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Home My WebLink About305 FLOWER ST - Building PermitsrJ CITY OF COSTA MESA �` _ � Bl/ILDING DIVISION • ' � DEVELOPMENT SERVICES DEPARTMENT � � PERMIT PERMIT NUMBER �� 698-01774 (714) 754-5273 • Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Joba.ddress: 305 FLOWERST Suite: Vicinity: ROOF OF SINGLE FAMILY DWELLING ParcelNunmber: i1725322 Zoning: Applicant: WATKINS, EDWARD E. Address: 289 LILAC LANE CA COSTA MESA � ',� f -': i� ., � ��,d Owner. GLESENKAMP LOUIS T Address 305 FLOWER�ST //J///� `. / C(. OSTA MESA,CA , ,�/%� �_/ % � �� i. � - - Arch /.Eng : ',� Address � � � ' �/ a ' P.Ian Check: `�; Permit SMIF,Res SMIP Com:� �� - OtFier. • Inspection.' Tota I: SETBACKS MAIN STRUCT ACCESSORY PARKING NOTES: mesa, ca Status: ISSUED �y � Applied: 09/30/1998 Issued: 09/30/1998 ' Phone: '- 71A.953:0851 �HM � Zip; 92627 ' - �-� �; � ��` . � � llr �� `� � � � ' � .A r' �� ; Fhone.,�'.714.5484209/ /\�\ 1 � "��) �.:-�. ti r Zip: 92627 _�'� � �� , / C � �ION `\`•;��\� �� /�\\ � � � \� ��.�� \. �'. �� V`. �-, � Phone� 714-966-8303 ��^\��, �� Zip::,92827 \��A � � `�ti �, License:,,393321 � : ,"_ �-��. � �- '�� .'��\ . . � � , .._ i �� '� r �.. � . r ' :�� ' a1 ' � . ,- ', A� � i „� iV .-'Phone - � . ,, k i � � - .1 `�, 1\�"��_- ' �' Zlp � _ t.- - \b.� � _ , � i; � License: �� j� �`� ' - 'ii `� . . �, r. � , SCOPE OF PERMIT V ` � ' � , � -� �l � ;TEAR OFF OLD COMPO ROOFING AND APPLKNEW�CLASS'A' COMBO ROOFING. INCIUDES DWELLING , JAND DETACHED GARAGE: - ' � - '� � 1 - � � ` .._. , � ...,:��zi.... _��_::Il:� ', •� ,i . .__. _ .___ -. _ �: _.. �i . .-_t , � ' . � � , .. � $0.00 � $99.75 �,, ,$0.50 $0.00 :$0:00 $0:00 �!� $100.25� ti Fronf- ..0-'0� � Front 0- 0 � �� Existinq: 0 � FEE.SUMMARY�� _ � ,� r� � , , �� : - " '� �� - ' ' � =-'-=Calc Valuation � � Sa,z3�.00 - �4 �� f - Claim Valuation ' sa z3Yoo / r , , , , �; ;: ��-=- � r; � : r �„ — - --- fj; � �i /;`;i � ��; i;. �, ,' �, , " ` �%% � , � �� , ' - �;�" ��•� %-;� , ... ��+�' i, . ..��, _ ...�•�'��" ,��, Rear 0-0 Rear 0-0 PLANNING'&ZONING �,., < - . �-'i�, . < < � �<, /!�,/. '�� . - . - . .�; � ��,� Left 0-0 - Right.�-0-0:�� , � �i;; � . ' Left � 0- 0 � � Right � i -0-'0 � ReQuired: 0 � PrOp05ed: 0 , . - . � EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under ihis permit to be considered legal, such work must comply with all applicable codes, and all required Inepections end flnel approval must be obtained. Failure to obtain inspections and final approval will result in ihe expiration of this permit. FOR INSPECTIONS CALL: (774) 7545628 WORKERS' COMPENSATION DECLARATION: � � I hereby eifirtn under penelry of perjury one of tde following declaretions: � I heve en0 will mein�ein a certlficate of consent to seN-Insure for workers' compensatlon, as provided tor by seciion 3700 of the Lebor Cotle, for the peAarmence ot ihe work for which Ihis pertnit is issuetl. P.7� I have and will maintein workers' compensetion insurence, es required Dy seqion 3700 of the Lebor Code, for the pertortnance of the work for w�ich Ihis pertnit is issued. T� My workers' compensetion Insuran e carrler antl pollcy number are: (�� t ceme�: �i �RTIL GOrJ �li,U S/�TiDE/ j,JS ✓�?/f.�G�' �'u�vp policy Number. _ z D S� y0 U.ViT r�ocn96,F (Thls secHon need not be completed!