HomeMy WebLinkAbout2910 ELLESMERE AVE - Building PermitsTN MpS
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i � CITY OF COSTA MESA � .' �
! � � BlIILDING DIVISION
77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
FOR INSPECTIONS CALL: (714) 754-5626
PERMITTYPE ELEC
APN: 13927215
JOB ADDRESS: 2910 ELLESMERE AV CM
Vicinity: BACK YARD
.
'I: `' '.. 1''::;._
PERMIT NUMBER: E09-00066
STATUS: ISSUED �
DATE ISSUED: 03I0912009 � �
ISSUED BY: KJB
Suite/Unit:
SCOPE OF WORK: GAS PIPING FOR A FIRE PIT AND BB� (2 OUTLETS), 1 TRANSFORMER FOR LIGHTING. (110). GAS PIPING SIZE WILL
BE FIELD VERIFIED. , �
OWNER: PERREAULT, CRAIG AND HEIDI A,
PHONE:
APPLICANT: JOHN LORD
PHONE: 949-235-1655
CONTRACTOR: JOHNLORD �
Address: 33552 PALO ALTO STUnit: '"
Ciry/State: DANA POINT, CA ZipCode: 92629
ELECTRICAL PERMIT FEES
Electrical Plan Check Fee: $0.00
Electrical Permit Fee: $41.70
Reinspection Fee $0.00
TOTAL FEES $41.70
�Address: 2910 ELLESMERE'AVE Unit
�City/State/Zip: COSTA MESA, CA
Address: 33552 PALO ALTO ST Unit:
City/State/zZip: DANA POIN7, CA
License No. 776370
PHONE: 949•235-1655
CELL:
�:"'t:.Q��Q�e'`.
' �5 6'IpIN��I SIZE �/JiLL
!ti1P.:)'i
NOTICE: The work authorized by lhis permit shall comply with all applicable handicap access requirements under Califomia 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 wdes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration,of.this�perm�t.,
, :. �.i, .;�,.... ,
GODEN. INSPECTIONTYPE . ATE INi111RL5 COOE1 INSPEG110NTYPE ORTE IN71PAL5
1616 Fized System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing / ( ^_
�1 77-TJZ
200 Final Re-Roof 210 Final Electncal y� '! l�x,� n/C-
201 Final Block/Retaining Wall 272 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 FinalSign 222 FinalSite ' ����;,i��.%:
204 Final Demolition 250 Final Building/Occupancy
WORKERS' C041PEN�TION DECLARATIO•
I hereby aHirm under penalry of perjury one of the following declarations:
❑ I have antl will maintain a certifcale o! consent to self-Insure for workers'
compensation, as providetl (or by section 3700 of Ihe Labor Code, for Ihe
pertormance of Ihe work for which this permit is issued.
❑ I have antl will maintain workers' compensation insurance, as required by
seclion 3700 of Ihe Labor Code, (or the pertormance of the vrork (or which this
pertnit is issued. My workers' compensation Insurance carrier and policy
numher are:
Carrier.
(This SecAon neetl irof be cromdeteE dthe pnmR is valuetl a! we hundred �Ilars (5100J w IessJ
Policy Number:
i
❑�certify Ihat in the peAormance of the work for which this permit is
issued, I shall not employ any person in any manner so as lo become subject
[o the vrorkers' compensalion laws of Califomia, and agree Iha[ if I should
become sub�¢ t to the vrorkers'FFF���iii���pensation provisions o Section 3700 of
ihe Labor de, I s� forthwith bordply with these pro�ion .
�� � J
CAppli rKS ignaWre Da�e
G-'
W NI : FAILURE ECURE WORKERS' COMPENSATION COVER4GE
IS UNLAWFUL AND ALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions o( Chapter 9(commencing
with Seclion 7000) of Division 3 0( the Business and Professions Code, antl
my license is in fu/ll force and ef(ecl. ^7
�Lic. �' D � Class# � � � /
Camr or's SignaWre Ozle .
�
C� NS RUCTION lEN G AGENCY:
❑ hereby aKrm that there is a construction lending agency for the
perfortnance of the v.ork fw which this pertnit is issued. (Sec. 3097, Civil Code)-
Lentler's Name:
Lentler's Address:
Signalure
OWNER-BUILDER DECLARATIONS:
I hereby aKrm lha[ under penalty of Oerjury Ihat I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for ihe following reason (Sec. 7031.5,
Business and Pro/essions Code: Any city or counry which requires a permit to
constmct, afler, impmve, demolish, or repair any slructure, prior to its
issuance, also requires the applicant for such permit to fle a signed statement
that he or she is licensed pursuant to Ihe provisions of ihe Coniractors
License Law (Chapter 9(commencing with Section 7000) of Division 3 of [he
Business and Pro(essions Code) or that he or she is exempt lheretrom and
the basis !or Ihe allegetl exemption. Any violalion o( Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
fve hundred tlollars ($500).):
❑ I, as owner of the property, or my employees with wages as their sole
compensation, WILL DO 7HE WORK, and the structure is not intended or
oftered for sale (Sec. 7044, Business and Professions Code: The Contracmrs
License Law does not apply [o an owner o( property who builds or improves
thereon, and who does such vrork himself or herself or through his or her own
employees, provided that such improvemeMs are not intended or offered for
sale. If, however, the building or impmvement is sold within one year of
completioq the ovmer-builder will have the burden of proving that he or she
did not build or improve for purpose of sale.).
❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WI7H
LICENSED CONTRACTORS lo conslruct !he projecl (Sec. 7044, Business and
Professions Code: The cont2ctors License Law dces not apply to an ovmer of
pmperty who builds or improves Ihereon, and who conlracts for such prqect with
a contrada(s) license pursuant to Ihe Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for this reason:
SignaWre Date
305]-0fi (3/0]�
Owner ID verified by tlriv�ense. ❑ Ves \❑ No
♦
Driver's License No. ' Expires:
Verifcation of Ownership by (rype of document, i.e. - pmperty tax bill or deed):
DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION:
❑ I hereby ceAAy thai no excavation frve (5) or more fee[ in depth into which a
person is required [o descend, will be made in connection wi�h work authonzed
by this permil, antl that no building structure, scaf(dding, falseuwrk, or tlemolition
or dismantling thereot, will be more than Nirty-six (36) feet high. (Chap. 32, Grp
2, Ar[ 2, Sec. 341, Title 8, Calitomia Adminislrative Code).
❑ As ovmer-builder, I will not employ anyone lo do work which vrould
require a permit from the Division of Intlus�rial Safery, as notetl above, unless
such person has a permil to tlo such vrork from the division.
Applicanfs SignaNre
Division of Industrial Sa(ety Permit Number: _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
t. Will the applicant or present or fuWre building occupant need to fle antl
certity a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of the California Health antl Safety Code requires, with some
exceptions, that a Business Plan be fled with the Costa Mesa Fire
Department by every business which has al any one time during a reported
year a quantiry of hazardous materials equal to or grea[er than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas
at standard temperaNre and pressure).
2. Does or will the applicant or present or future building occupant need to file
a registration form (or acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some
excep[ions, requires registralion with the Cosla Mesa Fire Department by
each business which at any one time has on hand a quantiry of acutely
hazartlous matenals equal to or grealer than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
�emperature and pressure�.
3. Does or will the applicant or preseM or fuNre building occupant need to
prepare an RMPP (Risk Management and Prevention Program (or acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of the Califomia Health and Satery Code provitles [hat the
Costa Mesa Fire Department may require the preparation, certifcation and
filing wi�h the Fire Departmen� 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 Califomia
Heal[h antl Safery Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or fuNre building occupant require for
the vrork which is the subject of this application a permi[ for such construc[ion
or modifcation from the South Coast Air Quality Management District or from
any other air pollution conirol district or agency? ❑ Ves ❑ No
(Section 658502 of the Califomia Govemment Code requires that the requested
intortnation be furnishetl on applications for non-residential builtling pertnits).
6. Will any part of Ihe faciliry to be constructed under Ihis permit be wiNin
1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
Qf "yes", the facilily must meet the requirement of Sections 25534 and 42303
of the California Health and Sa(ety Code).
7. If a permi[ fmm [he South Coast Air Qualily Managemen[ District or other
air pollution control district or agency is required tor the work which is the
subject of this application, have ail of the disclosures prescribed by California
Health and Safery Code Section 42303 been made? ❑ Yes ❑ No
8. (If'yes", attach certifcate of compliance from the appropriate air polWtion
control officer�.
CERTIFlCATE OF COMPLIANCE: I certify that under penalry of perjury the
information given above is correcL I agree to comply with all state lavrs and
city ordinances regarding Hazartlous Materials and Emissions.
SignaWre Da�e
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certi(y under penalry ot perjury that I have read this application and sta[e that
the infortnation given is correct I agree to comply with all state laws and ciry
ordinances relating to building construction, and authorize representatives of
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 thi .permit until fnal /in�spection.
Wre oi L vmer�sy D te 1�
L �
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( AnOlorqu�no e Ap011can1 + �Dale-"
CITY OF COSTA MESA
� pMsq B!/ILDING DIVISION
i . . � 7� FAIR DRIVE, COSTA MESA, CA 92626 • Q14) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
:
�. � FOR INSPECTIONS CALL: (714) 754-5626
°a'o,a,wone�''
PERMIT NUMBER: P09-00037
PERMIT TYPE PLUM STATUS: ISSUED
APN: 13927215 DATE ISSUED: 03I09/2009
ISSUED BY: KJB
JOB ADDRESS: 2910 ELLESMERE AV CM Suite/Unit:
Vicinity: . - .
SCOPE OF WORK: GAS PIPING FOR A FIRE PIT, TRANSFORMER FOR LIGHTING.
OWNER: PERREAULT, CRAIG AND HEIDI A, � Address:
PHONE: CitylState/Zip:
APPLICANT: JOHN LORD ' Address:
PHONE: 949-235-'1655 � . � City/State/zZip:
CONTRACTOR: JOHN LORD
Address: 33552 PALO ALTO ST
City/State: DANA POINT, CA ZipCode: 92629� � � - .
ARCHITECT: � License No. �
ENGINEER: License No.
2910 ELLESMERE AVE -.
COSTA MESA, CA �
33552 PALO ALTO ST :
DANA POINT, CA
License�No. 776370 '� �`?�-t�0i}37
PHONE: 949-235-1655
CELL:
PLUMBING PERMIT FEE SUMMARY
PLAN CHECK FEE:
PERMIT FEE:
TOTAL FEES:
$0.00
$35.80
$35.80
PHONE:
PHONE: �'
_ .5 •tr.Btl�.i i
NOTICE: The work authorized by this permit Shali comply with all applicable handicap access requirements under California statutes and related
regula[ions. (Ord. No. 92-28, § 1, 1241-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorizetl under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. FaiWre to obtain inspections and final approval will result in the expiration of this permit.
