HomeMy WebLinkAbout880 CAPITAL ST - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.cBaUILDING PERMIT �� FAIF DRIVE, COSTA MESA, CA 92626
Job Address: 880 CAPITAL ST
Suite:
Vicinity: ROOF
Parcel Number: 42239111
Zoning:
Status: ISSUED
Applied: 11/20/2002
Issued: 11/202002
npplicant: HAN, AUSTIN �SSUED BV: C_
Address: 1022 W ORANGETHORPE, ,,, . � � - � ; � _
- " -Phone: (714)87,1-9923 � � \,.
FULLERTON, CA"' �� . , Zip: 92838 ' � '� --
� .%:��'� " � i �'
Ownec MACKLIN; KENNETH S' � � �i � �� � ; � ��,,;A
Address /880 CAPITAL ST `� , . - _ - „, - , _ �` �. ��
� � Phone: . _ .. . ; �, . ��� � �\
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� - OSTA MESq CA� " - Zip: 92827 � -, _ � _ , ��• `
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Contractor: �ACE ROOFING SYSTEMS CO \ � , . '� �� ��
'Address:. 1022 W ORANGETHORPE � " � � c-��
� � . .. Phone:_ (714)871-9923 \ �:��� -' ` �:, i
� � FULLERTON,CA " `
�
� Zip: ` 92838� . License:'� 679543 � ' _ _ , . � ',�A �
Arch : . ' ' . i� E�9� , . ' �' . -
Address: - �- ' - - "� � � � .. Address:. � � - � .� `
. . � . ' ' _ Phone: . . '��. � '/�� Ph�one: ,- - • �:.
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� ��License: � �
,�Zlp: � ��� � License: -
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� �,..-�. -.--y ,-. SCOPE OF P-ERMIT.,_. �,-,. `,, - - �`
� TEAR OFF EXISTING ROOF. INSTALL 30# FELT, 30 YEAR,�COMPOSITION SHINGLES. 2,6005.F�INCLUDES ATTACHED GARAGE. �
, - '- ' -" — -'_. ' _ .,� _ �
� � � � FEE SUMMARY � � ' i � � `
��PlanCheck:� �' $0.00 ' � ,"����-. = �`!����, CalcValuation � ,� Sa,Sa000�`
� �. Permit: , $111.25 ---- - � ,y�„ � � _ Claim Valuation I;' � Sa;5so.00
�� SMIP Rea:' , $0.50 � - . � ; ,�- � i _' t'; l
SMIP Com: $0.00 , / � , .
Other: $0.00 .
r
� Inspection: �.� $0.00 , �_-::-:`--�. � ��r";' � A� � :
, �, �, ., _ „ ; _ i �� i
l� �Total: , $111:75 � ��
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'�,` � PLANNING.&ZONING � �' � /-= %
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SETBACKS " `� , �i < ' � /-- �/
� ,� , , ��. � ' � � � �..� � �
MAINSTRUCTURE-:Front ,�0=0�� '�Rear= 0-0 ��-LeH �^0-�0, � Righh 00>. iJ'/
. _ _ _ ._ . . _ . - , .' �. : � i
� `:. � ' . ' - � . � - �' - /' %�
ACCESSORY Front� ,0- 0� ;� ��� Rear 0- 0 LeB "0- 0 �� Right ���',0- 0. �;-/-
'- �., „ . . . . , , , , ,
PARKING Exlstinpr, 0_ � Required: ':0 ` � Pr000sed: . 0, � � `" �'
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NOTES: � -- . . � . � �.��';�
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requiremenis under California statutes and related
regulations. (Ord. No. 9248, § 1, 12-21-92)
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 this permit to be consitleretl legal, such work musl comply with all applicable codes, and all
required Inapeetions and final approval must be obtained. Failure to obtain inspections and tinal approval will result in tha expira�ion of this permit.
FOR INSPECTIONS CALL: (714) 7545626
2648�4fi �W00)
WORKERS' COMpENSATION DECLARATION:
I hereby aHirtn untllr penalry at perjury ane ot t�e following declaretions:
❑ I have end wil� maintein e certificete of consent to self-Insure for workers' compensation, es provided tor by saction 3700 of the Lebor Cotle, for the pertormence oi the
work far whic� ihis permit is Issuetl.
I heva antl will maintain wo ers' compensation insurance, es required 6y section 3700 of the Labor Code, for ihe peAortnance of the work tor which this pertnit is Issuea.
