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.��$TA�MESA BUILDINGSAFETY DEPARTMENT
- V.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For Applicant to Fill in Completely — Use Ink Only
BUILDING ///� �S, /_/ef" �r✓eL'�_[
ADDRESS %"(O 76j T
OWNER ��� � 19L��O/7{ wi �
MAIL �
AODRESS Z. �S e(� ✓eP �
CITV
�/�� /'•/CsQ NOL�T4J�S
CANSTflUCiION />Oy�
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BRANCH —
ADORESS —
ARCHITECT �t
ADDRE55 ,�7JrZ ��,J6 r0 /T�C�. �
CONTRACTOR Q�{/,%j�%�— LY.ct
ADDRESS }���! E�T/�P�/ C
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APPL�CATION FOR STRUCTURAL P.
RECEIV DATERECEIVEO TE
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FIRE
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APPpOVED
STATE CITV
LIC. NO. LIC. NO.
OFLOT (UO/� l�S INOWONLOTS �
USE OF ��� � /���,.Q�
EXISTING BLDG. �
Separa[e permits are required for
electric, plumbing and heating work.
USE OF BUILDING AND WORK TO BE PERFORMED
a 'f`O S
I hereby acknowletlge that 1 have read ffiis application antl state
thet the above informaiion is correct antl agree to comply with
ell laws ragulating builtling consttuction, and I shall not employ
any person in violation of the workman's compensation laws of
the State ot Californie.
I hereby certify that I am properly licensetl as a conttactor under
the State of California Business antl Professions Coda, Division 3,
Chapter 9, and that such licenses are in tull force antl effect, or I
am exempt from the provisions of the State of�a�jfornia Business
antl Professions �od , Divis' n 3 C apter 9. % �
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SiBnature ot V �
Permittee
Authorized Ageni
1
VALUE
DATE
L-1 / IP�� I BUILDING EW�
VAR SAPPROVED VApD$APPROVED
/
DISTANCE BET. ' BET. MAIN
MAIN BLDGS. ACCESS. Bl
VAR. # DATE
C.V.P.� _ , APPROVED
n
m
i
m
SQ. FT. a
THE AMOUNT SHOWN UNDER VA�UATION IS FOR m
THE PURPOSE OF E5TABLISHING A PERMR FEE Of�LY: �
VALUATION S p PERMIT FEE § QO �
�qj� /� �— PLAN CHECK $ � p
S�(%r4�G/ TAX E !/ Z V
TOTALPAID $ 2 �Z
,ORAA�E COUNTY BUILDING DEPARTMENT
� 636 Norffi Broodway ' ' � •
� .��� SANTA ANA, CALIFORNIA
� -� Fd�R� APFLICANT TO FILL IN
AooRe�ss 4.h7 F FSt.}-�ar S}
SCHOOL o�ST. Costa Mesa
OR TOWN
NEAREST �
CROSS ST. T�•'1�� M1��
APPLICATION FOR PERMIT �
._6������� ��
FOR OFFICE USE ONLY
RECEIPT NO. PERMIT NO.
�%�/ '/o�/�_
BY DATE REC'D. DATE ISSIiED
l� —y 3—�3 �, —� 3 � �
OWNER TIp�A (� Nf1T�T�7'(� AOORe�ss :��0� i�J �j� 5 r
A�ORE55 �+�+7 Newport Blvd '' SCHOOL OIST. /� � �fj .
.... .,,... . ���i / � C�.S •
TEL
=�TY Cos�� Mesa No.�e 6796
ARCHITECT OR 0�•mer LIC.
ENGINEER NO.
AODRE55
(��� uc..
CONTftACTOR `"'+•er NO.
aooRess
LEGAL LOT
DESCRIPTION NO. BIOCK I TRACT �1
IATTACH METES ��UND51 1
SIZE OF LOT 6o x 135 I NOW ON �ar � None
USE OF ( NO. OF I NO. OF
EXISTING BLDG. F�Ki�iee ROOMS
SETBACK LINE FROM:� REAR YARD 1
CENTER OF STREET 1 SIDE YARD ST
DESCRIPTION OF WORK
NEW I� AITERATiON I I qpDITION I
REPAIR I I MOVING I I DEMOLISH I
BUILOING O NO. OF
SIZE �SOO ROOMS � STORIES I
EXTERIOR WALL ROOF p��a �C.
COVERING � �Ctl GOVERING J T�
USE OF NEW
a���o��� Sin�le family residence
I HEREBV ACKNOWLE'JGE THAT 1 HAVE READ THIS FC
APPLICATION AND STATE THAT THE ABOVE IS CORRECT U�
AND AGREE TO COMPLV WITH ALL GOUNTY OROINANCES FRAME
AND STATE LAWS REG ATING 9UILDING CONSTRUCTION. BF
/ LATH.
/
SIGNATURE OF S / LATH.
PERMITTE � �7
PLASTI
. AUTHORIZED AGT. PLASTI
PERMIT PEE Sap MA50�
VALUATION � O PUH CHecK E J
1 � � �/J BOND'
. �' •,� �, r. � TOTA4 �j,.,�° FINAL
FF:E _ E
SM � 9-90-09 � -� � �
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INO.OF TYPE � GROUP
PLANS I
DATE(p D '
CORRECTIONS
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APPROVALS
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PLOT PLAN
Show location ond distances from
property line and between buildings.
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�GE COUN7Y BUILDING DEPARTMENT APPLICATION FOR PERMIT �
� 636 North Broadwoy � � � � � � � �
SANTq pNA, CALIFORNIA
e
STREET
PLOT PLAN
Show locotion and distances from
property line and between buildings.
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