WUE�. INSPEC110NTYPP DATE INTITIALS COUEI'� INSPECTIONTYPE OATE IN1111AL5
1616 Fixed System Final Fi�e Prevention 206 Final Mechanical ��
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Finai Electrical
207 Final Block/Retaining Wall 212 Finat Fire Prevention
202 Final Factory Kire Place 220 Final Planning Appmval
203� Final Sign 222 Final Site �� : i"', ��
204 Final Demolitipn 250 Final Building/Occupancy
WORKERS' COMPENSATION DECLARATION:
I hereby aRirm under penalty of perjury one of �he (ollowing declara�ions:
❑ I have and will maintain a certifcate o( consent to sel6lnsure !or workers'
compensation, as provided for by section 3700 of the Labor Code, for the
pedormance of the work for which this permit is issued.
❑ I �ave and will mainlain workers' compensation insurance, as required by
section 3700 of the Labor Code, for [he perfohnance of the work (or which this
pertnit is issued. My vrorkers' compensation Insurance carner and policy
number are:
Carrier
(T�is sec(ion need no( Oe wmple(e0 A lhe peimrt is va�uetl a( one hvntl�etl tlollars ($ I00J o� less.)
Policy Number:
0�-I,tertify Ihat in �he performance o( ihe work for which lhis permit is
`issued, I shall not employ any person in any manner so as to become subject
to Ihe workers' compensation laws of Califpmia, and aqree lhat i( I should
become sub' c to Ihe ers' c ensati0n provisions of Section 3700 0(
ihe abor C , I shall fo wilh ly with these pro� io s� �
�W�ro fsS nalure� �Date. —_
WA NI : FAILURE T ECURE WORKERS' COMPENSATION COVERAGE
IS U WFUL AND 5 ALL SU&IECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE L480R CODE, INTEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm Ihat I am licensed under provisions of Chapter 9(commencing
with Section 7000) of Division 3 of the Business and Professions Code, antl
my license is inIfull force and eHecl. -7
CLicr#-� �D 7a 'Class# � G � � /
�r � ..
Co n¢ rs SgnaWre _ , Date -
� _ _ — .
C RUCTION L lDING AGENCY:
❑ I hereby aKrm Nat there is a construction lending agency for Ihe
peAortnance of the v.ork fa wfiich lhis permit is issued. (Sec. 3097. Civil Code).
Lender's Name:
Lender's Address:
OWNER-BUILDER DECLARATIONS:
I hereby aKrm that under Denalry of perjury that I am ExEMPT FROM 7HE
CONTRACTORS LICENSE LAW for the following reason (Sec. 703L5,
Business antl Professions Cotle: Any ci�y or Counry which requires a permit to
construct, alter, improve, demolish, or repair any strucWre, prior lo ils
issuance, also requires Ihe applicant for such permit to Ne a signed statement
that he or s�e is licensed pursuant to N� provisions of the Contractors
License Law (Chapter 9(commencing wi�h Section 7000) of Division 3 of [he
Business and Professions Code) or that he or she is exempt lhere(rom and
Ihe basis for the alleged ezemption. Any vi0lation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
fve hundred dollars (5500).�:
❑ I, as owner of the propeny, or my employees vrith vrages as their sole
compensalion, WILL DO THE WORK, and the structure is nol intendetl or
oflered (or sale (Sec. 7044, Business and PrOfessions Code: The Conlractors
License Law does not apply lo an owner of property who builds or improves
thereon, antl who does such wrork himself or herself or through his or her ovm
employees, provided that such improvements are not intended or offered for
sale. If, hovrever, the 6uilding or improvement is sold within one year of
completion, the owner-builder vnll have Ihe burden of proving that he or she
did not build or improve for purpose of sale.).
❑ I, as owner of Ihe property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS ro construct the project (Sec. 7044, Business and
Professbns Code: The cont2ctors License Law dces not apply to an ovmer of
propeny who builds or improves thereon, antl who contracts for such project with
a contracta(s) license pursuant to the Contractors License Laws.�.
❑ I am exempl under sec.
Business and Professions Code for this reasOn:
SignaWre Dale
�(151<61]N]�
Owner ID verified by driver s license. ❑ Yes ❑ No
Driver's License No. Expires:
Verifcation of Ownership by (rype of document, i.e. - property lax bill or deetl):
DIVISION OF INDUSTRIAL SAFEN PERMIT CERTIFICATION:
❑ I hereby ceAify that no excavation (rve (5) or more feet in depth into which a
person is required to descend, will be made in connection vnth wvrk authorized
by this permi�, and that no huilding strucWre, sca((dding, falsework, or demolition
or dismantling thereof, will be more than thirty-siz (36) feet high. (Chap. 32, Grp
2, Art 2, Sea 341, Ttle 8, California Administra�ive Code).
❑ As ovmer-builder, I will not employ anyone to do work which would
require a permit from the Division of Industrial Sa(ety, as noted above, unless
such person has a permit to tlo such vrork from Ihe division.
