HomeMy WebLinkAbout3001 CAPRI LN - Building PermitsPP0.IECT AODPESS: 3 O O 1 CAPR I LN
i �UWNEfiSNRME: VARZAK NICHOLA:S
aoosess: 3001 C�aPRI LN
C05TA MESA,CA
540-8813
AflCN/ENGINEEX:
RODNESS:
uxir:
92626
HEG.NO.:
UNR:
PEp"unEE: HOMESTAR ROOFING ( 714 ) 538-1878
nooeess: 1539 ORANGEGROVE B
ORANGE CA 92665
LICENSEO LONTNRCTOP OECIAflATION: I hereby allirm thal I am licensea un0er provisions ol Chapter 9(commencing wii� Seclion
7IX10� ol pivision 3 0l Ihe Busines5 an0 Prot¢ssions Cotle. and my license is in lull lorce anC etfect.
ciTruc.: pyq971 STqTEUC.:SS6iOS cuss: C-39 /�
� Z �� -Q
Date: 4`�G � I Signa�ure: �� `P ti+
WOBREflS' COMPENSRTION OECIABATION: I �er¢�y aliirm Ihal I have a teM1ilita�e oi ton5en� Io Self-insure Or a CertifiCa�e 01 Work¢rs'
Compensalion Insurante. or a certilietl top thereol (S¢tlion 9800. LaU. C.
eoucrNo.: PWC1143]7—�10 EXP.ORTE: �9IOII93
can+vnxr: GOLDEN EAGLE
❑ Cenilietl capy is �ereEy �umi5�ea. � Cenifie0 coOY is IileE with �he cily Builtling Oivision.
ne: 7 ��b �Y? Applicanr. � r' Co QA4
E%EMPt10N FBOM WOflNEflS' COMPENSRTION DECIAPRTION: (1Ais secibn neeE not De comDleteO if the perrnA is lar ane Au�reO (510� or less�.
I cetlify IM1aI in I�e pedormance al �he wark �Or whic� �his permit is is5ue4 I shall not em0loy any person in any manner so as lo become
SUUjet1 lo I�e Worker5' CAmpenSalion Laws ot Califomia.
Date: Signature:
NOTICE: If. alter making ihis Ueclaration, you shoultl become sublect ta t�e Workers' Compensation pmvisions of Ihe Labor
CoGe, you musl lorthwi�h comply with such provisions or this permil s�all De Aeemed revokeE.
LONSTBUCTION IENOINC AGENCv: I herNby aifirm that there is a constmction lending agency for the oe�ormance of ihe work lor
�� wNc� I�is Oermii is issue0 �Seclion 3097. Giv. C).
LENDEP:
ROUflESS:
OWNEfl BWLOEN OECLAflRTION: I hereby afiirm Ihat I am ¢x¢m0� ��am Ihe CanVactors' State License law lor ihe followinA ��n
�Seciion 7031.5 Business antl Pmfessional Coee: Any ciry ol counry w�icA rtquires a Dermit to consimcl, atter, improve, tlemoli50. or
repair any Slmclure, prior lo ils issuance, also requires the ap0licant for suc� permi� Io lile a signetl sta�ement lhat he/s�e is licensed
pursuant io t�e Omvisions oi ihe Cantrac�ors' Sia�e License Law (Chapler 9(cammencing vnth Section 7ppp) oi Division 3 0l Ibe Business
an0 Protesvons Co�e� ar that he/S�e is ecempt ther¢�mm anU Ihe basis �Or I�e alle0e0 eMemp�i0n. Any vioWiion ai Set�ion 7031.5 Gy
any aOV�icant for a Dermit suGiecis I�e aOVli�nt to a civil penalty ol �Mt mort Ihan live hunOr¢E Gotlars (E500�.
I, as owner ol �he pmpeny or my emVlayees vnl� waqes a5 IAeir sole campensatian, wi0 Ao �he work, antl I�e
❑ simcture is not imenaetl or ouereU ior sale (Seciian 70a4, Business anC Pmiessional Cotle: The Comracmrs' State License Law
Coes noi apply lo an owner o� a pmperty who GuilEs or imDmves I�er¢on, and wM Ooes such work himselt/hersell ar I�mup�
�is ar Aer Own emD�oyees. provi4eU ��al suc� impmvemenis are not intenGed or allered lar 5ale. II, however Ihe buildinA ar
imOmvement is 5010 wilhin one year pf Completian, ihe owner vrill have t�e OurGen oi O�oving he/s�e Eitl not 6uild or imDmve
loi I�e Durpose oI Shce�.