/ the permlf is valued at one hundred dollars ($100) or less.) ❑ I certify that In the pertortnance of the work for which Ihis pertnit is issuetl, I shall not employ eny person in any manner so as to become subject to ihe workers' compensatlon laws of Califomia, end egree that Ii I shauld become sub�ect to the workers' compensation provisions of Section 3700 of the Lebor Cotle, I shall fonhwit� comply with thesa %p ovi�si ns. �� %�,p� / 7 Applicent Signature: `Ti/.I.GI/Lfi�2�� CN'� �" Date: �� )O—�� WARNINO: FNLURE TO SECUFE WORKERS' COMPEN�T�IXJ WVERAGE IS UNLAWFUL AND SHA11 Sl1BlECT lW EMPLOYER TO CRIMINAL PENALTIES AND GVIL FlNES UP TO ONE HUNDRED T}1IXISAND DIXIARE ($100,000), IN ADDfTION TO THE �T �F COMPENSATON, DNMGES AS PROVIDED FOR IN SEGTION 3'lOfi OF THE LABOR CODE, INTEREST, AND ATTORNEV'S FEES. � IJCENSED CONTRACTORS DECLARATION: I hereby ettirtn thet I em licensed undar provisions ot Chepter 9(commencing with Section 7000) of Division 3 of the Business and Pmtessions Cotla, end my license is In tull force ana eNect. uc. a Class # G— 3�f Contredols Signature: ,"�^... �, oate: �'/ —�D —9iL CONSTRUCTION LENDING AGENCV: ❑ I hereby aMrtn ihat Ihare is a construction lending egency for the pedormance of the work for which this pertnit is issuetl. (Sec. 3097, qvil Cotle). Lentlers Name: Lendafs Atldress: Slgnature: Date: OWNER-BUILDER DECLARATIONS: I hereby attirtn thet under penalry of per�ury ihat I am EXEMPT FROM THE COHTRACTORS LICENSE LAW tor the following reason (Sec. 7031.5, Business entl Protessions Code: Any ciry or counry which requires a perml� �o consirucL alter, Improve, demolish, or repeir eny simctura, pdor to its issuence, elso requires the epplicaN tor such permit ro file e signed stetement ihet he ar she is licensetl pursuent to the provisions of the Cantracmrs License Lew (Chepter 9(wmmencing with Sectlon 7000) at Dlvision 3 ai t�e Business and Professions Code) or thet he or she is eaempt iheretrom anO t�e basis tor ihe alleged exemption. Any violation of Section 7031.5 by any epplicant for e pertnit subjects the flpplicant to e civll penalry ot not mnra than fiva huntlred tlollars ($500).): ❑ I, es ownar of tha property, or my employBes with wages as iheir sole compensation, WILL DO TliE WORK, and ihe structure is not Intended or oNered for sale (Sec. 7044, Business and Professians Code: The Contrectors License Lew does not epply to en owner of properry who builds or improves thereon, end w�o tloes such work himsetl or herself or Ihrough his or her ow� empbyees, provltled ihat such improvements are not intentled or ottered lor sale. Ii, however, ihe building or Improvement is softl within one year oi completion, the w+f�er-0uiltler will have ihe burden oi proving that he or she did not Duiltl m improve tor purpose of sale.). ❑ I, es owner of the properry, am EICCLUS��ELY CONTRACTING WITH LICENSED CON7RACTORS ta wnsiruct ihe project (Sea 7044, Business and Protessions Cotle: The contredors license Law tloes not apply to an owner ot pmperty who bullds or improves thereon, and who contreds for such project with e contrector(s) license pursuant to the Contractors License Laws.). ❑ I em exempt untler sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivefs license. ❑ Ves ❑ Na Drivers license No. Expires: VeAficetlon of Ownership by (rype ot tlocumenL �.e. - properry te< bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMR CERTIFICATION: ❑ I hereDy cently that no excavatlon five (5) e� more teet in depth inta which a person Is required to descend, will be made in connection with work euthorized by thls pertnit, entl Ihat no buildin9 siructure, scallolding, telsework, or demolition or dismantling thereot, will be more than ihirty-six (36) teet high. (Chep. 32, Grp 2, Art 2, Sec. 341, Tltle 8, Gellfoml9 Atlminlslrative CoOB). ❑ As owner-builtler, I will not amploy anyone to do work which would requlre a pertnit trom the Division of Industnal Safery, as noted ebove, unless such person has a pertnit to do such work trom the division. Signature: Date: Division of Intlusirial Safery Permit Number. CER7IFlCATE OF COMPLIANCE AND AUiHOR�TON OF ENTRV: I certify under penalry of perjury thet I have read this epplication antl state that ihe informetion given is correct. I egree to comply wit� ell stete laws antl ciry ordinances releting to building construction, and authonze representetives of the Ciry of Costa Mese [o enter upon tha above-described property for inspection purposes. I agree nol to occupy or allow occupancy of eny building authonzed by this pertnit un�il final inspection. Ip`eture Of ner s) �_ �_ pate_ r 7 ij And/Or Authorizetl App�icant Date f��j_!, INSGECTION TYPE 1616 Fixed System Final Fire Prevention 1288 Pool Spa Final 200 Finel Re-Raof 201 Final BIocWReWining Well 202 Finel Factory Fire Place 203 Final Sign 204 Finel Demolitlon 2a48d8 � I�� G —� �Cw LQQEj INSPECTIONTYPE 206 Finel Mechenicel 208 Final Plumbing 210 Final Eleciricel 212 Final Pire Prevention 220 Finel Planning Approval 222 Final Site 250 Finel �� . . . Aop�icanLto fill in alLzpaces exteo� thoze within heavy bortler lines antl sign all avPropriate Oeclarations. _ . �- � ' -� - . -� � . . . . � t y � l. Y dF COSTA MESA r� • CON/STRUC/T,�ION PERMIT r-� PERMIT NU. TRACT NO.- � LOT NO. � UNITNQ � -; � � , � . � . . 445f, ,l5/05%9G ' .� . '=SnF.r ' T: ProlecfAddress 3 i% 7 �h �� Wh . . r6>� ��Y'f � �� . . . . � 1._ ,.r - . � . �� ' ', . � - AppiiCdnt 5 Mdi[I1ng pA�ddress ` � S/ /_� ^��"�I �D W -. J� � TVPE OF CONSTRUCTION ; , NEW ' ADD, _ALTERATION. �REPAIR - - � � � ' /�ON I � )i �h/�:y.7�.v K y� � � ❑ CONVERSION- ❑bEMOLISM ❑ OTH^ � � q p # . ' - ' ' _ . � .•. ' Zoae . . ' Owner s N e �'A one '•� DESCR� IPTION F WORK)iJSE'6F-&EBG. �€�� ' � - � - Address �� ' y�Ij/ S'�( �j�� /.j �% ,�p� �. . _ ' '_ S Main Bwlding: Y � ACcessory.Building' . � - � � Arch/Eng[ '�� ' LicenseNo. � ` � TYPEOFPERMI��tvRA�IN�DATION LJ�STRUCTVRHL� ' T FronY �- �" � - ' - • � 0, Addre55� '""' - � � � 1 � O TENANT -LJ ELECTRICAL ❑ PLUMBING O MECHANICAL ,, ' , B Rear '� � � � ' - `� N Contractor's Name � � ' � � Phone � .n� �OTHER - � � .' . � Right ' � ' � � . ' N --�EtiK��L� �. • PROJECT DESCRIPTION SQ. FT. ' � oCcuPaNCV Addresslmailing) �= �� ; �p � A- I � , - - •K' . . . G ' K � � ' CONSTRUCTION TY,PE ' ' ♦ � �VALUATION § ' S Left � . � . , � R City License No. — - ' , � zONE ' ' GRAOIrvG CU.vDS. � ACRES , p��g, Ref. # � Parking Req�/Provided; � ' � ' '� E LICENSED CONTRACTOR DECLARATION � • � � � - ' . Q 1 hereby affiim that I am licensetl untler provision5 of Charter 9(commencing Remaiks: ' � � � � : ' ' Planning Notes: ' � � � � '' M , with sectlon �000) of Division 3 ot the Business and Protesslons Cotle, antl . � ' my license is in full force antl