Applicanfs Signamre
Division o( Intlustrial Safe�y Permit Number _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will Ihe applicant or present or (uture building occupant need to file and
certify a Business Plan for emergency response to release or threatened
release of a hazardous matedal? ❑ Yes ❑ No
(Section 25505 of the Cali(omia Heallh ana Safery Code requires, with some
exceptions, that a Business Plan be fled with the Costa Mesa Fire
Department by every business which has at any one time during a reported
year a quantiry o/ hazardous materials equal to or grea[e� than a weight of
500 pounds, or a volume o( 55 gallons, or 200 cubic feet of compressed gas
at standard lemperature and pressure).
2. Does or will the applicant or present or fuNre building occupant need to fle
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the Calitomia Health and Safery Code, with some
exceptions, requires registration with Ihe Costa Mesa Fire Department by
each business which a[ any one time has on hand a quantity of acutely
hazardous materials equal to or greater than a weigh[ of 500 pounds, or a
volume of 55 gallons, or 200 cubic �eet of compressed gas at stantlard
IemperaNre and pressure).
3. Does or will the applicant or present or fuWre building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acu�ely
hazardous matenals)? ❑ Yes ❑ No
(Section 25534 of the Cali(ornia Health and Sa(ety Cotle pmvides Ihat the
Costa Mesa Fire Department may require me preparation, certification and
fling with Ihe Fire Department o( 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 Califomia
Health and Safery Code been fully complied with? ❑ Yes ❑ No
5. Does or will �he applicant or present or future building occupanl require for
Ne work whiCh is lhe subjeCl of lhis applicalion a permil for such constmction
or mOdification trom the South Coast Air Quality Management Distnct or from
any other air polWtion control district or agency? ❑ Yes ❑ No
(Sectqn 658502 of the Califomia Govemment Cotle requires that the requestetl
infortnation be fumished on applications ta nornresidential builtling pertnits).
6. Will any part of Ihe laciliry lo be constructed under Ihis pertnit be within
1000 feet /rom lhe outer boundaries of a school? � Yes ❑ No
Qf'yes", ihe facilily must meet the requirement of Sections 25534 and 42303
of the Califomia Health antl Safery Cotle).
7. If a permil from the Sou[h Coast Air Quality Management District or other
air polWtion contml district or agency is requiretl for the wvrk which is Ihe
subject of this application, have all ot the disclosures prescnbed by Califomia
Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
8. (If yes", attach certificate ot wmpliance from the appropriate air polWtion
control officer).
CERTIFICATE OF COMPIIANCE: I certify tha[ 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.
$iqnalure Daie
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalty oi perjury that I have read this application and state that
the information given is correcl I agree to comply with all state laws and ciry
ordinances relating to building construction, and authorize representatives of
the Ciry of Costa Mesa to enter upon the above-Uescribed pmperty for
inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permit until final inspection.
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PLANNING DIV
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NOTE: ADDITIONS, D
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PERMIT TYPE
CITY OF COSTA MESA �
B!/ILDING DIVISION
77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.wsta-mesa.ca.us
FOR INSPECTIONS CALL: (714) 754-5626
PERMIT NUMBER: E07-00905
ELEC
STATUS: ISSUED
DATE ISSUED: 11/15I2007
ISSUED BY: RMD
JOB ADDRESS: 2910 ELLESMERE AV CM Suite/Unit:
Vicinity: SIDE YARD � � ,
SCOPE OF WORK: UPGRADE SERVICE PANEL.T0,200A AND RELOCATE TO SIDE YARD FOR SFD, .
OWNER: PERREAULT, CRAIG AND HEIDI A, �Address: 2910 EILESMERE AVE Unit:
PHONE: . . City/State/Zip: COSTA MESA-, CA
APPLICANT: DAVID LYONS . - . .. � - � Address: -. 10192 EATHEL Unit: �
PHONE: 714-816-1763 ,- � ' City/State/zZip: �CYPRESS, CA
CONTRACTOR: DAVID LYONS . License No. 850866
Address: 10192 EATHELUnit PHONE: 714-816-1763 � --
City/State: CYPRESS, CA � ZipCode: 90630 - � � � . � � .CELL: ' � .
ELECTRICAL PERMIT FEES
Electrical Plan Check Fee: $0.00
Electrical Permit Fee: $54.00
Reinspection Fee _. $0.00
TOTAL FEES $54.00 _
•
I
♦
��
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related
re9ulations. (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 fnal approval will resWt in the expiration of this permit.
L OE/. INSPECTONTYPE ORTE INTI11A15 COOEp INSPEC110NTYPE �pTE INTI11pL
1616 Pixed System Final Fire Prevention 206 Pinal Mechanical
7266 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 BuiidingiOccupancy
WORKERS' COMPENSATION DECLARATION:
I hereby affirm unCer penalty of perjury one of the following tleclarations:
❑ I have and will maintain a certificate of consent to self-Insure for vrorkers'
compensation, as provide0 for by section 3700 0( the Labor Code, (or the
peRormance of Ihe vrork for which this permit is issued.