I, as owner ol I�e pmpetly. am eecl45ively contraciing wilh Iicense0 conlraciors �o con5tmci �he pmlec� (Sec�ion 7044, BuSinesS
❑ antl Protessions CoOe: The Comractors' State License Law Goes not apDly to an mvner ol pmperry who builds or improves Ihereon
an0 who toniracls for such Omiectg with a contractorls) license pursuant to Ihe Coniractor5' State License Law). I am aware
��at O�ool ol iheir Worker's Compensa�ion inmrance snoul0 Oe pmviGeE �o me.
� I am exemp� untler Section: 8. 8 P, C.
lo� Inis reason:
Dale: Uvnec
I Go here�y ceNly ��at I am aware oi antl up0ersiand t�e requiremems of Calilomia HeaIN an0 Safety Cotle Sec�ions 25505. 25533, antl
25534 and Ihat I or any luWre builtling occupam willlwill no� (circle onq need �a comply wi�h saitl slaie co0e5 antl ��e requiremenis �or a
Dermil lo� cons�mclion or mo0dicaiion Imm �he Nir �ualiry Manapement Oistnc�. fle5�0en�ial constmction aDP����ions are eKempi �mm
Ihese oravisions.
Oale: /lpplican�:
I here�y cerii�y Ihal 1 have read I�is a001icaqon antl stale Ihal Ihe a�ove inlormation is rort¢c�. I agree Io comply wilh all city anG couniy
orGmanc¢s ana state laws relaling �o GUBtlmg rqn5tmciion antl hereby aulMr2e re0�esenlative5 oi Iltis dry to enter upan I�e above�menlionetl
D�operly �por in50et�i/on puryoses.
�ate: 7—�f� `� 7 2 Signaiure: ���Q�
\
od�er's ucense or Sodai 5ecurny
i6a1-46 W�ne—Bwldmq; Green—Cotle Enlorcemem: Canary—Aoolicenl: Pink—Revenue: Goltlenrotl—Assessor
CITY OF COSTA MESA — BUILDING PERMIT PERM NO; H 05910�
PERMIT NO: B' 059109 PLAN CHECK NO: N GOVT: N SUPP: N
CONSTRUCTION TYPE: V—N PERMIT TYPE: STR FURPOSE; ALT
JOB DESCRIPTION ; T/OFF RR W/48SF MAXITILE ICH04t3682 SQ FT; 13,800
CLAIM VALUE; 13,800.00 CALC—VALUE: 13,800,00 GROUP OCC: R-3 /
C,OMMENTS; RR W/ MAXITILE & COMP
iE iE iE �lE #�%�IE-)f 9E-IF �%iE df �1F iE �h 1E �lE if �fE iF�lF �� iE iF�% IF 9k�%� �If �� if �f k�%-k �IE �1E i4 if iE if 3E if �l( �k iE �%��(-dE lf iE�IF �k �lf 1E iFiF�lf-iE iE iE �K� �E �%� %iE-%� if �� if dE fE 9t �1E iE #�lF-%
7. O N I N G R E Q O I R E M E N T S
S F.. T B A C K S
------------ MAIN BUILDING ---------- --------- ACCESSORY B[7ILDING ---------
FRNT: FT IN REAR; FT IN FRNT; FT IN REAR: FT IN
LEFT; FT IN RGHT; FT IN LEFT: FT IN RGHT; FT IN
PARKING REQ • PROV; PARCEL; 13954319 ZNE: REF NO:
PLANNING NOTES>
� i• "
if iF �F ib iE it iE iE iE iE iF iF 1E �F if 1E �E if iF i! 1E iE af 1E k iF iE iE iE iE �f iFiF iE iFif aE iE i41E iF iF iE iE i! iE 3t if if i! iEiF?f 3F iF iE iF �lE jE iE iE iE if X� aE 3k 1( iE IF 3E if iF 3� R iF iF iE iE iE
D E V�:L O P M E N T S E R V I C E 5 R E Q U I R E M E N:T S
ZONING APPROVED BY DATE:
BUILDING APPROVED BY ; DATE; '
�
APPLICATION IS$UED BY; -S/�i' DATE: O'� )(j�Z�
if�itifiFifiEiEihikifiFiF3EfF�lfiEiFiFitiE3kiF r f � i4ifitkifibiFifif}F�"�'�'���iE#�
iFjE1ElfiE1ElkitiEiEiEiEiEiE�FikiFiFifiEifiEiFifitiE3Ejf#iE1flEikiEilif�EifiFiki F3EikiEiFiFifiE iE1EiFiefEiEifiEiElEiFif3f�ElfiFiE'14�E#�iEiF*jFiEiEiEiFih
LEGALIZATION;N F E E S[ M M A R Y STRUCTUFiAT� SEGMENT:Y
BLDG PMT PLUMBING ELECTRI MECHANTC FIRE SMIP/RES GRADING
