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30652
COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
P
"AY 15-75�alu•OO 653' -
7�.
APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Complete/
RECEIVED BV
DATE RECEIVED DATE ISSUED
MAY 1 5 1975
BUILDING
ADDRES
C_ PERMS )'t2
' '- �1 / L
OWNER �S
A.P. NO. $
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ADDMAILRESS (ff(//'Z' /��J
BUILDING
A�DJDRESS
,�
CITY (/�/�P NO`ACT
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/7
COY
BLOCK
CONSTRUCTION
W A DP
LENDER
7pe
BRANCH
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OWNER /":
ADDRESS
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TEL.
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S
OR ENGINEER /l / �P N l
FIRE
ZONE iYPES GROUP
ADDRESS /� /(� Yry
APPROVED
CONTRACTOR /�-
BV DATE
11-7f
ADDRESS, / �/
,
TEL.
�t
OF
USE OF NEW /
CITY NOS ���
r
PNL
PLAKE
BUILDIN tV"
STATE CITY
YARDS APPROVED
YARDS APPROVED
LIC. NO. �� / / LIC. NO.
MAIN BUILDING
ACCESSORY BUILDING
SIZE
NO. OF SLOGS.
(FROM C/ S EET
ll
OF LOT X
NOW ON LOT
R INT T
FT ('
USE OF
EXISTING BLDG.
r. s -e'
SIZE OF NO, OF %��J(l/yf-S
-5;9 rT ROOMS STORIES
NEW BLDG. 7 UJ'L
L. SIDE F
EXTERIORWALL�y9'vC//
ROOF
COVERING i/
COVERING LFJ
REAR F bd-
USE OF a ILDING AND RK TOBEPERFORMED
DISTANCE BET.
BET. MAIN &
/LI
MAIN SLOGS.
ACCESS SLOGS.
VAR.#
DATE
(J/fJ
C.U.P.gls
APPROVED
T i'1. O
KO
APPOVE
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BOLD FOR SECIA
TAX
I hereby acknowledge that I have read thiseppli Ion antl ate
that the above Information is correct and agree o comply with
'
all laws regulating building construction, and I shall not employ.
any person in violation of the workmen's compensation laws of
1O
the State of California.
i hereby certify that I am properly licensed as a contractor under
SO. FT. LLXXJla Lr..Q1V�
THE AMOUNT SHOWN UNDER VALUATION IS FOR
the Stateof 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 PERMIT FEE ONLY:
am exempt from the provisions of the State of California Business
VALUATION
and Professions Code, Division 3, Chapter 9.
PERMIT FEE $
PLAN CHECK $ �s
Signature of �,�l50
Permittee 7 Lt/l•L. /
$ �3
Authorized Agent
TOTAL FEE .$
7�.