❑ I have and will main[ain workers' compensation insurance, as required by
sectbn 3700 of the Labor Code, for Ihe pedormance of the work for which [his
pertnit is issued. My vrorkers' compensa�ion Insurance carrier and policy
�pnu�,mqb,,e�r are:
I� (1'M1�issec(.onneetlirotbemmdetetlr/Ihepermdisvaluetlatonehuntlretl�llarz(Ef00)wlessJ
Policy Number:
C❑ I-certi/y that in lhe peAormance of lhe work (or which this permit is
issued, I shall not employ any person in any manner so as to become subject
Owner I� verified by driver's h.. .,.. ❑ Yes ❑ No
Dnver s License No. Expires:
Verifcation o( Ownership 6y pype of tlocumenl, i.e. - property tax bill or tleetl):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICA710N:
❑ I hereby certify that no excavation fve (5) or more (eet in depth in[o which a
person is required to descend, vrill be made in wnnection with work authonzed
by �his pertnit, and ihat no building slrucWre, scaffdding, falsework, a demolition
or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 32, Grp
2, Art 2, Sea 341, Ttle 8, Califomia Administ2tive Code).
❑ As owner-builder, I will not employ anyone ro do work which would
require a permit fmm Ihe Division of Industrial Safety, as noted above, unless
such person has a permi[ to do such work (rom ihe division.
to the workers' compensation laws of Califomia, and agree that if 1 should
becom subject b[h workflrs' compensation provisions of Sec[ion 3700 of qppii�nrs s9nawre
the Lab r Code, I sh fo 44ith compl with these provisions.
� // _ 9�_� � Division of Induslrial Safety Permit Numbec
Ap��nPs aWre� —Da� �
WARNMG FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE
IS UNIAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAI.
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
AnORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aKrm Iha[ 1 am licensetl untler provisions of Chapter 9(commencing
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future builtling occupant need to fle and
cerli(y a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of the California Health and Satey Code requires, vnth some
exceptions, [hat a Business Plan be fled with Ihe Costa Mesa Fire
Department by every business which has at any one time dunng a reported
year a quantity of hazardous matenals equal to or greater than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic (eet of compressed gas
at standard temperature and pressure�.
with Section 7000) o� Division 3 of the Business antl Pmfessions Code, and p. Does or will Ihe applicant or present or tuture building occupant need to fle
my license(��is -in full force and eRect. /� a registration torm for awtely hazardous materials? ❑ Yes ❑ No
�cr#- O �G q �Class # l.�—�a (Section 25533 of the Califomia Health and Safe�y Code, with some
- f �_//_l�_a��exceplions, requires regislration with the Costa Mesa Fire Department by
each business which al any one time has on hand a quantity of awtey
�Comraaor' - Wre -' - Dale hazardous matenals equal ro or greater [han a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet o( compressed gas at stantlard
CONSTRUCTION LENDING AGENCY: [emperaWre and pressure).
❑ I hereby aKrm that ihere is a construction lending agency for the 3. Does or will the applicant or present or future builtling occupant need to
peAormance of Ihe v.ork for which this pertnit is issued. (Sec. 3097, Gvil Code). p�epare an RMPP (Risk Managemen[ and Prevention Program for acutely
Lender's Name: hazardous materials�? ❑ Yes ❑ No
(Seclion 25534 0! Ihe Cali(omia Health an0 Safe[y Code provitles Iha� [he
Lender's Address: Costa Mesa Fire Department may require Ihe preparation, certification and
filing with the Fire Department of an RMPP by businesses which are requiretl
_ _ [o register acutely hazardous materials with the Fire Department.
OWNER•BUILDER DECLARATIONS:
I hereby affirm thal under penalty of peryury lhat 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
constmct, alter, improve, demolish, oi repair�any:stmClure, pnor to its
issuance, also requires Ihe applicant foi such-permit to fle a signed statement
that he or she is licensed pursuant to the.proJisions oYthe Contrecrors
License Law (Chapter 9(commencing with Section 7000) of Divi5ion 3 of the
Business and Professions Code) or tha[ he or she is ezempE IHerefrom and
lhe basis for the alleged exemptioa Any violation of Section�7031.5 by any
applicant tor a permit subjects the applicaN to a civil penalty of not more than
five hundretl dollars (5500).):
❑ 1, 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
oNered (or sale (Sec. 7044, Business and Professions Code: The Contractors
License Law tloes not apply to an owner of property who builtls or improves
thereon, and who does such work himself or herselt 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 vrill have the burden of proving that he or she
did not 6uild or improve for purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to consWct Ihe pmject (Sec. 7044, Business and
Professions Code: The cont2ctors License Law does not apply lo an ovmer of
property who builds or improves Ihereon, and who contracts for such projecl wiih
a contracta(s) license pursuant to the Contractors License Laws.).
❑ 1 am exempt under sec.
Business and Professions Code for this reason:
5ignature ' oaie
305]-46�3I0])
4. I( an RMPP is presently required, has Section 25534 of the California
Health and Safery Code been Wlly complied with? ❑ Yes ❑ No
5. Does or will Ihe applicant or present or fuNre building occupant require for
the work which is the subject of t�is application a permit for such construction
or modification from the South Coast Air Quality Management District or from
any other air pollution control distnct or agency? ❑ Yes ❑ No
(Secl'an 65850.2 of lhe Califomia Govemment Code requires that the requested
infortnation be fumishetl on applications fa non-resitlential builtling pertnits).
6. Will any part of the facility to be cons[ruc[ed under Ihis permit be within
1000 feet from the outer houndaries o! a school? ❑ Yes ❑ No
Qf 'yes", the facility must meet the requirement of Sections 25534 and 42303
of the California Health and Safety Code).
