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COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
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APPLICATION FOR BUILDING PERMIT
F Ap licant to Fill ' mpl to
RECEIVED BY
I DATE RECEIVED DA7 ISSUED
1 1 S 1975
'04-011177
BUILDING
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ADORES c e
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OWNE /`/ i"t ,0 S
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PE 11m/ 11' V
A.P. NO. (� -/14,04,
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AMAILDDRESS J / /P %/ T //
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BUILDING � /I z
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CITY /fP NOL S% /[
I /%OA CT ,I rL02T BLOCK
CONSTRUCTION
ADD I ALTER I REPAIR
LENDER
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BRANCH
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OWNER �S
ADDRESS
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ZONE VPE GROUP
ADDRESS % 7 �%/� l/" �" '
APPROVED I
CONTRACTORn / (/ l
BV DATES
AD OR ESS / �j j
TEL.
CITY NOj
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NO. NS
PLANS
USE OF NEW
IL
BUILDING c)
STATE CITV
/
YARDS APPROVED
YARDS APPROVED
LIC. NO. �? LIC. NO.
MAIN BUILDING
ACCESSORY BUILDING
SIZE/ NO. OF SLOGS.
`/
(FROM C/ StTRE T)
•Y
OF LOT l�O NOW ON LOT
RONT F
USE OF
EXISTING SLOG. / ?WA1 /
R qIrlF
SIZE OF/ NO. OF/J`J/j.'
a,T.
NEW BLDG. GJ ROOM$�$$TO RIEj S
L. SIDE
FT.
EXTRIOR A ZO
ROOFERING
COVEERIING
./�Jv
COV TLS
REAR FT
USE OF BU AND AND WORK TO BE PRFORMED
DISTANCE BET.
BET. MAIN &
MAIN SLOGS.
ACCESS SLOGS.
CURP,$
APPROVED
r
APPROVEC.A
HOLD FOR SPEC
AL REQJ&Rftk:N'1 a
I hereby acknowledge that I have read this apPlicativ and state
,
that the above information is correct and agree to comply with
all laws regulating building construction, and I shall not employ
any person in violation of the workman's compensation laws of
1 �
l l `�jL SQ. FT.
the State of California.
I hereby certify that I am properly licensed as a contractor under
THE AMOUNT SHOWN UNDER VALUATION IS FOR
the State of California Business and Professions Code, Division 3,
Chapter 9, and that such licenses are in full force and effect, or I
THE PURPOSE OF ESTABLISHING A PERM R FEE ONLY:
am exempt from the provisions of the State of California Business
VALUATION
and Professions Division 3, Chapter 9.
/Code,
Signature of 7 l^_ 1 /`te,{ i, a _ /
Permittee , I ' I t/'� �
$23 JC/'V
PERMIT FEE $
PLAN CHECK $ �a
Authorized Agent
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TOTAL FEE $ .
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