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COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 917 COBTA ME6A, CALIFORNIA
For Appliean+ io Fiil In Compietely
TYPE OR PRINT
■ MAIL
COSTA MESA. CALIFORNIA
TEL.
NO.
TEL.
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FIRE
F�RECEIVED
n MAY 171969�
fINANCE OEPT.
CITY OF COSTA MESA
APPLICATION FOR PERMIT
BUILDING
For Office Use Only
ev
COSTA MESA. CALIFORNIA
ZONING
NO.OF I USE OF
ruxe 7 aw�oin
U6E OF YARDS EVES
EXISTING BLDG N APPROVED ALLO
CCNTER OP'8TH erM / REAR YAR�7. �� FRO TR L1Ne ei.'(�� FT. l�
` � .
SIDE YARO ILEFT �� IRIGHT � R.SIDE FT.
DESCRIPTION OF WORK �`-'
BUILDING
SIZE
EXTERIOR
COVERING
USE OF BI
NO. OF
d shingle
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1 HERBBY ACKNOWLE�OE TXAT 1 HAVE REA� TNIB APPLIWTION THE AMOIINT 6HOWN IINpEH VALUAT�ON IB FOR THE �
AND BTAT6 THAT THE ABOVE IB CORREGT AND AGREB TO COM- pYRP09E OF E6TABLIBHING A PERMIY FEE ONLV.
PLY WITH ALL CITY OROINANC¢6 ANO BTATE lAWB PHGULATIN6
BUILGINa CONBTRU ION. VALUATION
BIGNATURE OF �'ERMIT FEE $ �
PERMITTE � '
$ ��%,( � PLAN CHECK $
AUTHORIZED AGENT /'J �� �— TOTAL FEE V �
r ia �_ 42b0�
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 120P COSTA MESA, CALIFORNIA 92626
For App(icant to Fill in Completely — Use Ink Only
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ADDRESS /% �7 �
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BRANCH ^
ADORESS
ARCMITECT� n/6 A/��A✓HrJ TEI.
ADORESS
CONTRACTOR (/w/v✓I` �UILy �Q(�'P��I
ADDRESS �(pZ /.;C.L�7F�SJ7`f/` ('%V �
CITV �S/'/ /'IF�J� NOL����Z
STATE CITV ��
LI4 NO. ' UC. NO.
OF LOT ��✓ x V(J NOW ON LO S �
USE OF /��A/�
EXISTING BLDG. ��U/'[
Separate permits are required for
electric, plumbing and heating work.
USE OF BUILDING AND WORK TO BE PERFORMED
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er� —�-th�..< 00 a8� : {,:.: ::,�., 1
A L AT ON FOR STRUCTURAL PERMIT
R C 1 ED DATE RECEIVED D TE ISSUED
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_ � �) RMIT N .
A.P. NO. ,
BUIL�ING ��� ^y�
ADDFESS �f't�f
� TRACT �OT BLOCK
W ADD ALT R P
OWNER V(��1�
t�� �� y� VALU$
SE I�CYva�'�
FIRE
ZONE TVPE GROUP
APPROV ED �� A��i
gy DATE � /
ZONE� NO.OF/
ats'w` L
VARDS PPROVED
MAIN BUILDING
OISTANCE BET
MAIN BLOGS.
VAR. #
I heraby acknowledpa thet I have reaA this application antl staie
that the above information Is correct and agree to comply with
all lews re8ulatln8 huiltling construction, entl I shall not employ
any Oerson in vlolallon of Me workmen's compensaiion laws of
the State of Calitornia. /
I hereby certify that 1 am proparly licansatl as a contractor untler �
She State of California Business entl P�ofessions Cotla, Division 3, THE AMOI.
Chapter 9, antl that such licenses ere in tull force and atfect, or I THE PURPQ
em ezemDt from thd Provisions ot the Steie of California Business VALUATION
and Protessions tle, Divizion 3, Chapte� 9.
S(gnaSure of � A rO
Parmlitee f $/ Cja
Authorized ABant
OF
D"
.i
VSE OF NE�
BUILDING
VAROS APP
ACCESSORV
BET. MAIN &
ACCESS. BLp
DATE
N
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N
JN UNDER VALUATION IS FOF m
'ABIISHING A PERMIT EE ON V: �
PERMIT FEE $ D a
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PLAN CHECK $ �^
0
LL
TAX $ �
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TOTALPAID $
- • -• nivuvi, xusseii n �anxs
JOB ADDRE55 782 Allegheny Avenue_ _
GENERAL CONTRACTOR Owner/Bldr.
-"AP No. 141-523-11 LOT TRACT
- .�.
� �'llfs'=•'ts�'TIONS Si nofu
�,
�`\� 5t;�>: ..
`GAS+
WATER
ROUGH PLUM9ING
FOP. SWR. LINE [� HOUSE CON. �
SPRINHUNG SVSTEM
MISCELLANEOUS
POUGH HEATING AND AIR CONDITIONING
TEMPORAqY SERVICE OR POLE
UNOERGROUN� � POWER �
ROUGH WIRING Ci
BOND 9EAM [] STEEI
SHEATMING
FRqME AND FLASMING d
LATHING - IN n OUT
PLASTER.BROWN COAT
STRUCTORAL. FINAL
REINFURCE
H i, VENT., REFRIG. AND A.C., FINAL
F .NG. FINAL AN� GAS TEST n
EIECTRIC_ FINAL
BUILOING, FINAL
SPECIAL REpU1REMENTS
7-L-/O
BUILDING PERMIT
RIPTION oF WORK Add Z Bed
ZONE VALUES 12,000
PE GROUP
SUBCONTRACTOR _ �
& Familv Room