkAbout2770 DESOTO AVE - Building PermitsAOOPFSSO:BIIILdNc: 2'�'�O DESOTO AV
°""Ea�E"'Q'ox'":CLURE, RALPH E TR
, "D���2770 DESOTO AVE
COSTA MESA,CA
uv�. �uur+o �oonEss:
APCXRECTOR ENfdlFFF.
ARCII OX EfM.'S AOONE53:
UNT:
92626
uc xo.:
UNT:
c«+m�cTarsruxe:THREE D ROOFING ( 909 ) 598-1474
camncroasxuuxo19532 GREENWILLOW LANE
wonessROWLAND HTGS. CA uc.ao: 617467
917 4 8 uxT:
LICENSED COMXACTOHS OECLAXATION: I hereby dlim uMer penely d pa�ury ihet I am licenaed under prowiom M Cheqa 9
(mmmentl�p wnh SeUion ]000) oi Oiwun 3 d the Buaiiroea eed Pmfenaiona Code. end my lieems c in lull lorca erd eXatl.
uc.no.:055413 uc.cuss:C39 ��6�1�7 q�67 EXP: Q1/93
om i 1 ��1�(o co�v.a�.: -ut.'C.r.re
NEfl BUILOEF DECIAPATION: 1 Mreby etFrm uMx penely d perjury the� 1 am xemq tmm Ihe Controtlae limnse law la ihe
dbxiq �aavon (5adion )tt11.5 Buaiiasa eM Prdmeiom Cade: Am� c�Y a�MY �� n0uiies e pemiil lo marNx.i. elier. imprws.
�emd'e�, ar repei e�ry m�ucture, pia to ib'vweMe, eho reQuime �M apDlimnt (a wch pmmn io fib e u0� ��� � M or eM
IioeneeE punueni to ihe provisions d Ihe Comreaon Limnse Lnw [Cheqer 9(mmmenwp xilh Sadun )000) d D'v"sbn 3 d tM
dueimea and Prdessbru Coae� or �het he a eha ie examq thxeirwn end the beaw Iw ihe ellepeA eKempion. My videtion o/5edian
]031.5 by eny epplirsnl lor a permX wEjede Ihe epplicenl to a mil penelry d �wl more Ihen Me hurMred ddlen �550U]).
� I, ai ovmar ot IM propeny or my empbyeee wnh wepea m Ihek wle mmpevelion. will Eo �ha wwk, erd iM rouc�ure u nd iMeMed
w oMerad lor eele (Seclion ]OCd, Butinasa end Peo/aeeions Code: The Comrenon liroroe lnwtloee ml epplyto en ownxd proparry
who WtlEe a inpmvea tMreon. end who doas euM woek IimmX ar hanatl w throuph ha a Mr own ampbyeea. povidaC thel wah
improvemenU ara rat imeMeE a dlered lor eele. M, however, the buiNifq « inprwemaru ie eotl v.ilhin an yeer d mmplelian, IM
ow�rrbuiNer wiil M1ave IM burdan W o�'��9 he or aM Ek rrot WiW a impove ta IM puryme d eeb�.
� I. ea owrcr d tM G�W�Y. em ecdu+iveM coMredYq wuh liureed canvectae to m�mua Ma V�M� (Sefion 1060. Bueinna vM
Prdseuwu Code: The GonUeqon lirome Lew doea m� ePGN �o en ox.ier d pW�Y who Wilde ar'vnVp+es ihaean end who
eonVeeb M mch praqds xith a mMeetlor(s) Icen�eA punueM to iM CaM�etlaa Lieenae lewl.
❑ I un ssemp uMm SxYim: B. d P.C.. M Nia reawn:
Dete: Owmr:
I do Mnby cenM � 1 em awere d eM uManteM IM requiromenta d Calfanu Heellh vM SdNy Coda Saebna 25505.255�3. eM
255J0, eM thet I a e�ry Mun hiki�q oaupenl will / wil nm (arcb ma) need �o cwnpy wYh eeiE etate aodee eM �M reWiremema b
apemiillammvunionormodifwe�ionhomthaRi u3eT1.%nepemamOmrid.RmideMielrnw�ueuneppYulbruenezemqhamthesa
Dre: Avvik��
WOXKER'S COMPENSATION DECIAPATION: I Mreby elR�m under penelty d perjury wr d ihe Idbxi'p Eetluetom:
� I haw uM Mil meinten e ceMkete d wneenl to eett�inaum br xwkere' compenealian, n provided tor by Setlim 3100 d Ihe Lebor
Code. ln the peNarmemn W Ihe wwk In wkch t�ie permn u ivued.
