The URL can be used to link to this page

Home My WebLink About185 FAIRWINDS LN - Building Permits • Opectti4;11, CITYOF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENTPERMIT NUMBER PERMIT E99-00459 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesaELECTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 185 FAIRWINDS LN Status: FINALED Suite No COssued: 05/25/1999 Vicinity: v VI ssued: 05/25/1999 Parcel Nunmber: 41914209 Applicant: MAGNESS, JENNIFER ISSUED BY: LIr 1 Address: Phone: Zip Owner: STEPHENS, BARBARA JEAN Address STEPHENS,CARL J COSTA MESA,CA Phone: 185 FAIRWINDS LN Zip: 92626 Contractor: MC KENNAS AIR SUPPLY Address: 1207 S ST COLLEGE Phone: 714-879-4444 FULLERTON,CA Zip: 92632 License:626029 SCOPE OF PERMIT 3.5 TON A/C UNIT&75K BTU FAU UNIT CHANGE OUT. REPLACING EXISTING UNITS. REF:M99-00248. FEE SUMMARY Quantity Quantity ISSUE FEE $22.00 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3•units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixtg $0.00 0 • up to 50 kva/kw $0.00 0 Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0 Switches $0.00 0 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 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 considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(6/00) DECLARATIONS ° WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed iY the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit is Issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS COMPENSATION COVERAGIS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPE I (DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: i —r r f'' I hereby affirm that I am licensed under provisions of Chapter 9(commencing [v Ijii See,tion'' 00)of D ision 3 of the Business and Professions Code,and my license is in full force and effect.Lic.a i.3" Class N Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the properly,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: O I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). O As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has e permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature end pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP Is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes u No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed Under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑No 8 (If'yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE MD AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) Date And/Or Authorized Applicant Date ODE 6 INSPECTION TYPE PAIL INTRULS PODEI INSPECTION TYPE, PATE INTRIALS 1616 Fixed System Final Fire Prevention _ 206 Final Mechanical 1266 Pool Spa Final _ 208 Final Plumbing 1 L�, /�.,, 200 Final Re-Roof _ 210 Final Electrical /Q",/'f by. 6x' CvJ 201 Final Block/Retaining Wall 212 Finat Fire Prevention __ // 202 Final Factory Fire Place _ 220 Final Planning Approval 203 Final Sign _ 222 Final Site 204 Final Demolition _ 250 Final Building/Occupancy Res Appl Service to 200a Service to 1000a Service over 1000a Motors to 1 hp Motors to 10hp Motors to 50hp Motors to 100hp Motors over 100hp drops $0.00 Sub panel to 200a Pole Light Pkg Sign Circuits Temp Pwr Pole Intermed Pole $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $11.00 1 $0.00 0 $0.00 0 $0.00 0 0 Investigation Fee $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 __ I Low Volt Wiring System / Ckt Misc. Conduit Misc. Conductor Circus ( gen or ride) Circus (mech ride or lights) Christmas Tree Stand Fireworks Stand Other Electrical Fee $0.00 Plan Check Fee Reinspection Fee $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TOTAL CALCULATED FEES $33.00 COMMENTS / SPECIAL CONDITIONS 0 0 0 0 0 0 0 Communication CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT J �mP PERMIT (714)754-5273 • Fax(714)754-4856 Job Address: 185 FAIRWINDS LN Suite No Vicinity: Parcel Number: 41914209 Applicant: MAGNESS, JENNIFER Address: Owner: Address: Contractor: Address: FULLERTON, CA Arch/Eng: Address: MECHANICAL PERMIT STEPHENS, BARBARA JEAN STEPHENS,CARLJ - COSTA MESA, CA 185 FAIRWINDS LN MC KENNA'S AIR SUPPLY 1207 S ST.COLLEGE , Phone:(714)879-4444 Zip: 92632. _ License: 626029 " Phone: Zip: Phone: Zip: 92626 Phone: Zip: License: SCOPE OF PERMIT 3.5 TON A/C UNIT 8 75K BTU FAU UNIT CHANGE OUT. REPLACING EXISTING UNITS. PERMIT NUMBER M99-00248 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: ISSUED Applied: FEE SUMMARY Issued: 05/25/1999 Quantity ISSUE FEE $22.00 Repair /'Alt Absorbtion Unit Inst FAU <100 k BTU $13.25 1 Repair/ Alt Refrigeration Unit Inst FAU >100 k BTU $0.00 0 Ventillation System Repair / Alt Cooling/Heat $0.00 0 Evaporative Cooler Inst / Rep. Recess Wall Htr $0.00 0 - Commercial Incinerator Refrig. Sys <100 k BTU $0.00 0 Domestic Incinerator Refrig Sys >100 k BTU $0.00 0 Compressors / Absorption Systems Gas Piping , 1 , $0.00 0 Up to 3 hp / 100k BTU Factory Fireplace "' $0.00 0 , . - ,. 3 To 15 hp / 500 k BTU Hood w/Mach Exhaust - 50.00 0 .: .- 15 To 30hp/ 1,000 k BTU' VAV Box - $0.00 0 • .. 30 To 50 hp / 1,750 k BTU Vent Fan / Single Duct - $0.00 ' 0 . Over 50 hp / Over 1,750 BTU Appliance $0.00 0 Boilers Fire Dampers .. $0.00 0 - _ Up to 3 hp ' Smoke Dampers $0.00 0 3 To 15 hp - - Inst or Relocate Appl Vent $0.00 0 - 15 to 30 hp Air Handlers < 10000cfm _ $0.00 0 - 30 to 50 hp Air Handlers > 10000cfm SO.00 0 Over 50 hp Floor Furnace SO.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee Plan Check Fee Reinspection Fee TOTAL CALCULATED FEES COMMENTS / SPECIAL CONDITIONS V -V Status: ISSUED Applied: 05/25/1999 Issued: 05/25/1999 Quantity $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 '0' $0.00 ' ,0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 $0.00 $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 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 considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5628 DECLARATIONS WORKERS' COMPENSATION DECLARATION: - I hereby affirm under penalty of perjury one of the following declaratlens: 1' ❑ 1 have and will maintain a cenHicate of consent to salt -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. and will maintain workers' oomperssa8on insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this pemlit is issued. My workerl' cc!TensaInsurance carder and policynumber ere: Carrier: Co( -�!>07 Policy Number: (This section need not be cornpleled if the permit Is valued atone hundred dollars ($100) or less.) ❑ I certify that In the performance of the work for which this pernit Is Issued, 1 shall not employ any person in any manner so as to become subject to the workers' compensation law of Celifomia, end agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these p visions. Applicant Signature: Date:r7 WARNING: FAILURE TO SE ORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100.ODO), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that 1 am Ilcen ed under provislons of Chapter 9 (commencing with Section 7000) of Division 3 of the Buslnesss and Professions Code, and my license is in full force and effect. Lic. a Class e Contractors Signature: Data: C - CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.E by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a Person Is required to descend, will be made in connection with work authodzed by this pernil. and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Dale: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need 10 file and certify a Business Plan for emergency response 10 release Or 111realened