7. If a permit fmm the South Coast Air Quality Management OiSUict or olher
air pollution conhol district or agency is requiretl for the vrork which is the
subject of [his application, have all of the disclosures prescribed by California
Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
8. Qf'yes", attach certifcate of compliance trom the appropriate air pollution
control oKcer).
CERTIFICATE OF COMPLIANCE: I certify Ihat under penalty of perjury the
information given above is correct. I agree to compty with all state laws antl
ciry ordinances regartling Hazardous Materials and Emissions.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalry of perjury Ihal I have reatl this application and state that
the information given is correct. I agree to comply with all state laws and ciry
ordinances relating [o building cons[ruction, and authorize representatives of
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 huilding
authorized by this pe it unC fnal inspection.
Sgr�lu o Owner(s) Date
/ / — /� 0�0�
CM/e[Auth tlAp0licant —Dale
C
' 1��':'9
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 317 COSTA MESA. CALIFORNIA
FOR APPUCANT TO f/LL /N COMPLETECY
TYPE OR PRINT
BUILDING 2910 Ellesmere Avenue
ADDRE55
COSTA MESA, CALIFORNIA
owNERKenprof Development Co..Inc
Newport Beach TN0.6—
K,W, Koll
1 �E«e,e_,�.. I:�T 59
1-1R ZH3
�EE RFCEIUED
L'�v� a-.y-���
FINAIVCE DEPT.
CIIY OF COSTA MESA
APPLICATION FOR PERMIT
BUILDING
FOR Off/CE USf ONLY
I PECEIPT NO. 1IP RMIT
RECEIVEO §Y I UAT�=C�^EO -I F�R �
WT `i]
BUILDING
nooreess
COSTA MESA, CALIFORNIA
FIRE
ZONE TYPE GROUP \ Ii
ZONING
IT��^^ ZONE /� / IP AN6 �LYBUeILOI
� � ,.,
SIZE 75$ZOO I NO.OF BLDGe. 0 ypRDS
OF LOT rvow oN LOT REOUIRED
USE OF None ICENTEH LINE ST.1
EXISTING BLDG.
6ET9RCK LINE FROM
CENTER OF STFEET SO � REAR YARD 2
SIDE VAR❑ I LEFT lO � I RIGHT �
DESCRIPTION OF WORK �
NEW I A II ALTERATION I II ADDITION
REPAIR I IIMOVING I IIDEMOLISH
5 ZI�LOING 18�0 b`f ROOMS O 1� STORIE',
EXTERIOR WA�UCCO IftOOF Di�iII
COVERING COVERING
USE OF BUI�DING I�ND WORK TO BE PERFORMED
a a i�
1 HENEBY ACKN GE THAT I HRVE READ TNIS APPLICATION
AND STATE T THE BOVE IS CONFECT RN� AGREE TO COM-
pLY WITH TL CITY O DINANCES A D STATE L S REGULATING
BUILOING C STNU N. �
SIGNATURE F
PERMITTEE
AUTHORIZED AGENT
J FT.
J � FT.
THE AMOUNT SHOWN UNOER VALUATION IB FOR TNE
PURP09E OF EBTABLI6HING A PERMIT FEE ONLY,
VALUATION ��
PERMIT FEE $
S�Q/ 'y�S � PLAN CHECK S �y
TOTAL FEE $ 'S_�%�—
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X
�oon�ssaeuiwNo: 2g10 ELLESMEAE AV
avr+EaewuEiF�wm:SHERRARD ROBERT J
��S%2910 ELL�SMERE AVE
COSTA MESA,CA 92626
�VPL.Y.UIPq 1DDPES9:
/iHCNRECT OR fNtlNFFA:
IICN.ONFHO.'S ADDPES9:
uc wo.:
UNT:
UNT:
cartn�crarsru�eYELLEN ROOFING ( 714 ) 771-0963
LOHIN�CfOR4 MYlMO 61 12 K Z S ER D R
�oox�saH.B. CA uaw.: 684268
92647 uHt:
LICEN4ED COMFRCTOFS �ECUPATION: I Mreby eflim uMm pem�y d pmjury �hal I am Icemed uMar qoviebne d C er e
Icomm«,diro .;m sxua, �aool a olmon a a �na aninw w Raa.'vn cma. ew mr �+e o in �w �ac. v�d snea.
cmuc.No.: uc.cuss:C-39 � .:684268 ES
Deb: ��ma:
OWNEP BUILD R DECLA �RTION: 1 heMy eKum ivMa paWy d perjury RW I am vrnp han t reaon l'xaros lew la Na
Idbvnq rseaon (Seaian )W t.5 Bueima eM Prdaevwu Code: MY uY a odvaY r,tuN n0�rm a V�I lo mrmbuc�. Ma. impove.
'anoleh. a ropv ury avumae. prin b n cwence, ebo repima tM epWimtl la ach psm! lo Ne a apned nmxront tlui M a�M
IiwnfGd WA�� lo IM pONSiMf d Ne CONtBtlIXf IKMf! LGw'C�NpIM 9(MIIIIiM9�� WG�1$ldiJn iW0) d �Iveqn'J d Ihe
.d,�,,, ,�d a,dw�o�n coael � �,m ne «.ne a..,mw �n,.d.a�,� .m me mm e,. u� •o.a.a ss.�,qo�. rn.em� a s«,�
)03t.5 Ey em/ epplimN 1« e pamu abpQf Ihe eppfratl lo e tlN peroEy d nol mae tMn �ive hunEreE Ea�en �5500�.