PERMIT 153.00 1,38
SMIP/NON—RES
PLAN �
ISSUE FEE
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
TOTALS----> 154,38 0,00 0.00 159.3A 159,38 .00
REVENUE DIVISION TOTALS--> COLLECTED: 154,38 OVER/SHORT; .00
BLDG PMT PLUMHING ELECTRIC MECHANIC FIRE SMIF/TOT GRADING PLAN—CHECK
153.00 1,38
iE iE iE iF iE iE j("1(-iE if iE iE iE lE 3E 3F if iF 1E 1E iF ik 1E iF iF iE iE iE fE 1(� if iP iE iElE iE iFif iE 3E ik 1E iE IE 3E iE 1F if iE * iF 1E if iFlE iE if iF 1E iF ik 1E iE iE ik iP if if 1EiF iE �E iE iE i't iE !F!(� if
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 C05T
SFR 13800 REROOF BY VALUE RESIDENTIAL NOZONE 1,00 13,800,00
END OF FEES
� CONSTRUCTION AND PLANNING POOL &_ A
�APPROVALS Permit# Date Inspector qppROVALS Permit,'`k 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. Electriwl Conduit-Undrgrnd. 55. ElettriWt Bond�ng
5. Steel Reinforcement 56. Rough Plumb�ng & Pressure Test
6• Electrical UFER Gmd. 57. APPROVAL TO COVER�GUNITE
7. Footings 58. Etectrical Conduit•Undrgrnd.
8. Foundation 59. Gas Pipe, O Undrgrnd., Test
9. Wat¢r Pipe�Undrgrnd. 60. Backwash �ines, RTrap, � Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
17. Property Sewer Line & House Connection 62. Backwash & Feceptor•Final
72. Sewe� CaP 63. Heater & Vent-Final �
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing � 65. Electrical�Final
15. Rough Electrical-Condu�t , � 66. Solar System-Final
16. Rough Elearic Wiring ' 67. Fencing & Access AnPioval
77. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical�T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heaiing & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVAIS Permit #
21 . Ducts, in Structure 70. U�derground Hyd.o
22. Ducis, Ventilating 71. Product Piping OGas ❑Oil
23. Gas P�Pe�Rough & Test 72, Underground Flush
24. RoofFraming 73. Undergrnd.StorageTank�Gas ❑Oil
25. Roof Sheathing �(S ���� 74. Overhead Hydro
26. T•Bar Ceiling (StrucWrai) & Monocoat 75. Dry Chemical
27. Freme and Flashing 76. Dry Standpipe
28. Lathing & Siding � � 77. FIXED SYSTEM FINAL
i
29. Insulation I I ' 78. FIRE PREV. FINAL
30. Drywall Nailing � I � HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat � 79. FINAL INSPECTION
32. Electrical Power Meter-Final ' 80. FOOD CERTIFICATE ISSUED
33. Fina� Electric � � Notes:
34. Final Hea[ing & Ai� Conditioning �
35. Final Gas Pipe-Test �
36. Hood or Canopy �
37. Fina� Factory Fireplace
38. Final Plumhing
39. Water Service=Final
40. Gas Service-Final
41. Solar pomesiic-Final '
42. Backflow Preventer . '
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING )/l��l r�t!'��
48, FINALPLANNING �
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
51. CEFiTIfICATEOFOCCUPANCY
No. Date
�
- " Carter si�n Ca�pany
2'7� W 5th Street
Santa Ana, California
Attetttlon: Mr. George Tintle
�:._
Jenuary 14, 1966
Sub�ect . 3ign located at 3001 Capri I,ane
Leasee-- Mesa Verde Realty
Gentlemen:
Field invest:[gatian has revea d thet the sign on Lot 28�
Tract 2998, Pes�it No. 21467 vhich s erected on Jaz►uary 22�
19fi4 ia et111 up.