My workers' comp n Io ura�rrierpeA d policy number are: � ,�+� �
arner: /l�� L � r-../ � PoGcyNumber: Ld I"�B � I,
(This secHon need no��e C6mp eted i e permif �ed at one hundred dollars ($100) or less.)
❑ I certify Ihet in the pertortnance of the work f h this pertnit is Issued, I shall not employ any person in any manner so es to bec e subject ihe workers'
compensat lon lews o i Ce li fornia, en tl eqre
comply with tMese provisions.
Applitant Slgne�ura:
WARNINO: FAILURE TD SECURE WORKEFS' CAMP �
TFKKISAND DOIURE (E100,000), IN ADDITION TO
;ome su b �ect to i he workere' compensation pro�isions of Section 370 t the La Cotle, I shall forthwith
� oeca: 1� 2o O '/
ISUNLAWFULANDSHALLSUBJECTANEMPLOVERTOCRIMINALPE TIESANDC ILFlNESUPTOONEHUNDRED
�TIIXJ,DAMAGESASFROVIDEDf-0RINSECTION3lO60FTHElABORCODE,INiERE ,PNOATTORNEV'SFEES.
LICENSED CONTHACTORS DECLARATION: �
I hereby attirm ihat I em licensed untler provisi ns of Cf�apter commenc with Saction 7000) ot Division 3 of iha Business and Professions Code, and my license is In tull
force and ettect. Lia M qass N
Cantractor's SlgnaN�e: Date: �l'!
CONSTRUCTION LENDING AGENCY:
❑ I hereby aflirtn that there is a conswction lending agency for ihe pertormance of Ihe work tor w�ich ihis permit is issuetl. (Sec. 3097, Civii Code).
Lender's Name: Lender's Address:
SlgnaWre: Date:
OWNER-BUILDER DECLARATIONS:
I hereby aHirtn that under penalry of perjury thet I em E%EMPT FROM 7HE CONTRAC70RS IICENSE LAW for the following reason (Sec. 7031.5, 6usiness antl Professions
Code: Any ciry or counry which requires e permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requiras tM1e epplicent for such pertnil
to tile e signeC stetement that he or she Is licensed Oursuant to the provisions ot ihe Contractors License Lew (Chapter 9(commencing with Section 7000) of Divislon 3 of ihe
Business antl Professions Code) or Ihet he or sha is exempt therefrom antl the basls for the alleged exemption. Any violation oi Section 7031.5 by eny apDlicant for a permit
subjects the epplicant to e civil penalry of not more ihan five hundred dollers ($500).): -
❑ I, as owner of Iha property, or my employees wiih wages as Ihelr sole compensation, WILL DO TME WORK, and the structura is not inientled or oHered tor sale (Sec.
7044, Business antl Professions Code: The Coniractors License Law does not apD�Y �o an owner ot property who builtls or improves ihereon, and who does such work
himsatl or hersetl or ihrough his or her own employees, provided ihat such improvements are not Intendetl or oHared for sele. tl, however, ihe builtling or improvement is
sold within one year of completion, ihe owner-builtler will have the burtlen of proving thal he or she ditl not bu�ld or improva tor purpose of sale.). �
❑ I, es owner of the property, am E%CLUSIVELY CONTRACTING WI7H LICENSED CON7RACTORS to constmct ihe pro�ect (Sec. 7044, Business and Professions
Cotle: The conirectors License Law does not epply to an owner of property who bullds or improves thereoq and who contrects tor such pmject with a contractor(s)
license pursua�� to the Contrectors License Lews.).
❑ I em e:empt under sec. Business entl Professions Code for ihis reason:
Signeture: Date:
Owner ID veAfied by tlrivers license. ❑ Ves ❑ No Drivers License No. Expires:
Verificetlon oi Owne�ship by (type ol document, i.e. - property tax blil or dead):
DIVISION OF INDUSTRIAL SAFETV PERMIT CER7IFICATION: �
❑ I hereby certily thet no exwvatlon five (5) o ore feet In tlepth into which e person Is required to descenq will be matle in connection wlih work euthorized by ihis
permit, end ihAt no building sirucWre, sce old4ig, ialsework, or demolition or dismantling thereof, will be more �han thirty-six (36) feet high. (Chap, 3.2, Gry 2, Art 2, Sec.