release o1 a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant Or present or future building Occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight Of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does Or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code Provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant Or present or future building occupant require for the work which Is the subject of this a plication aemit for such constructlon or modification from the South Coast Air Quality Management District Or from any other air pollution control district or agency? Yes 8 No (Section 65850.2 of the Califomla Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 OI the California Health and Safety Code). ... _. 7 If a permit from the South Coast Air Quality Management District or other air pollution controll disrobe or agency is required for the work which is the subject Of this application, have all of the disclosures prescribed by California Health and Safely Code Section 42303 been made? ❑Ves ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described Property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. Signature Of Legal Owner(s) Date S- And/Or Authorized APPIZIMI Date CODE j,' INSPECTION TYPE' ' PAIS RiTMA CODE! INSPECTIONTYPE gag 1616 Fixed System Final Fire Prevention 206 Final Mechanical ! g 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Hoof 210 Final Electrical 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Piece 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 24x6<6 PROJECT ADDRESS: 185 FAI RWI NDS LN UNIT' OWNER'S NAME: STEPHENS, CARL J ADDRESS: STEPHENS CARL J 185 FAIRf4INDS LN COSTA MESA,CA 92626 ARCNIE NGINEER: 222-3600 flEG.NO.: ADDRESS: UNIT: PERMITTEE: CARL STEPHENS (714)222-3600 ADDRESS: 185 FAIRWINDS LN C.M. CA 92626 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in lull force and effect. CITY LIC.: STATE LIC.: CLASS: Date: Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance. or a certified appy thereof (Section 3800. Lab. Q. POLICY NO.: EXP. DATE: C .COMPANY: 7 Cehihed copy is hereby furnished. ❑ Certified copy is filed with the city Building Division. Date: Applicant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not be completed it the permit is for one hundred (5100) or less). I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the WorkersCompensation Laws of California. Date: Signature: NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that mere is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civ. C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than live hundred dollars (S500). I, as owner of the properly or my employees with wages as their sole compensation, will do the work, and the C)a structure is not intended or altered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a properly who builds or improves thereon, and who does such work himself/herself or through his or her own employees. provided that such improvements are not intended or offered far sale. It, however the building or improvement is sold within one year of completion, the owner will have the burden of paving he/she did not build or improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Professions Code: The Contractors' Slate License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a conlractor(s) license pursuant to the Contractors' Slate License Law). I am aware that proof of their Wor 's Compensation insurance should be provided to me. ❑ am exe I untl a on: B. 8P. tort re lv/ / Date: Ovine I do hereby cemty t I am aware of d understand the requirements of Californiaa ih an afety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will/will not (circle one) need to comply h said state codes and the