� � ners.�d :e maim.m won(en• comoeme�o� imurenm. e, �.c�� M sea:n a�oo w me leno. coe.. ror me ro�am� w m.
wM lar whidi Mb permu'v muW. My wakera' canperue�ion imurvice farrier eM poW.y numbx va:
c.�: STATF FC7Nil EXPIRES
vwryr+�m�: i��a�si—aF 09/01/97
�rnn .aabn ,�e nor ne mmcbree � rne w�F � ro. � n�,�d,ad ed� rs�ool w�.�
� I cMN ihet in Ne peilwmence d IM wak lor whk� ihie permn iv bsueE. I Mall iwl employ ury psaon in enY mwrer ao v to
become eubjed to the woMan' cwnpenuliw� 4x+ N Cditwnu.eyd� eprea that R I ehouM Exoms aEpU to iM xwYen'
//�� compe /�'/�una d Sed'an 3]OU W Ihe Lebor COEe.�/o1Nhv11� py ' Ihove piwiaiau.
� I ���� ib AOdeeM: `,/
Wem/np: Fellun ro ixuro worten' comperwtlon eavereps /s unbwlul, ertd aMll �uD�sef en �mployx to eNMnsl pmaltls1 e�b
elWl flias up ro wro hundrotl fMuunJ tlollan (Sf00,000A /n eJJltlon ro Ms cwf ol romperusflort d�p� ++PANtleC br In
9xUon 91�6 0l Ms Lebor Cotle, /nM1rul, entl �ttomsya I�u.
CONSTflUCiION LENDINO AGENCY: I MreW �im uMer perully d q�ury ihe� Ihan o e can&�uUion bnNnp eqezy M tlro
parlormenoe d tM xak br wTitli Ihe pamiY e bwed (Seaon 309], CH. C�.
LENDEH'S NAYE
LENOEP'S ADDNE53:
1 ce�M IMI I liew meC No epWication eM qete ihet IM ebove intwme�ion o canad. I eYne to mnPN xilh ell dly eM aounb ad'muaae
yd BIPo! 19w! 1OI91vp lo buildvq <OIIS�futlion BM hIXBby 9UIMfRG IlpMM�91NB3 d Ih6 CIy�00N> upOn IM GbbA�TBMi011BE p10pXt/
tairopaeion Wrpoees.
_ noniPLn PEDo•ro
i-S�S�
(5151�46.WP) Whne-BuildiqdSelery:Oree�rFb:CviW-APV��t:Pink-Revenue:0okeniaFMamsa
CITY OF COSTA MESA — BUILDING PERMIT
PERM NO: B 080298
PERMIT NU: B 080298 1 PLAN CHECK NO: N GOVT: N SUPP; N
CONSTRUCTION TYPE: C'—N PERMIT TYPE: STR PURPOSE; OTH
JOB DESCRIPTION : T/OFF RESTH 6 REROOF W/EAGLITE S.SPSF SQ FT; 9,800
CLAIM VALUE: 9,800.00 CALC—VALUE: 9,fS00.00 GROUP OCC: R-3 /
COMMENTS: SMOKE DETECTOR REQUIRED PRIOR TO FINAL � c �. o��4 � o
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Z O N I N G R E Q U I R E M E N T S
S E T H A C K S
------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING ---------
FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
LEFT: FT IN RGAT: FT IN LEFT: FT IN RGHT; FT IN
PARKING REQ: PROV: PARCEL: 14164101 ZNE: REF NO:
PLANNING NOTES>
_>
'lE �(' iE 1E 1f 1F 1E iE jE ff fE ik iE 1F 9E If if If 1ElElE iE'lF 1E �E �E ik'IE iE IE 1E jE i(� iE 1E iE ih iE 1E 1f 1E 3E 9E �E iE iE ik iE iE fE iE 1E 1E iE iE fE iE 1E'lE if')E 3E'k iE 1E iE if itlf # iE iE 1E if �lE �f !E jE fE
D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N'T S
i �
ZONING APPRC�VED BY . DATE:
BUILDING APPROVED BY : DATE:
APPLICATIdN ISSUED BY:
��,�.�,���*����*��**�,�,�.,�������������-������'����������������,�.°��*�� I � * 6�
LEGALIZATION:N F E E S U M M A R Y STRUCTURAL S GMENT:Y
BLDG PMT PLUMBING ELECTIiIC MECHANIC FIRE SMIP/RES GRAUING
PERMIT 162,25 .98
" SMIP/NON—RES