341, TNIe 8, Cdlitomia Atlminisiretive C .�I
❑ As owner-builder, I will not amploy eny ne t w hich would require a permit from the Division of Indusirial Safety, es note v��less sy�h person hes a
permit to do sUch work irom ihe divisio � /
Signature:
Division of Industrial Safery Permit
�ate:
HAZARDOUS MATEA�ALS AND EMISSIONS CEF7IFICATION:
1 Will the epplican� or present or future building occupant need to fiie and certify a Business Plan tor emergency response to release or Ihreatened relaese of a hazardous
meterial7 ❑ Yes ❑ No
(Sedion 25505 of ihe Celifomia Health and Safery Code requires, with some exceptions, ihat a Business Plan be filed with the Costa Mesa Fire Depanment by every
business which hes et eny one time during a reponed year a quantity of harartlous matenals equal to or grea�er ihan e weight of 500 Dounds, or e volume of 55 gallons,
or 200 cubic teet of compressed gas at stendard temperature and pressure).
2 Does or will ihe applicant or present or future builtling occupant need to file a registration fortn for aatety hazardous materials? ❑ Ves �] No
(Sectlon 25533 of Iha Califomia Health antl Sefery Gode, with some exceptlons, requlres regisiretion with the Costa Mese Flra Depanmen� by each buslness whlch at any
one tlme has o� hend a quentiry of acutely hezardous matenals equel to or greater Ihan e weight ot 500 pounds, or e volume of 55 gellons, or 200 cubic feet of
COitIDf0556d 985 BI S�enC2rd IBmpBfeWfe entl pfB55ur8).
'm
Of
prepare en
(Section 25534 ot t�e Celitornia Health antl Safery Code provides ihat ihe Costa Mesa Fire Depariment may require Ihe preparation, certification antl tiling with the Fire
bepariment ot en RMPP by businesses which are required to register acutely ha¢artlous matenals with Ihe Pire Department.
...........................................................................................................�...........................................................................................................................................................................................................................................................................
4 If fln RMPP is presently required, has Section 25534 of the Califomia Health end Satery Code been fully complied with? ❑ Yes ❑ No
.........................................................................................................._...........................................................................................................................................................................................................................................................................
5 Does or wlll the applicant or present or tuwre building occupant require for Ihe work which is the subiect of this a plication e permit for such constmction or motlulcatlon
irom ihe Sou�h Coest Alr Oueliry Manegement Disirict or irom eny other eir pollutlon contml dls�nct or agenc�? � Yes �J No
(SeCtlon 65850.2 of Ihe Califomie GOvemment COde requires that the reque5ted information ba tumishetl on epPlications for nomresidenliel bullding pertnit5).
..................................................................................................................................................................................................................................................................................... .......................
6 will en ry P ... ...................................
y part af the lecili to be consiructed undar this ermi� be wlihin 1000 feet from �he outer boundanes of a school9 ❑ Yes O No
(tl yes", the faciliry must meet the requirement oi Sections 25534 antl 42303 ot Ihe Califomia HBalih and Safery Code).
..................................................................................................................................................................................................................................................... .....................................................................................................
7 If e Oertnit from the South Coest Air Oueliry Menegement Distnct or other eir polWtion control tlis�rid or egency is required for the work which is the subject af this
epplication, heve all ot ihe tllsclasu�es prescrib0d by Calitomia Health antl Sefery Code Section 42303 been matle? ❑ Ves ❑ No
B Qf'yes", attach Gert�ncate ot compllance lrom ih�
CERTIFICATE PF COMPLIANCE: I cetlity Ihat
regerding Hazeldous Matenals and Emissions.
SlgnaNre: n ^
CERTIFlCATE OF COMPLIANCE AND i
correct. I egrea to comply with all siate
ebove-descnbed propertytorinspeaion
SlgnaNre Ot
COUE t. INSPECTIONTCPE
t616 Fixetl System Final Fire Prevention
1266 Pool Spa Final
200 Final Re-Roo�
201 Final BIocWRetaining Wall
202 Final Fectory Fira Place
203
20A
Finel Slgn
Finel Damol�iion
penelty of perjury �he information given above is correG�. I agree to comply with all stata laws antl city ordinances
Dete:
:ertity under penalty of periury Ihal I have read ihis epplication antl s�ate Ihet ihe intormation given is
gie-Eai�ling construction, and authonze representatives of the Ciry of Costa Mesa to enter upon the
or allow occupency oi eny building authorized by this permit until final inspection.