effect. � - i � � � r . � � � - , . � � i , � ' , • - . , , ' S L'icense Class' ' - Lic¢nse No. ' ' - � oate � ' ISi9nature � � � � PLUMBING • .FEES • . . � � � �' • � WORKERS' COMGENSATION DECLARqTION' I ShOw¢fs ELECTRICAL ' � FEES , � I bereby affirm that I h5ve a'cer[ificate'of consent to self-insure or a certificate � Bar Sink � 4 • � ' � , , � 1 of �Wo�kers'•Compensation �Insurance, o�-a-certifletl-copy th¢�eof (SeGtion' ' gack410w Prevenfer ServiceSink,. • ' 3800, Lab. C.) � � � � � � I • �' . Automatic Washer � ' � Trensformer ❑ 15-50 KW Policy No. ' Company � ' Backflow Irrigation � Sewer Ca ' ' � �� - ' . � ' ' � 50+ KW j � � i P . ,. ConstructionPoleSub. � B C¢r[i�ietl copy is hereby turnishetl. � ' ' � , � � � � ' � ' i Certifietl copy I5 filetl with the city Builtling Oivision. , 63[htubs Sewer Connection ;� Cooking Unit � . � � Meter up to 100 amps . � � Date � � AOPlicant � ' , • , • . � � , ' " • � .s ' ' Clarifiers • _ � ' Solar Collectors . ' � ' @XEMPTIONFROM.WORKERS}COMPENSATIONDECLARATION ;-.-.- .: , . . .—�.-- .- �; -- . - -�Di5hwB5h2�-}� -�- � .— �M2Lf/-�OOVEF1002TpS`--.- -� (This seclion neetl not be completetl it the permit is for one huntlretl ($300) or ' ' O Iess). � � � � ' Dishwasher � � � Solar Piping�, � � � � �.�r � Dryers as ❑Electric � Sub'Panel � • ' • ' I certifythat�ln the performance�of tne work for,which this perm�t is.issuea, 1� . ' ' ' � snall not employ any Derson in any manner so' az to become subject to the � Drinking Fountains � Solar Tank � � Fan. � � ' ,��,/ � i Work¢r5' Compen5ation LdwS ot Calitornia. 1 , . � � � �` , �' I ' MOtOfS CJU�1 HP 01 %�8 I � . Date � � � Si9nature � Fioor Drains Swimmin Pool w/S a� ' • � . - � �NOTICE: If, after making this tleUaration, you shoultl become subject co the � ' ' � 9 P � F'A.'U' � Inc.Solar��9;75 HP 0�6-15+ Workersi -Compensation provisions of'the� Labor Cotle,'you must fortnwitM1 � -- Fioo� Sinks �Urinal � � ' ' compry'witti such p�ovisions o� thi5.permit�5ha11 be tleemetl revoketl. � � ' Z- Fixtures� . Microwave CONSTRUCTION, LENDING AGENCV: � � � -' '� �� G25ServiCe , ^Outle[5 Watef CIoSe[ �' � � � ' ' I hereby�affirm ihat there is a coFnstruction lentling agency for the pertarmance J � � � Pole Light ' of the work �for which thi5 permih is, i55ueB'($ection 3097 civ. CJ ' jnterce� tors � -_ Weter Heater ' � ' LenOer's_ Name � ! P ' ' ' Outlets � � , ° Range � ' � � �enaer's Atltlress , � � ' - " � _ - Kitcheri Sink : � � �- � '_ Water Service �. - � � Switches � /D Sign ' ' OWNER BUILDER �ECLARATION , ` • � - , � � � I hereby affirm thai I am exempl from the Contractor•s License'La� for the ; Lavatoties �� . ' _ Auto-Wash - , G2�ba 2 Di5 OSdI ' � � following reason (Section ]031.5 Business antl Professional Cotle: Any city or 9 P „Standing;Sections ' O county which requires a permiTm construct, alter,�improve, tlemolish or repair P=Trap � ' .Laundry TraYs: � � j J - � Generamr �0-5 KW 05-15 KW � any st�uctur¢, priOr t0'its issuance, also requi�es tbe applicant for Such pe�mit � � �' ' ' T�ash COrilpdCtO� ' O to tile a signetl�statement'that he/sM1e is Iicensetl�pur5uant [o the provisions o/ ROOfA�ains� � r - � ' ' - . 