PLAN ',
ISSUE FEE
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
TOTALS----> 163.23 0.00 0.00 163.23 163.23 .00
REVENUE DIVISION TOTALS--> COLLECTED: 163.23 OVER/SHORT: 00
BLDG PMT PLUMHING ELECTRIC MECHANIC FIRE 5MIP/TOT GRADING PLAN—CHECK
162.25 . .98
1E 1F 1E iE 1E 1E 1f jE 3F if iF iE iE if 1E if if iE iE iE �E iE jE iE iE IE iE iE iE iE if 3E iE iE if ik 1E iF iE 1E if iElE if If 1E if iE iE iF 1f if if iE if !f iF iE 1f if 1E 1ElE iE iE 1E fE iE 1F iE iE iE 1E jF if 1ElE 1f �E
I N D I C� I D U A L ; F E E B R E A K D O W N
TYPE QTY D E S C R I P T I O N. UNIT COST TOTAL COST
SFR 9800 REROOF HY VALUE AESIDENTIAL NOZONE 1,00 9,800.00
END OF FEES
�1 00218547—�0113548 T C�T 163.23
DATE: 11/OS/95 TIhE: 09:50
�'CONSTRUCTION ANDPIANNING � POG SPA . l
�
' APNROVALS Permit# -` � Date Inspeetor APPROVAIS" Permit# Oate inspecror�
i. Temporary Electrical Service or Paie 52. Pooi & Equipment Location � (
2. Soil Pipe�Undrgrnd. �. 53. Steel Reinforcement . � _
3. Electrical Conduit Utility�Undrgmd. 54. Forms '
A. Electrica� Conduit�Undrgrnd. � 55. Elettricai Banding I
5. Steel R¢infprcement 56. Rough Plumbing & Pressure T2st i
6. ElectricatUFERGmd. 57. APPROVALTOCOVER�GUNtTE
7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gai Pipe, O U�drgrnd., Test i
9. Water Pipe�U�drgrnd. � ' 60. Backwash �ines, P�Trap, C7 Undrgrnd. `-
10. Structural Fioor SYstem . 67. APPROVAL TO DECK; � i
71. PropertV Sewer �ine & House Connection 62. Backwash & Receptor�Pir7al I
12. Sewer Cap . 63. Heater & Vent-Final �
i 3. Roof Drains 64. Plumbing SYstem - Final
14. Rough Plumbing 65. Electrical�Final
i
15. Rough Electricai�Conduit 66. Solar SYrtem�Pinal �
16. Rough Electric Wiring . � 67. Fencing & Access Approval �
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
78. Rough E�ectrical-T Bar Ceiling � 69. POOI/SPA SYSTEP,9S FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT .- i
20, Rough Factory Fireplace APPROVALS Permit # �
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Venti�ating 71. Product Piping � Gas � Oil
23. Gas PipC-Rou9h & Test 72. Undergrou�d F(ush
24. Roof Framing 73. Undergrnd. Storage Tank O Gas ❑ Oil
25. Roof Sheathing / J'J �6 74. Overhead HVdro �
26. T�Bar Ceiling (Struct�raU & Monocoat 75. Dry Chemical I
27. Frame and Fiaehing 76. Dry Standpipe
28. Lathing & Sidin4 77. FIXED SYSTEM FINAL
29. Insulation 78, FIRE PREV. FINAL
30. Drywall Nailino HEALTH DEPT. REQUIREMENT
31. Plaster Browr Coat 79. FINAL INSPECTION
32. Electrical Power Nleter�Finai 80. FOOD CERTIFICATE ISSUEp
33. Final Electric Notes: �
34. Final Heating & Rir Conditioning �/���
35. Final Gas PiPe-Test (
36. Hood ot Canopy
37. Final Factory Pireplace
38. Final Piumbing
39. Water Service-Final
40. Gas Service-F(nal-��
41. Solar pomes2icFinal
42. BackfloW PrevenEer
43. Backflow IrrigatioP
44. �andscaPe Irriga2�on Sysrem .