As you lmov these �s sre Permittefl for one year or
until the houses in the t ct or lots,as the case may be, are
sold� xhichever is sooner.
We w appreciate your comtacti.ap t,his oYfice at your
earliest con ience concerning either removal of or reneval
of thie eign.
rlb
Very truly yours,
David 21ei'ghton
Senios Planner
> �
e
CITY OF_COSTA ME$A, (
t'
�'
�
;.
�.
IFORNIA
OWNER'S NAME R°bert E. Caznp �
ADDRESS OF STHUCPURE
3001 Capri I,ane �
DA,FE: Apri1 26, 1966
I hereby acknowledge that I have been informed by the Building
Safety Department that the soil in this area is of an expansive nature when
vater penetrates and that the Building Sa.fety Department recotmnends slab re-
inYorcement. Meeh reinforcing is not con�idered adequate. I i�rther agree
to hold the City of Costa Mesa harmless in the event of ar�v failure of slab
or Yooting. �
0
e
•Signed• /
� signatuze of ovner
. �
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„ . . . _ -��,—� -z,----rr-�-- . . „
0
CITY OF COSTA MESA
�_= Building Safety Depariment
' 21467
Application for permit for the 4abrication and erection oF classified signs.
Location
Building $ite Address ���� � ���\ L�tNE_
T°9 No. a� FEE RECEIVED
Type of Sign � � �.�I.u�) 17AIF 2 2 �8s4
❑ Elec. � Non-Elec. � FINANCE OEPT.
Name of Leasee ����A �lF�n� �F41�-Z�' Phone
Contractor CAR��� 51C�1� CNI�\�(�hiY State License No. ��l � S'�%—
Address Z1 11�\AL_ _��' S i. City SANTh {�\V!� phone �\ —1 l Cn �,
Architect or
Engineer State License No.
Address
Description: �Tract Sign
•— �
� Appurtenant and Incidental Advertising Sign
❑ Off•site Advertising Copy $ign
Phone
� Roof Sign
❑ Gas Tube, Elec. Sign
Sec. 1.37, 1.44
Two copies of plans and specifications shall be submitted with application for permitfor each sign. Plot on plan
sheets proposed� location of sign and locations of all other signs at site. Minimum size sheets SHALL be 18" x
24" and non•erasable.
� If between property line and established setback line, owner is to sign written agreement with the City.
$ignoture of Properiy Owner
Date
C�TY OF COSTA MESA
FO OFFICE USE ONLY
Date Issued �-" �� Permit No.
Fire Zone Type Group
Approved by Date /z `
PLANNING DE TMENT
Zone�—� A. P. No. �3 1— y� Z— ��
BIdg,Sire Address 3�0/ C�+Pr(� `-�/ne,
Legal Owner "`in�/t �+✓/.lpi r �opir �1'!.r .
t
Address 63a W� � �� �'h�/
C�ry Las ��e�ta Ca�i�-
Area of Sign: � ft. — in. X�D {t. --��, = 60 �
Required Bldg. Setback to
Center line of Street
Location of Sign:
Behind Bldg. Setback Line []
Between Property Line ond
Bldg. Setback Line (�
� oL �✓� o�7e-
Front 30 � � % Feet �`
The undersigned hereby agrees to fabricate and erect the advertising structure within the intent and meaning and Right 7 7 t Feet
in strictaccordance with the provisions of Ordinance 63-13, Ordinance 344, the Electrical Ordinance of the City �,o � /
of Costa Mesa, and all amendments thereto. Left yG (� �` 'C7 Feet �yO�' r��i pr
ALL APPLICATIONS MUST BE FILLED OUT BY THE APPLICANT. ALL FOOTING, FRAMING, ELECTRICAL projection�oH � Feet
AND FINAL INSPECTIONS SHALL BE CALLED.