'the Conlracror's License Law (Chapter9,(mmmencing wlth Section ]000) of I -� ' � ' ' � . , 'Division 3 of the Business antl Professions Cotle) or tha[ he/she is ezempt q t - . � _ .therefrom antl th¢ basis fOr the allegetl exemption. Any, violation of Section � � _ � ' - . � - � � ' . , � � ']03L5'by any appllcant (or a permit SubjeGts tM1e'applicant to'a civil' • ' �-� - - Pe,pdlty of-not more than five huntlretl tlollars ($500).� � � � � , i ' � � - , ' _ � . � . ' �. � ��1, I, as owner o( the property ' ' a es t ' ple � - ReinspeMion- fee , � � $15 `- � ! Issue Fee . ; , - $ 3 ' � ' , will tlo the work,'antl the structure.is•not m entle or offeretl , Reinspection Fee $15 luue Fee• � � ' ;$ 3 ' fbr sale ction J044, Business antl Professional Cotle: The Contractor's �^ �- '- �' � MECHANICAL � FEES ' � icense Law'tloes not apply to an owner of a property who builtls Or improves ' •- � - � -- � thereon, antli wno tloes such work himseif/herseli or,mrough his onnet own • � � � • ,� _ DEVELOPMENT SERVICES REQUIREMENTS: ' ' employees, provitletl that Such.improvemen[s'are nobintentled o� off¢retl�for ; BOiIB� r: �� I � HOOd Ofi Typ¢ I� ❑, . . • . Sale. tl, however, the builtlin9 or improvement is soltl within one year oi com- . �� Cano ' S i �� Zoning Approved By Date pletion,'the Owne� will have the bu�tlen of proving hE/she tlitl not builtl o��im- DUCf - Und¢f C�iround � � PY ; Typ¢ II ❑ ' . `J - � ; I prove for the purpose of sale). � , , , � � : . ' � Building Approved By Date i ❑ I, as owner of the property, am ezciusively cont�acting with licensetl con- � Duct -StfuCtu/el . RCffig2�dtiOn $yst¢Rl Appli�'ation ISSued By ' � Det traCto�s to cons[ru[[ [he project (Section 7044, BuSiness antl Prafessions Cotle: ' i � ' , , ' _ The Contractor'S ,License. �aw does.not appiy ro an owner ot property who Dutt-�Ventilating- - ' � ❑0-700,000 BTU--Od00,000 BTU �- , ' �SUMMARV OP FEES ' � � • i � builtls or improves Ihereon,-antl who cont�acts for such project5 with a con- � � � ! � . vacmr(sl license pursuant to the Contractor's Lirense Law). I am a'ware that' Exhaust System ❑ Multiple ❑ System Repair/Alteration ' BUILDING PERMIT $ SMIP � I$ + � � proof 01 their Worker's Compensatian insutance shoultl be provitletl to� me. . � • i - � PLAN CHECK � $ ' � � PEFiM1T ' . + ❑ I,am'exempt untler Section e. & P. C. for this reason FirepVFacL�Blt. ICBO # Pire Dampers PLUMBWG �$� � � ��SSUANCE $ DatP,.Fs � Owne � �� ' � ' Heating System & Ducting Registers � . ' . � ENERGV P.C. ' $ � 1 PIAN CHECK 25%� $ 'I' fiereby- ertity thzt"i have iea this applic5tiori antl state that the above � ❑0.700,OOOBTU 0700,OOOBT � � G• r7, GRADING �$ � information is correct. I agree to comply with au city antl county ortlinances . � ' ' ELECTRICAL '$' antl-state laws relating to builtling construction, antl hereby authorize repre- ' , � � � . PLAN CHECK 50%, $ ' MICROFILM $' ' • s¢ntatives of�[hi icity o enter p the above-mentionetl�prop ty for • ' � , � ' � z inspectionp rp s s; 1 Dates + , � MECHANICAL � $� TOTALFEE $`/� Si9nature ' � � Reinspectian Fee $15 Issue Fee $ 3 PLAN.CHECK 25%' $ ' � � ' Drivers' License r;55 � . . CMF 0865-46, rev. 30/B4 White - Builtling; Canary - qpplicant; Pink - A¢ounting; Goltlenrotl - Assessor ' � _ . _-. .,. _ . .. , . ,r. �CONSTRUCTION AND PLANNING POO� & SPA � ��- APPROVALS Permit# Date Inspector - AppROVALS Permit# Date � Inspector i. 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 Si Pressure Test 6. Electrical UFER Grnd. � � 57. APPROVAL TO COVER-GUNITE 7. Footings ' 58. Electrical Conduit-Und�grnd. . 