requirements for a permit lot construction or modification from the Air Duality Marta9 t�D ji 1. Re rual construction applications are exempt from these provisions. ,'V �� Date: 7 I hereby certify that I have read this ordinances and state lays relating to property for inspection purposes. Signature: Y:Ipree to comply with all this city to enter upon the; Drivers License or Social Security •: 1641.46 When—Bmldmg: Green—Code Enforcement: Canary—Applicant: Pink—Revenue: Goldenrod—Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: IB 054278 PERMIT NO: IB 054278 PLAN CHECK NO: N GOVT: N SUPP: Y CONSTRUCTION TYPE: PERMIT TYPE: OTH STR PURPOSE: OTH JOB DESCRIPTION COMPLIANCE INSPECTION PERMIT SQ FT: CLAIM VALUE: CALL—VALUE: GROUP OCC: R-1 1 COMMENTS: NOT AN APPROVAL FOR CONSTRUCTION Z O N I N G S E T B A C K S R E Q U I R E M E N T S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- 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: 41914209 ZNE: REF NO: PLANNING N TES> > iF iE KiE IF is*iE*iF RF BE iF iF iE JE 9F*****BE*BF*****KRF IF RF IF%iF***BE**JF*9F**9E iE iF*iE iF JE iE JE iE BE *RF JE****BF*iE iE*iE *9E RF iF *iF iE D E V E L.0 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 ZONING APPROVED BY DATE: — BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: l DATE: "S BEJFBrBFit***iFk*iEiFiF*iERE**;fiEJt *iE**iF***iEk iF* iE BFk kit*iE*RFiF**9FiF iE iF iF*******iF****kiE RE RF JEeF**iE**JF RF RFiEiF RE iF iF***iF*k9t iE aE JE iE *RF RE iF*iF RF iE**9E*******iF* LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 30,00 SMIP/NON—RES PLAN ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 30,00 0,00 0,00 30,00 30,00 ,00 REVENUE DIVISION TOTALS--> COLLECTED: 30,00 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 30,00 8E 8E iEk kiF**iE iF iE iF k iF if*iF BE iF*iE*k**ii*iF BFiF*1F*iF iE iF****�F*iFiF*iF RF*JF 1.E kiF*JE**iF+F**iE JE*k*****iF******k9F* 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 INS 1 BUILDING RE—INSPECTION FEE 30,00 30,00 END OF FEES CONSTRUCTION AND PLANNING PO( SPA APPROVALS Permit # Date Inspector APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement Conduit Utility-Undrgrnd. 54. Forms .3:,Electtical , ..,k EleeiCical Conduit-.Undrgrnd. 55. Electrical Bonding '-5i-Sfeti' :Reinforceg7e�t 56. Rough Plumbing & Pressure Test Z,6._ Electrical UFE :Grnd. 57. APPROVAL TO COVER-GUNITE iings 5-� 58. Electrical Conduit-Undrgrnd. 'M 2nj 8Foundation -j 59. Gas Pipe, ❑ Undrgrnd., Test t .9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, O Undrgrnd. ti• • 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line-& House Connection 62. Backwash & Receptor -Final rD 12. Sevier Cap 63. Heater & Vent -Final ' 13. Roof Drains _ 64. Plumbing System - Final 14. Rough Plumbing; 65. Electrical -Final 15. Rough Electricat-Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring SAn 68. APPROVED FOR PLASTERING 18. Rough Electric5?'T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT tAPPROVACrr`:"Perrhit +_.2L_ 20.i Rough F.Sctdr: Fireplace y = K J • .f t 21.:DuZts, in_Str�ctufe,k=10. ndergreund:Hytlio ' v. 22.• Ducts, Ventilatin 9�. -*r -71. Producift jing 0Q4s CYPil .+3 �. 23.Gaf_ ;..%.-• 2. UndergrduLnd FlPT&st ,. t- q 24. -Roof Framing p - Y J C' •. i 573 xUndergrn(?Storajys-,'Tank EJ Gas �O 0'rl •'v 25.Roof Shgthin 9 .+t :2 .: n7x L'174.�Overhead - ,�- - Hydro` y�?.n7 2 a�. 26.:T -Bar Ceiling (Struciural) & 6lonocoat f' 7 t^ a 75.cDry Chemical 27 *-Frame and Flashipgv ? k 76: DPry Stand r, k 7. max'; E o I28.rLathing.& Siding j_k .. -a^n s S. .•• x 77,'= FIXED SLSTENitt;F1NAL• .• '29. Insulation `1'.d Ln !: > 78. IRE PREV. FltyAj. .� DrywallAailing t-* - �+ I ti x :n MEALTHDEPTrREQI•NREMENT .�30. _ '_31. Plaster B�rowa,Coat.y, i J9.