45. Sound Attenuatihn
1
46. HandicaP Regulations
47. FINAL STRUCTIDAE & BUILDING ��.r6
48. FINALp�RNNING - ----
49. Electric Release to Edison �`
50. Gas Release to Southern California Gas Co '"
57. CERTIFICATE OF OCCUPANCY
N0. Date
May 6, 1969
M�: Ralph Clure �
2770 De Soto Avenue '
Costa Mesa, California -
Deas Mr. Clure: ,
The private swimming pool constructed by Anthoe�y Pools
on your property, receiveii fina inspection and approval this
date.
In order that your pool will be a�safe one and for the
purpose of advising yo of your reaponsibility regexding the
�requirements of the Cos Mesa Municipal Code, we refer you
to Section 8107, a copy o which is attached.
This letter is directed to you so that you will be aware
of our ordinanc d can make a complete safety check of your
pool area.
. Youra very truly,
RICHARD HANHART
Director of Building Safety
RIi : dh
� H. , LAWMASTER 8 CO., NC.
7940 MAIN STREET — STANTON, CALIFORNIA
828-8040
68CM5-186AA)-002
XXX
Field Data on Tesi Specimens Core_— Concrete._ Gunite Grout/Mortar___—�
Project Ralph Clure Pool i Permit No.���/�
Project Z770 DeSoto Fve., Coeto Mesa, Calif,
Location
Contracror Architect
_ Antho� Pools _ _ __
Location in $trudure Floer., wall, bond beam Engineer
Date Moulded 10/29/68 No of Specimens fi
Slump 4„ _ Specimens Marked __ _ _ _ _ ____
SpecTied Strength at 23 _days 2000 P,5.1. Mix Designation
Age to be tesi�d__Z__days 28 days days__days
READY MIX P�,qNT Conrock Graham AGGREGA7E SOURCE
Weather Condi}ipn 1 Yd. _—_Yd. Batch
Cement Monolith Type I Cement, Ibs.
Admix None Sand
Specimens made by �. �. �prague T4
Data by
Delivered by
Date Delivered
REMARKS:.Q�`�����,/—'/— /1/�
�- .�- �
Lab. No.
Date of Test
Specimen Dim�nsions
Area
Ultimate Load
Lbs. per sq, in.
H/D Corrected
6775
7 Day
11/4
6.�sx�z
32.07
� Water, Gals.
�`�L�,uV���
BUI DIIVG SAfETY DEPT.�
� OV G 1968 �
–sea' -- — - t�i�
`�,8i9�t��tl�t?�I�2�3,4�5t�
�
FOR IABORATORY USE ONLY
6776 6777 6778 G779 6780
Test 7 Day Test_ _ 7_ Day Test __
11/4 11/A
6.21X12.375---- 6X1Z.125 _.
30.29 _ 28.37 __
I41_,000 __ 97,500
_ 2,619-� 3,004_ _ _ 3,084_ __
7 day test ave
RCE�62�7
�,902
�MLF:lL.—o.,.--� �T C'v-1.�.._._.
_Day Test _ _
further test s
quired ,
� , :', ! 8� i 0�
� COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 917 COBTA M��1. CAL�FORPI�A
For Applicanf fo Fill In Complefely
COSTA MESA CALIFORNIA
E
1 STATE
NO. OP
6ETBACK LINE FPOM
GEMER OF BTREET �� REAR YARI
SIDE YARD I LEFT ].�L � ( RIGHT %�
DESCRIPTION OF WORK
�a�
NO. OF
��?�� ROOMS � STORIES
ic�co I ROOFW�OCI shake &
J ' COVEFi� G
JD WORK TO BE PERFORMED
:,nR_�-f'Pileosr� N
r,-�. a6s� *�**99:b0
APPLICATION FOR PERMIT
BUILDING
For Offiee Use Only
rsece�rr rvo. � {�
oare iesueo
COSTA MESA. CALIFORNIA
FIRE
ZONING
NO. OF /� U8E OP N
P1J�NH / _ HUIIDIN6
LEOAL
YARDS ♦
APPROVED
icenren uxa e'r.� �
I
1 X¢REBY AGKNOWLmGH TXAT � MAVE PBAD TH�9 APPLIGTION
ANO 9TATE THAT THE A60VH IB COHRECT AND AGR¢C TO COM-
PLY WITH ALL CITY OPWNANCEB AN� 9TATE LAWB i[C6ULATIN6
Bl111O1N6 CONBTRURION.