❑ i.mo.o«amswwe�v«�n�ww.«..n.,,o.+..in:.d.00mw�+..aeoma�kd,em..u���e:oawsm,d
«on«ee �u.de (s«mn �au. a�nea end rrdeaenmcoee: ine cavreaaa liceme Lew aoea nm wWr�o � o.n,e.a aovam
who ddM a inpa'm tnereon. and Ma doea aud� r.ak f'anrtl a MnN u Wa� h"a a her own emWq*ee, pwideU �1W wch
imprwemem� are nd imeMed or d1aeE In ede. tl, lwwwm, ilw Witlieq u inpv.emem n eok wnAin me yeer d mmolMon, iha
ownm-0uitla vn0 heve iM EUNen d Y�q he a Me EN nal ddid a'unpwe la Ihe Wmoae d vebl.
� I. ee oxner d IM poperry. em extliavNy conirmip xiih 4mroad canveciars io ronmuf the pqetl (Seaion ]w�. Bualreee vM
Prdenione COCe: Tha Cavreeaa lkense lew don mi epply w en a�mer d popany r.fio Wbe a imrywm tlwreon vd x/w
conlrxb la urh pqeaa wilh e caureaa�e) IkenaeE punuent lo Iln CaN�erlaa Licenee lewl.
� I em e�emp uMer Saciion: B. 8 P.C., b Nu iwmn:
Deie: ��:
I do Mmb �M�M thet 1 em ewve d utl ind�eewd tM �puinmwro d Callam� ibetlM1 eM SelotY Cod� Seaiwe 25505. ?55]�. enE
255�1. end UW I a enY Mw WtldinO omqe�a. wip / W ria (mcb one) neeE m mnWN rN oiE tlete ao0a� eM iM nGu'v«mm� M
e V�e laodu��uniana modSmionhanNSAr�'empe��iwv Oiuekf. Raddavel oorm�uaion WO�iaroars ewnq ham IMaa
wwida+•.
ome: Mq�'sru:
W ONKEN'S COMPENSATION DECL�R�TION: I MrMy elf wtlr peml�y d prjury me d tlro IaOowi�q Aetlereibm:
� I Mw vM wJ meiruen e mMiute d muent io �W imun br rMere' canpenmian, m po+idad In by Swion ]ro0 d ihe leEv
cod.. �« ine o«�nnw,c. a u» wk �« wNcn tiv. w�m o u.wa.
❑ � new d,e w� meim.n r.omm�• oomo�+do� ����`e. m ma���ee M swian ��oo a ine �m« coen. �« me wno,mence w me
wwk I« xhirh Ihe pe�mil w muE. My �vMn' avmqeuetion Inwrencs finir ud po4cy wmber me:
c�;..:
Gaky NumEer:
�ThID bC1kM1 n000 �w10s cwyJenE I IM Po��l 'e hM OM MpMIW EOtlB9 �51N� V IpD.f
!�[] 1 cenN �� in Na perlormerce d �M wak lor which iM pemu o mueE. 1 Nell m� empby em/ penon in m r io
Eocome wljs lo �he xo eii campanWim �en+ d CeflmJe. apns OW J I NwN E m� � jee i s
canponae I� �+aiom o �wjion ]� 00 d Ihe LeEar CoEe. I anh ' h mmply wiN Ifwe Dro ebn
Dmo: // �OMiuN:
Wemlrp: F�Nun ro wcun wark�n'romp�rwtlon cov�rp� l� un (�ns �IWI ub/�ct an wrploy ro MMiul pm�M�� �nE
elvll M�� �p b aw ��nErM NouaaN JWYn (SfOq000A h Mtlldon ro eM co�� o/ ro�wnutloR u provWM Ior In
Sxtlon J106 0! lM LeDor Ceds, IMw�s4 a�M ettamry i fMx
CONSTRUCiION LENqNO �GENCY: I heraby dfiem uMa pmuCY d per'�ury iha ihss o a aonYrvqion bMiiq pa�ey lor the
peN«mence d IM wrk 1a wh'rJi Oie o�� "v eweE (Sw'v� aw]. Cb. CI.