�
COUE� INSVECTIONTYPF
206 Final Mechanical
20B Finel Plumbing
210 Finel ElecMcel
212 Finel Fire Pre�ention
220 Finel Planning Approval
222 Final Site
250 Finel BuiltlinglOcCupe�y
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CITY OF COSTq MESA
P.Q BO%1POp
COSTA MESR, CRLIF0.9NIp g�B�40D
ADDRESS SERVICE qF
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fee due 70C
REC�BVED
First-Class Mail
Postage and Fees Paid
USPS
Permit No. G-70
AUG 1 7 2005
CITY Ur w�i,v w�ESH
BUILDWG DIVISION
ACE ROOFING SYSTEMS CO.
`Oti�,D22�N/0 RAN G ETH O RP E �
FULLERTf" ^" " " . . � . � � .
� ' ACEFt02/ 92d331C3G isos os oeiovios
- � FORM 994%
� � �:HCF FOGFING SYSTEM CO
. 0031 M.HSN 5T
�THNTON G!\ 90bd0-2452
gc.c;��/q II�I��II,���II��I��I�II���;�I�I�I��I�I�I���I�I��II����IIII���I
ApDFE550F BUII➢ING: g g 0 CAP I TAL 3 T
oxr+Easru�EiFa�m+:MACKLZN, KENNETIi S
�o"�� MACKLSN ANNA M
880 CAP`iTAL ST
COSTA MESA,CA 92627
�vv�. WuuNc woxess:
AXCNRECTOBFNtlNFEP:
APCII OH FNO.'S ADDNE55:
uc. xo.:
UNT:
UNT:
CONTHACTdI'SIUYE:NOCK PLUMBING (714)895-1296
CQRNRCTORSMNING 11612 KNOTT ST
�ooness: GARDEN GROVE CA uc.wo.: 707775
92841 uNr: 17
LICRlSEU COMRAttOflS OECLGPATION: 1 Mreby aflim uMx penely d pe�jury Mm I em IicenseE uMx pansions of Cheqx 9
(commenarq wilh Senion ]OW) d Oivia'vn 3 d Ne Burimae anA PMeasiona Code, vd my 4mrae o in tull lace eM eNM.
cmuc.No.:050386 uc.cuss:C-36 uc"�77 EXP: 02/98
�.: f—/ S - '�fg c��«: �
OWNER BUILOEN DECLAR�TION: I Mreby eifirm uMer perely M perjury thm I am e�emq Irom tM Contretlae Lironae law Iw Ihe �
Idbwaq reeson (SeGbn n131.5 Busi�aea eM Profeaaions Coda: Any cry or counry whxli nquirea a pe�mM1 lo oonsbuct, allx, impwe.
Eemol'sh, or repei eny avucture, prior ta ib hsuence, eko requiree �M epplirant for euch permil to file e aiB^ed ele�ement Ihet M a eM
e lironaed puiauaM to iM povi+iom d Ihe Coeurmoro Lioame lew IClapx 9(oommend'p wilh Setlon ]000) a �^'ebn 3 d tlr
Bueineas enE Profeeabna COEej or Ihd M a eha e eaemq Ihxahan end ihe beaw /a 11w elbped ezemqion. My violmun d Seann
�osi s M�v roW�� �« e vamn .�,4em �ne wdKem io. d.�i roNM d �a more m.� �ra nu�drea adws Rsoop.
� I. av ownar ol �he propeMY or mY a^dM�s wilh wegee ss Ihar ade compenaelion. will do IM xwk. eM Uro avucNre w nd ime�MeA
w dfarad I« sab (Sxiion ]WJ. Bueim» eM Proleavma Code: TM Comredaa limnsa lew doee ml epply lo en ovmerd propary
who buida w inpeovee ihereon, end who doea euch woM Nmadl a MneL a IMaqh hb a Mr own employeee, peovidad �hm euch
impovememe era nd inleMed a dlered lor sela. II, however, ihe Euikin0 or im0�men1 ie aotl xilhin oiro yeer d mmpblon, Me
o�,«a��ua w�n n� ma w,e� a v��w n, «� ad � w�u « �mw� r« ma wm� d.�).
❑ I. m ovmar d Ine MWsM. em eaduviM' conirea�6 wiN licensatl canlrectae ro conatrua �M vmiea (Seabn lou. euaires. uM
Pmleseiam COEe: The Ganlrmae license Lew Coee ml epqy W an owner d papMy wlw builde a improvs thnean eed xfio
contrecb la auch projeea wnh e mM�edor�s) IiensM Wnuent to the Comredwa lioanse lew).