81GNATU'RE OF ]�ZeSa Del Mdl+ DeV810pMBI7t CO
1 AU'7HORIZED
-S`-c
TXE AMOUNT eHOWN UNDEP VALUATION 18 FOR THH
PURPOBE OF, E9TABLIBHING A PERMIT FEE ONLv. y
VALUATION /�'- '
PERMfT FEE $ U'
�j N
� 20,288�0� PLAN CHEGK $ � J� o
f
9— p
TOTAL FEE �
LL
�urvntK CLURE� RA
�106 ADDRESS 2770
'�GENERAL CONTRACTOf
�j/ S. � 4� - 1a� _m
J In_. ECTIONS
`�� SOIL
`Gn5
WATER
ROUGH PLUM6�NG
PROP. SWR. LINE � HOUSE �
SPRINKLING S�STEM
MISCELLANEtlUS
HOUGM HEATING AND AIR CON
TEMPOHARV 5ERVICE OR POL
UN�ERGROUNO ❑ POWER
ROUGH WIRING
TRENLHES FORMS �
FLOOR SYSTEM � � �
BOND BEAM STEEL RE
SHEATNING
FRAME AND FLASHING
LGTHINf. — IN I—I OIIT r
5 TURAL, F
REFRIG. AND A.C.. F
DATt
l7
IL'L•C�1l�:�:�yl:7�i�7J�S�L
SUBCONTRACTOR
r ::
riaa�lia�a
� JOB ADDFiESS
'� GENERAL COi
J P— Yo. l 41 —)
1. ECTIONS
SaIl
:yGas
ur......
BUILDING
01�' WORK
)UP J TYPE
SUBCONTItACTOR
�
, ._ . -: �
� ''275.49
� COSTA MESA BUILDING-SAFETY DEPARTMEM
P.O. BOX 1200 � GOSTA MESA� CALIFORNIA Y2t26
For AppllcanP ro Fill In Complefaly
TYPE OR PRINT _
BUII.DINO • ��.f� �
AODHE98 V
COSTA MESA, CALIFORNIA
[fWNAR . � . \ _ l. U F�
Pnrn ,� „ :.,.
SEP 12-67ci,,;,,00 277 � : ::.: ..:.6 'C
APPLICATION FOR PERMR
BUILDINfi
For Offlco Use Only
APPROV[D /
ARCHITECT TEL BY DATE � �
OR ENGINEHR CR_ NO. -
ZONINCi
ADDRE88
ZO NO.OI OitOIN[M�Ju��
�LAN� � lUILDINO(;�
CONTRACT U �� 0'
'''7 ��� �a.� go�
AD RHW � / �� �. D[uullnoN
CITV ��/ A. P. NO. I� CY I�— �/
$TATe � G` I_ q( _ N L � .� 80T TO SI [ S RBAR PHiNO SHALL BH LB88 THAN
LIC. NO. 0 U W �O
6R8 ��{ � NO.O��LDos. �LAWBD N.B.C..RBQUIRHMHNT)
OFLOT xC �3 � NOW H
USEOP I YARD6APPROVHD YARDSMPROVED
EXISTIN6 BLDO. MAIN BUILUIN6 ACCE630RY BUILo1No
/ <FROMGLYTRQ 1 ,
Y6TOACN L�X[ FROY Fp�� p��
cenrsn or crnirr R�AR YA D
SIDB YARD L,IiFf RIQfIT R. i1Dt 'F' FT.
DESCRIPTION OF WORK �. sic rr. �{ rr.
�j UHB OF
1 HEREBY ACKNOWL6D06
AND BTATB TXAT TNB A!