Ground Cleamnce �� � Feet —�
$ignature of C. U. P.�C. ' Date Approved
Permittee C�R��=i� 5��+�\� i"E'1 The amount shown under Valuation is for ihe purpose of
establishing a permit fee only
Clearance Chap. VIII, Art. 5. Section 8504 (b)
Authorized Agent � W�A VALUATION Permit Fee $ � --��yr$�g� ture (Planning $taff)
Recd. by �
FORM BU-30-1M-]/63
Date //�� l � � �
Plan Check$
Total Fee $ � �
Signoture (Dept. of Public Works)
Date: ��Z- L ���
JOB ADDItESS
GEN�RAL COS
Uate! _ GROUP I&J TYP]
SUBCONTRACTOR
� 25600
'COS:A MESA BUIIDINCrSAFETY DEPARTMENT
: P.O. BOX 72110 COSTA MEBA� CALIFORNIA Y2E7D
For Appllmm fo F(il In ComplNely
TYPE CR PRINT
COSTA ME3A. CALIFORNIA
86Tp�CK LIN6IM01�
DESCRIPTION OP WORK
�OD
1 N[R!!V �CKNOWL[pOQ TNAT.1
•NO BTAT6 TXAT TM[ I1pOVt ID
PLY WITN ALL C�TY OR
eu��o�xo coHstrtu
H16NATLN! Or
PeRM1TTe
AUTN0111I[D AO[NL
e �o�. Q
ua To cor.
ncouu�nna
CiTY 0� C�sSTA MtSA
APR 19 1966
1rPLICATION FOR PERMR
ILD ��i For ! �� �'
NO.O! U�[01
�un� � euLLou
uo��
/4P.N0. /..�1 % �� Io � �Ur/
NOTE: NO EAV E OVERHANO tHALL DB LBHB TMAN
VARDOMPROVED I YARDeMPROVBD
MAIN BUILDIN6 AGC6880RY BUILDINO
VAN. $
i— �o �j I DAT6 L{ — I p—
v �
L W
HOLD FO}' SPECi L RE F �
^'y� `�
,�OOso.rr. � �q �
TXQ AMOYM �NOV/N UND6R V�LUATION IB /OR TMG �
'URP09i 0► ffTApYBXINO A P[11YIT IH[ ONLY. �
VALUATION � �p �
PHRMIT FEH
II33� 3'74 9 A w°
�vwivr;n �tunr, nooerc L. DAT�
JOB ADDRESS 3001 Capri Lane Buu.�
�f
�: GENERAL CONTRACTOR Owner-Bldr. DESCRIPTION OF WORK F
Date
Final
SUBCONTRACTOR
:-� 2C51 I
' �COSTA MESA BUILDINCrSAFE7Y DEPARTMENT
� P.O. BOX 12M COSTA MESA, CALIFORNIA Y2E2E
�
For AppltcaM fo Ftll In ComplNely
TYPE OR PRINT
�uao�Na 300 L 1 'E,
�ooRenn
CO3TA MESA, CALIFORNIA
owNs� ob e�- E-LAMP
MAIL 3001 CAptz� LtR�1E
ADDq
i• ��_ ..� SQc3'IL
6TATH
LIG. NO.
61ZE
OF LOT �'4 /
U8B OF
HXISTINO BLD6.
BETBACK LIN[ fROY
T¢L
DESCRIPTION OF WORK
WALL
'1 N[R6GY ACKNOWL
♦no er�n Txwr n
PLY WITM ALL GITY
sU1LDIN0 CONBTRII<
� AUTMORIZ[D AO[tfr
�
NO. OP
�ROO�MB
I ROOr
JAN-9-67 00 257 �***�`*3.00
A►PLICATION FOR PERMR
DUILDINO
For Of((c� Up Only
�
� zoNiNc . v
mI1� No.or u.aornsw{� 1'�Lr
LJ �/ ►IAtI� 2 �YILDINO \Jy i
� �
"°"� �T � � ��i-rz z9
oucnimon
A.P.NO. J � � ��b Z —'��
NOTB: NO EAVE OV ERHANO 6HALL BB LE88 TNAN
/ ALLOWED
YARDDAPPROVlD
MAIN BUILDINO
(FqOM C/LY�A[[T)
NT 7 �
R. QID
/
L.HID FT.