� I em eumq uMer Sactian: 8. 8 P.C.. la Nw �eeson:
Dete: �Tier
I da hereby ce�lM1/ thet I em ewere d end uMenienC tM reyuiremeMs d Cel�anie HeeXh enE Sebty CoEa Sediam 25W5.255�3, eM
2553a, vM thm I a eny Mure buiMirq aaupent vrill / wil rwi (ofcb me) metl ro camply wih said mme mdu eM �he roquiremeMs br
e pertnX formnewciion a modificelion homtha�'v�0ue ITy�egemenl DMrN1. Raidemiel oonst�udian eppfutiamera ewemqham Meea
we.;s�e.
ome: AoW�em: �
W OflKEN'S COMPEN5ITION DECUR�TION: I Mreby e/firm urder panel�y d pe�jury aie d IM /dbwi�p Eetluetom:
❑ � nwe ana wi� mam�.n. o.nifra�e a oonsen� io sen:reuA �«.axai cwnw�smion. m a� �a M s.r�on a�ao d me �ana.
, COEe. lor ihe peAarmenca M iM xnrk lor which thie pe�m� ie iaued.
� �] ineved,e�;�mdma;��an•cano�m����.m�a��eMsen�a�ooam.�no,coe..rormeo«+am�ame
wak lor whiM iM1is permn ie ivuad. My warkeie mmpanaetbn imurence raner eM poliry number ere:
c�«: GOLDEN EAGLE EXPIRES
rakY N�mna�: 0 9/ 01 / 9 8
(rnis sxrion �eed mor ba canWe'ee l me v�x u ro. wro hu�mee edlamislool w rev.)
� I cenly ih+t in tha pMwmence d �M work la whch Ihie permtl ia iv�ed.�dW anY Perean in enY menner eo ea �o
bacoma wbjetl ta iM warken' mmpemetbn lav.a d Cefilanie. ree J I become wEjeU to tM xakna'
Cq�Ip0fIe9�W11 /pNVIeq11B OI SBdq101o13�I00 W IM LBW! COEB� I 8M19II IO WII�1 COIII 'MI1�11 p 1810fL9.
Oe / � S � / O Applicanl:
Wem/n0� Fallun h axuro woilrsri �o�.�..ao� �.�,y. �, ��I.wwt .�e.n.n,�a��.�.�,omy.� ro�nm�w �.ro...�w
clvll nr�ea up ro om nwered tMuuntl tlo/Nr. fst00,0001, ln Mtlltlan ro M. cast ol mmp�nurron, am�pu aa provMM ror In
Sxtlon 3]P6 0/ fhs Lebor Cor/s, lnfs�saG eM ettomsy� /su.
CONSTHUCTION LENDINO ROENCY: I MreEy alfirm uMer panelly W parlWY �� Ihere ie e wnatrudion bMinp epency la tM
oen��ce a me waic ror.nd, mu v�+ s s.�,ed Iseao� aos�. c:. cl.
LENDEfl'S NAME:
LENOEP'S AODFE55:
I ceniy R� I hew read Ihia eppli:etion eM ame thel Ne ebwa iMwmvion u cortep. I eprae to cwnply wnh dl oy uM counry adinenma
eM aieie lewa rele�ing to build'uq cansorutlion eM hereby eWhorae rtprmentetivee d tAe rily to enler upon tM abwa�memuneA pmparry
�o� ins0etlian WrW�._ _ _ _ . _ _ —__
o�e: � —! S f �
(St51�68.WP) Whue-BuilEiip 8 Sdety; Grear�File; Cenery-AppFrant: Fnk-Revenue; GOIEenm�A+eeesor
CITY OF COSTA MESA - BUILDING PERMIT
PEAMIT NO: P 086455 PLAN CIiECK NO:
CONSTRUCTION TYPE; V-N PERMIT TYPE: PLU
JOH DESCRIPTION : DISHWASHER CHANGE OUT
CI
� -000
PERM NO: P 086455
GOVT: N SUPP; N
PURPOSE: OTH
SQ FT:
CLAIM VALUE: CALC-VALUE; GROUP OCC; R-3 /
COMMENTS: NO OTHER WORK ASSOCIATED WITH THIS PERMIT
+t*at**�rititx it*�*�*+t+��*�+rit**x+r*+r�r+�*�it�r����r+t+r�r***�**�***+r**�*�*��r�*+r+r*��r*�*�r+�*����it�r
Z O N I N G R E Q U I R E M E N T S
S E T B A C K S
------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING ---------
FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT ZN
LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
PARKING REQ: PROV: PARCEL: 92239111 2NE: REF NO:
PLANNING NOTES>
7