`'FINAL INPECTIQN „t+. -32:.jElectricitPovnerfv_leterFinali _ _ znl i!-:+.*eo.k.FOODCERTIFICATEISSUED � inI Electri :'' `' t IT) I k "'Nods: .33.vV X134. Final Heating&!{rrrConditionigg5 :x . r Is ^U• 35 ,:Final Gas Pipe -Test' tnt ^ J M36. Hood or -.Canopy S,R „_K ti t S ri:� • '37?-Finar FaEtory Fireplace ' SM ri . [r, I -f.. X ,^� r ,•; _ -38. Final Plumbing --- •'.39. Water Service-FinalY 'i ' ? •' o°^ �'x T, i } Q Y i40. Gas.$ervice-Final n t.•:v. p• ,S htr, l I fLL T41. Solar Domestic -Final K i`- •• `rte I 1 �p :K �:� '- '" • `42 Backflow Preventer' 0J x - rs h- -�� { _ 43. Backflow IrrLiation" 'T'�-� - ` * •^ ^� C% a ? * C, ) ;,44. Landscape Iigatiop SystemD. _q t;t u. Y !n : :� -1. - 7'K z 'U :�W :r ,1 t: :U :K o . 45. _Sound Atten-Lotion _ 46.6 Handicap,Regulaticps - Lt - `, :...K a: u: ,r OO 47. cF INAL STRUCTURE & 8UI1*_'DI NG . ti , I��I�•��! e t C � r48_'FIN,ALPLANNING . P _ ,v r.49.JElearic Release to Edison i e ! r+ :r 5: rC �• 'y �50.>Gas-Release to Southern California Gas Co :L51. CERTIFICATE OFFOCCUPANCY K. : 7 No. Date PROJECT ADDRESS: 185 FAI RWINDS LN UNIT: OWNER'S NAME: STEPHENS, CARL J ADDRESS: STEPHENS CARL J 185 FAIRf4INDS LN COSTA MESA CA 92626 ARCHIENGINEE R: (714)222-300 REG.NO.: ADDRESS: UNIT: PERMITTEE: CARL STEPHENS (714)222-3600 ADDRESS: 185 FAIRWINDS LN COSTA MESA CA 92626 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in lull force and effect. CITY LIC.: STATE LIC.: CLASS: Date: Signature: WORKERS' COMPENSATION DECLARATION: I herebyalbrm that I have a certificate of consent to selhinsure m a cer if tate of Workers Compensation Insurance, or a [eddied copy thereof (Section 3800. Lab. Q. POLICY NO.: EXP. DATE: —OMPANY: Certified copy is hereby furnished. ❑ Certified copy is tiled with the city Building Division. Date: Applicant: _ EXEMPTIDN FROM WORKERS' COMPENSATION DECLARATION: (Th I cemfy that in the performance of the work for which this permit sulaccl to the WorkersCompensation Laws at California. is section need not be completed it the permit is for one hundred (5700) or less). is issued, I shall not employ any person in any manner so as to become Date: Signature: NOTICE: H. after making this declaration. you should become subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply with such provitions or this permit shag be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit S issued (Section 3097. Civ. C). LENDER: NO ADDED AREA 6 NO ALT'S ADDRESS: TO 'STRUCTTURAL ; 4.501 LEMENT3S, Re_+ove sld,'w.50 OWNER BUILDER DECLARATION: I hereby atlrm t a�lI am exempt from the Contractors' ors' State for thal/s o4nr (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prim to its issuance, also requires the applicant for such permit la (fie a signed statement that he/she is founded pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penally at not more than five hundred dollars (3500). I, as owner of the property or my empployees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sale (section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himselflherself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however the building or improvement is sold within one year of completion. the owner will have the burden of proving he/she did not build or improve lot the purpose of sale). and owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business 11and Professions Code: The Contractors' Stale License Law does not apply to an owner of property who builds or improves thereon and who contracts for Such projects with a cpntractor(s) license pursuant to the Contractors' Slate License Law), I am aware that proof of their Worker's Compensation insurance should be provided to me. IN I am exempt under Section: B P 70 4 4 B. s P. C. mr Ims reason. 