PLY WITH ALL CITY
BUILDINO CONSTR pry
SIGNATURE OP
PERMITT6
AUTHORIZHD AGiNT�
�IBTANC6![T. BET. MAIN Q
BM � MAIN BLD ACCESII. BL�
� �' VAR.�i DATB
K7M8 ' RI C.U.P. APPROVHD
R�vw�wa eY/ RP% 6� (V = o�t[ '7' -(
'r /f�/'yJ ' LL
{V
�
�
BQ. PT. �'
0
TH8 AMOUNT 9XOWN UNDBP V�LUATON 16 FOH TMB j
1YPP098 OP [lTI�BLIBHINO A PERMIT FEe ONLY. 23
VALUATION OO �
PERMIT FEE E
s � �� 6---- -- w
TOTAIFEE S � �D�
OWNER �
JOB ADDRE
G�NERAL (
�� 141
INSPECTIO�
soi�
GAS
W ATER
ROUGN PLUM9
PROP. SWR. L
SPRINKLING 5
MISCELLANEO
AND AIR CONOITIONING
UNDERGROUNO U POWER U
ROUGH WIRING
TRENCXES . FORMS STEEL REINF.
FLOOR SVSTEM
SHEATMING
FqAME AND FLPSHING
LATXING - IN ❑
P' 'ER, BROWN COA
V
BUILDING. FINPL �/�!/�'] �/��/.
DATE
11- 22-67
PERMIT N0.
FIRE ZONE VALUE b 1
SUBCONTRACTOR
6
N +V�
:
COSTA MESA BU0. DEPARTMENT
P.O. BOX 1200 � COSTA MESA� GALIFORNIA 92020
For Appllcant ro Fl11 In Complately
TYPE OR PRINT
wooRess O c�s�
COSTA MESp, CALIFORNIA
CITY �-�`� i
ARCHITECT
AD RQII[ �L `� Q � ._/ �
c�n Y h —
BTATQ TiL �1/ ' '�
LIC. NO. N . �4� b
OF LOT ` , � t f ,Q �( 5 � oI or o�oo�.
nOw oN
USH OP ��
E%18T3N0 BLDO. 'I'� �-' C- `� \ �"1 Q
cnewcK uHe rnor
ceNTeR UI iTR6R ' RBAR YARO
SIDB YARDI L[RT I RIOHT
DESCRIPTION OF WORK
i. -
ll � , �
ir
e - �. G,
� N8HC9Y ACKMOWL6DOi '�AT �
•ND 9TI1T6 TX �V6 1�
PLY WITN ALL TY OR MG�Q
BYILOINO CONBT 10 f
SIGNATURE OP
PERMI778
AUTHORIZQD AG[NT C
�
PIRH
�-� ,a '�3 �t*�S:OC
APPLICATION FOR PERMR
BUILDINf3
For Offlm Use Only
R6Ci1R NO. YI
IONIN(i
NO.
�. No. �--1-�-ri —V �
f6: NOBAVCOV[pHANOGMALLBBLE86THAN
' TO HID6 S RBAR P. L
�EB
_OWHD .(U.B.G.REOUIRBMENTI
YAHOOMPROVHD YARDSAPPROVHD
MAIN BUILDIN6 ACGHIIHORY BUILOINO
!OM GL DTR6I(Tl
)NT R�.
IIDt Fi. �
— • — 1 ii
DIDTANC[!Cf
MAIN BLDqi.
VM.IF
BBT. MAIN Q
ACCE88. BLt
DATE
•L'
TXIB APPLIGTIOH T116 AMOYNT lHOWH UNOBR VALUATION le POp TNR j
D AOP![ TO COM. �YXPOlB OP QBTABL�8HIN0 A PBNMIT P88 ONLY, y
U1WY P[OULATXO yAWAT10N r �
' PERMITFEE J � -
I � �
s � � w . ----� w°
I
TOTALFEE
� : � - 2�a4 �
COSTA MESA BUILDING-SAFEfY DEPARTMENT
V.O. BOX 7200 COSTA MESA, GALIFORNIA 92l26
For Appllcanf to Fill In Completaly
TYPE OR PRINT
B°"°�"� �77G i�� S oTo �
ADDRESD
COSTA ME3A, CALIFORNIA
[fWNPR 9?�L P/�f � L U RE'
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