RBAR O IT,
DI@TANC6 B6T.
MAIN BLD69.
VM•#
HAV[ 11fAp'(NI� A►►LIGTON
COpR[C1' AND AOII!{ TD COY.
AND �T�Y�},AW� 11tOy4TN0
YARCeAPPROVHD
ACC6980RY BUILOINO
Q
DAT6
a
m
�
ec. �r. �
TN� AMOYNT tNOV✓N YND611 VALUATION �B IroP TXB
IYRtOG[ 0/ �I�AGLIDHINO A P6qYlT Pi8 ONLY. �pI
VAWATION O0 � CQ 7
PHRMIT F88 �
s� SU w
a
3 6U
TOTAL P6H
UWNtK
UAIt
BUIL[
ERAL CONTRACTOR Bill Berrv DeSCKIY I IUN o� wuKK tslocx wall _
lo. 19Q-462-01 LOT 2a TRACT 2995 FIRE ZONE VALUE 3 1,600.00 _
SUBCONTRACTOR
ROUGH PLUMBING
PROP. SWR. LINE �'
SPRINKLING SVSTEM
AN� AIR CONOITIONING
VICE OR POLE
ROUGH WIRING
TRENCHES �FORMS " $TEEL REINF.
FLOOR SVSiEM
BOND BEAM n STEEL REINFOftCE n
SHEATMING
FftAME AN� FLASHING
LATHING - IN n OUT
PLASTER. BROWN COAT
HEATING, VENT., REFFIG. AN� A.C., FINAL
PLUMBING, FINAL AND GAS TEST �J
F INAI
BUIL�ING, FINAL
,�' 3b585
� COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COS7A MESA, CALIFORNIA 92626
For Applicant to Fill in Completely
BUIIDING � e
ADDRESS
OWNER C
MAIL
Z ADDRESS �.
W W TEL.
a U CITV D NO.
Z
Z Q CONSTRUC�ION
a m LENDER
J � BRANCH
J N
m J AODRESS
J m ARCHITECT TEL.
a OR ENGINEEF N
U N
Q
w ¢ ADDRESS
p, w
J O CONTRACTOR �
m Z
J� ADDRESS Q C(.
w w TEI.
�= CITV . U NO.
Z F-
w � STATE CITV
y� LIC. NO. IIC. NO.
� � $IZE NO.OF BLDGS.
OF LOT NOW ON LOT
'USE OF
EXISTING BIDG.
F" SI2E OF NO. OF
Z NEW BLOG. ROOMS STORIES
V E%TERIOR WALL ROOF
COVERING COVERING
J USE OF BUILDING AND WORK TO BE PERFORMEO
a
a
a ��
� 1 �
F-
ti
Z
O
UI hareby acknowletlpo thot I have reotl this eppliceNon and state
� that the ebove information Is correct antl apree to comply with
� all laws regulatlnp build' struction, antl I shall not employ
F„ any person in violati of the orkman's compensation laws of
y the State of Califor
z1 hereby certity th I am erly licen es a conbacror untler
the Stete of Colif m B iness ontl Professi m Code, Divlslcn 3,
Chapter 9, entl t � su licenses ore In full rca antl offeet, or I
am exompt from the pr v ns f MaStero rnia sm
antl Prof slons nve, Division , optar
Signatur ot
Permittee
Authorized Agent
rwl n�
'9'�'_ 'j
[ 1' I /� . ....'..1 ` .JV
APPLICATION FOR BUILDING PERMIT
A.P. NO. �
BUILOING
ADDRESS
FIRE
20NE
APPROVED
20NE NO.OF
PLANS
YARDS APPROVED
DI5TANCE BET
MAIN BLDGS.
V AR. �
VALVATION
� ��4v
LOT BLOCK
ALUE OO
$
GROUP
DATES���
SE OF NEW 'I
IILDING LOC� K
VAROSAPPROVED
BEf. MAIN &
ACCESS. BLD
DATE
STATE
Q `_' m
O
!N VNDEF VAL N IS FOR �
laBLISHING A PERMIT FEE ONLV' m
¢
/' m
PERMIT FEE 5 �
7
m
PLAN CHECK § �_ E
2 0
LL
TOTALFEE $ �—