if iF ik ik iE it * iE iE IE iE iE iE ik iE if 3E iE iE i! iElE iF IE if iE iE it iF ik if iF iE iF iE iE ik iE iE iE iE if iE iE if i! iE iF ik 1E iE iF iE if 1E iE �lt it iE ik iF ik iE iE �E iE k if it iE iE iE i! iE if �E iF iE iE
D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S
ZONZNG APPROVED HY DATE:
HUILDING APPROVED BY : DATE:
DATE:
1E�EiF1FiFiFifiF i@�
STRUCTURAL SEGMENT:N
APPLICATION ISSUED BY: "
k iE iE 1F iE iE �F �t iE iE aE iE 3E �k 1E 1E'1F if 1k iE if 1E
LEGALIZATION:N F E E S U M M A R Y
HLDG PMT PLUMBING ELECTRIC MECHANIC
PERMIT 8.75
258
PLAN
ISSUE FEE 22.00
BUILDING-DIV-> PERMIT ISSUE PLAN-CHECK
TOTALS----> 8,75 22.00 0,00
REVENUE DIVISION TOTALS--> COLLECTED: 3
BLDG PMT PLUMBING ELECTRIC MECHANIC FIR
30.75
FIRE SMIP/RES GRADING
SMIP/NON-RES
TOTAL PAID DUE
30.75 30.75 .00
0.75 OVER/SHORT: .00
E SMIP/TOT GRADING PLAN-CHECK
1f iE 3E ik iE if 3E 1E'1E ik'k �E 1E 3f if iE 1E iE iF'lE'1F if iE'1E if iE ik 3k if if if it if ik Iklk iF iI' 3E ik 1E if if'lf ik if iE 1f 1f 1F k i6 iE i(�!E iE'� 1E jf if 1f iE jE 1!'1E iE iE iE iE �f if'1f i! if ik jk aE iE'1E
I N D I V I D U A L F E E B R E A K D O W N
TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST
PLU 1 DISHWASHER 8.75 8,75
END OF FEES
�Xp:i�ED
DATE -� b � .�-0(7
81-IS-1998/89:58 q!I/f38.75
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PERMIT:086455
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INSPECTIONS LIAI
Form 210—SM-11-59 S-B P
DATE 1'25—�1
BUILDING PERMI
CT FIRE ZONE DESCRIPTION OF WOAK Res
DATE I GROUP I& J TYPE V ZONE
�3�L.�I SUBCONTRACTOR � PERMITS ISSU
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COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 917 COBTA MEBA, CALIFORNIA
For Applieani fo Fill In Complefely
TYPE OR PRINT
BUILDING �('/ii �Q �'TU � �
ADDRE55 O (J
COSTA MESA. CALIFORNIA '
OWNER ���V�J I�J�1 �1CO�S�/✓
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DESCRIPTION OF WORK
X ZO ROC
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STORIES
7 R�i% S
FEE RECEIVED
6 J�N 2 s �sst 6(��
FINANCE DEPT.
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For Oftice Use Only
RECEIPT NO. PEHMIT N�
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FIRE
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APPROVED .
BY .��I– DATE ��
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Z I NO. OF USE OF NE�j'�
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DESCRIPTION
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YARDS EVES
— APPROVED ALLOWEP
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APPROVED
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I HEREBY ACKNOWL¢OGE THAT I HAVE READ TH�9 }PPLIGTION TX2 AMOUNT SXOWN UNDER VALUATION I6 FOR TH¢
AND BiATE THAT TXE ABOVE I6 GORRECT ANO AGREE TO COM- pURP088 OF. EBTABL�SHING A PERMIT FEE ONLY.
PLY WITH ALL CI1Y ORDINANCEB ANO 9TATE LAW6 RE6ULATINO
BOILDINO CON9TRUGTION. VALUATION o-fj
SIGNATURE OF � PERMIT FEE $ e� �—
PERMITTE / / / �J J—
� $/5 /_ /_� PLAN CHECK $ � /
AUTNORIZED AGENT / ��/ �/ '�a �5a
TOTAL FEE