LENOEH'S NANE:
�ENDER'S RDOFE55:
1 cenM �het I heve roeE Nia eppliution vd mms �het tM eEws'vdarmetion e cortea. I ep�m �o comdY �uh ell rnY enC coumy atlmvices
enE etete lewe relelinp Io Euilevq conatruaion vd MreW emhorixe r peeemvivm d ihu 6ry m antar uqm the ebwa�momionod o�veM
�'���'°�'�°��°�'"'GREG YEL oEN
Pn �, Gy �b
Dma:
Sqnetu d / � a
(5�5ts8.WP) WAue-Bu�ldvq85a1ery:G�eamFb:Ceroey-Rppiunt:Rnk-Reuenue:GdtlenmE-A�amv
CITY OF COSTA MESA — HUILDING PERMIT
ERM NO: H 077285
PERMIT NO: B 077285 PLAN CHECK NO: N GOVT: N SUPP: N
CONSTRUCTION TYPE: V—N PERMIT TYPE: STR PURPOSE: OTH
JOB DESCRIPTION : T/OFF RECOVER W/ 25 YR COMP SQ FT: 3,700
CLAIM VALUE: 3,700.00 CALC—VALUE: 3,700.00 GROUP OCC: R-3 /U-1
COMMENTS: REROOF RESIDENCE
ik iF iE 1ElE 1E 1E �E iF �IE iE aE �E iE �f ik iE iE iE if 1E if iE 1F ik �IE iE fE iE �E 1k fE 1E fF it �IF iE 1E 1E fE iE fk i6 �IF iE i!'lF iF �f 1k 1t ff �E 1E �IE iE �f 3F iF iE iE if ik if iE iF iE �f jF iF it'lE'IF 1E k iE if �E k
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 HUILDING ---------- --------- ACCESSORY BUILDING ---------
FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
PARKING REp • , PROV: PARCEL: 13927215 ZNE: REF NO:
PLANNING NOTES>-
�
IE ff 1F if iE iE iE iE it if iE iE iP iE iE iE iE it iE iE it it iF it if it iE if if 1f iE iE if iE iE iE if iE iE iE 1E if iE iF jf iE iE it it if it IE iE i41E iE �E 1E tt iF iE iF it iE iF it iE iE iE iE 1E iE iE ik iE if it 1E it
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
ZONING APPROVED'�BY DATE:
HUILDING APPROVED BY : DATE:
APPLICATION ISSOED BY: DATE; %'� � ' /�o
1F iFlE iE iE ik f4 if ik 1E if 1E iE IE 1E iE iE 3E 1E iE 1E if IE 1f iI� 1E iE iE 3E IE If iE��{F1E IF
LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
PERMIT 87.25 .50;
SMIP/NON—RES
ISSUE FEE
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
TOTALS----> 87.75 0.00 0.00 87,75 87.75 .00
REVENUE DIVZSION TOI'ALS--> COLLECTED: 87.75 OVER/SHORT: .00
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
8%.25 .5�
IE iE iE 1E 3E iElf IE iE iE if ik iE 1F If 1E 1E 1E iE iE IE if IE iE 1f iE IF 1E 1E li iE 1t if 1f IE iE iE jE 1f iF 1F �E 1E Ib iE 1k �IF 161F If if 1F iE K Ik ik iE iE �E iE 1f iF if 1F 1E iE iE IE iE IE 1E IE iF iF IE iE 1E aF iF
I N D I V 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 3700 ALTER HY VALUE RESIDENTIAL NOZONE 1.00 3,700.00
END OF FEES
�`. L _�. .' . .; _ ' _;' ' .
CONSTRUCTION AND PLANNING
qPPROVALS Permit #
1. Temporary ElecVical Service or Pole
2. $pil Pipe•Undrgrnd.
3. Electrical Conduit Utitity•Undrgrnd.
4. ElRctrical Conduit�Undrgrnd. �
5. Steel Reinforcement
6. EVectrical UFER Gind.
7. Footings
8. Foundation
9. WBter Pipe-Undrgrnd. � ' '
10. Structural Floor Svstem '
11 . Property Sewer Line & House Connection
12. Sewer Cap -
73. Raof Drains - �
74. Rough Piumbing '
15. Rough Eleci�ical-Condult _'
16. ROugh Electric�Nirinq
�
77. ROugh Wiring Si9n " �
18. Rouqh Efectricaf•T Bar Ceiiing
79. ROugh Heating & Air Conditioning .
20. Rough Factory Pireplace . ..
21. Ducts, in Structure �
22. Ducts, Ventilating
23. Gas Pipe-Rough & Test
24. Roof Framing
25. Roof Sheathing �.
26. T-8ar Ceiling (Structurall & Monocoat
27. Frame and Flashing
28. Lathing & Siding
29. Insulation `
30. DrVwall Nailing
31. Plaster Brown Coat
32. Electrical Power MeterFinal
33. Final Electnc � �
34. Fi�al Heeting & Air Conditioning
35. Final Gas�Pipe-Test
36. Hood or Canopy "
37. Final Factory Fireplace �
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Pinal
41. So�ar pomesticFinal
42. Backflow Preventer
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING
48. FINA�PLANNING
49. Electric Release to Edison
50. Gas Release to Sauthern California Gas Q
Date
POOL ,PA
Date Inspector qPPROVALS Permit #
52. Pool & Equipment Location -
53. Steel Reinforcement '
54. Forms .
55. Electrical8onding
56. Rough Plumbing & Pressure Test
57. APPROVAL TO COVER�GUNITE
58. Electrical Conduit-Undrgrnd.
59. Gas Pipe, O Undrgrnd., Test
66. Backwasfi Lines, P-Trap, � Undrgrnd.
61. APPROVAL TO DECK •
62. Backwash & Receptor-Final
63. Heater & Vent•Finaf
64. Plumbing System � Final �
65. ElectricabFinal - -•
86. Solar SYstem-Final / � '
67. Fenting & Access Approvat ��
68. APPROVED FOR PLASTERING
69. POOUSPASYSTEMSFINAI
_ FIRE DEPT. REQUIREMENT
APPRDVAIS � Permit #
70. Underground Hydro
71. Product Piping O Gas ❑ Oi�
72. Underground Flush
73. Undergrnd.StorageTank OGas ❑011
74. Overhead Hydro
75. Dry Chemical -
76. Dry StandpiPe . , .
77. F�XED SYSTEM FINAL
78. FIRE PREV. FINAL
HEALTH DEPT. REQUIREMENT
79. FINAL �NSPECTiON
80. FD00 CERTIFICATE ISSUED
Notes:
m
Date �Inspector
0