8. Foundation - 59. Gas Pipe, O Undrgrnd., Test ' 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, O 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 � 73. Roof Drains , 64. �Plumbing System � Final. '� � 14. Rough Plumbing 65. Electrical-Final - � 15. Rough Electrical-Conduit . - 66. Solar System-Final ' '' 16. Rough Electric Wiring '},�-g �j 67. Fencing & Access Approval 17�. Rough Wiring Sign 68. APPROVED FOR PLASTERING 78. Rough Electrical-T Bar Ceiling , � 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning , FIRE DEPT. REQUIREMENT � 20. Rough Factory FireQlace APPROVALS Permit # � 21. Ducts, in Structure 70. •Underground Hydro 22. Ducts, Ventilating 71. Product Piping � Gas . � Oil 23. Gas Pipe-Rough & Test ' 72. Underground Flush - 24. Roof Framing � . _ 73. Undergrnd.StorageTank OGas ❑Oil 25. Roof Sheathing 74. Overhead Hydro ' 26. T-Bar �Ceiling (Structural) & Monocoat 75. Dry Chemical 27. FrameandFlashing 76. DryStandpipe � 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 �/ � G(1 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 . ' � � � , � 39. Water Service-Final - 40. Gas Service-Final � � . 41. Solar pomestic-Final , _ _ � 42. Backflow Preventer ' ` - � � � _ � 43. Backflow Irrigation � 44. Landscape Irrigation System � _ . � . � 45. Sound Attenuation ' • - � � , 46. Handicap Regulations - - ' 47. FINALSTRUCTURE&BUILDING , 46. Special Requirements Completed . � � - 49. Electric Release to Edison � �� ' • 50. Gas Release to Southern California Gas Co , 51. CERTIFICATE OF OCCUPANCY No. Date . CITY OF COSTA MESA BUILDING DIVISION OWNER-BUILDER VERIFICATION _ . . �� , � A city or county, which is required to give notice pursuant to Section 19830, shall attach to such notice, and, as a condition precedent to issuing a building permit, require the completion and require the return of, an owner-builder verification. Attention Property Owner: An 'owner-builder' building permit has been applied for in your name and bearing your signature. Please complete and return this information in the envelope provided at your earliest opportunity to avoid unnecessary delay in processing and issuing your building permit. No building permit will be issued until this verification is received. 1. I personally plan to provid—e She major labor and materials for construction of the proposed property improvement. L1dYes ❑ No 2. I(have/have not) �--�+-��'-� signed an application for a building permit for the proposed work. 3. I have contracted with the following person (firm) to provide the proposed construction: Name ��^- R Address City Phone ( 1 Contractor's Lic. No._ 4. I plan to provide portions of the work, but I have hired the following person to coordinate, supervise and provide the major work: Name '�"�^�e Add ress Phone ( Contractor's Lic. City 5 I will provide some of the work but I have contracted (hired) the following persons to provide the work indicated: Name Address Phone � Type of Work I hereby affirm that I have received a copy of the information set forth in Section 19830 of the State of California Health and Safety Code and have completed the above information to the best of my personal knowled in compliance with this State law. � Signed: � , +' Date: � Name: � i £S F ( rinted or Typed C.D.L. #or s.s. � , �� CMF 1042-46 754-5273