7/ WORK BY OWNER Dale: _�� 1! � Dwner. _ I do hereby certify that I am aware of and understand the requirements of Cab rni e 1 and 'afety Cotle Sections 25505, 25533, and 25534 and that or any future building occupant will/will not (circle On need to comp y with said slate codes and the requirements for a permit for construction or modification from the Air Quality Management District. Residential construction applications are exempt from these provisions. Date: Applicant; I hereby certify that I have read this application and stale that the above infor a n is correct. l agree to comply with all city and county ordinances and state laws relating to building construction and her more ra Se talives of this city to enter upon the above-mentioned property for inspection purppooses, Date: -1 r%/io=C_1 Signature: _ - Drivers License or Social Security a: 1641-46 White—Bwldmg: Green—Code Enforcement Canary—Applicant: Pink—Revenue: Goldenrod—Assessor CITY OF COSTA MESA - BUILDING PERMIT PERM NO: B 05435 PERMIT NO: B 054358 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: 5-N PERMIT TYPE: STR PURPOSE: ALT JOB DESCRIPTION ; ENCLOSE EXISTING BALCONY WITH GLAZING SQ FT: 1,000 CLAIM VALUE; 1,000,00 CALL -VALUE; 1,000,00 GROUP OCC: R-1 / COMMENTS: SMOKE DETECTOR(S) REQUIRED IN HOME.jj��jj� j kkkkkkk�kkkkk**�kkkk**kkkkkkkk kkkkkkkkkkkkkkkkkkkk**kkk §V *� Z O N I N GS E R T E B Q A U C I K R S E M E N TiVl[�� (('�� Fn ET ------------ MAIN BUILDING ---------- --------- ACCESSORY R Ft9 G R E ----- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR; FT IN LEFT: FT IN RIGHT: FT IN LEFT: FT IN RGHT; FT IN PARKING REQ• PROV: PARCEL: 41914209 ZNE: REF NO: PLANNING N TES> > kkkkkkkkkkkkkk kBFkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkfEkkkkkkkkkkkkkkkkkk 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 ZONING APPROVED BY It_ DATE; BUILDING APPROVED BY : DATE; IJ APPLICATION ISSUED BY: DATE; Go 2 kkkkkkkkkkkkkkkkkkkkkk kkkkkkkkkk kk kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk kitkkkk kafkk kkkkkkkkkkkkkkkkkkkkkkkkkkBEkkkkBEkkkk LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 25.00 ,50 SMIP/NON-RES PLAN ISSUE FEE BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS----> 25,50 0.00 0.00 25,50 25,50 ,00 REVENUE DIVISION TOTALS--> COLLECTED: 25.50 OVER/SHORT;00 BLD25P00 PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOOT GRADING PLAN -CHECK kklEkkkkkkkkkkkkkiEkkkkkkkkklFkkkkkkkkkkkkkkkkkkkkkksfkkkkkklfkkkkkkkiFkkkkkkkkkkkkkit 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 SFR 1000 ALTER BY VALUE RESIDENTIAL NOZONE 1,00 1,000.00 END OF FEES III w:U11d.',,' 7_J, —4, _" - CONSTRUCTION AND PLANNING POO SPA APPROVALS Permit # Date Inspector APPROVALS Permit # Date Inspector i 1. Temporary Electrical Service or Pole 52. Pool &Equipment Location ' i 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. EleciriCal Conduit Utility-Undrgrnd. - _54. Forms "k-- Electrical Conduit-Undrgrnd. = 55. Electrical Bonding S, =Steel Reinforcemen}: -56. Rough Plumbing & Pressure Test: ErecircalUFER�qrnd. - 5Y. APPROVAL TO COVER-GUNITE T <Fio{, eis 5' J r.58v Electrical Conduit-Undrgrnd. :c r a8'. Foundation G - ,597 Gas Pipe, ❑ Undrgrnd., Test _ ' 9. Water Pipe-Undrgrnd. •60. Backwash Lines, P-Trap, O Undrgrnd. 10. Structural Floor System : X61. APPROVAL TO DECK •�; 11. Property Sewer Line & House Connection L62. Backwash & Receptor-Final 12. Sewer Cap a 6g. Heater & Vent-Final 13. Roof Drains t .64. Plumbing System -Final 14. Rough Plumbing •• 69. Electrical-Final •{ 15. Rough Electrical-Conduit 66r Solar System-Final 16. Rough Electric.Wiring �67. Fencing & Access Approval 17. Rough Wiring Sign • /68'. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling 69: POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT �APPROVP LS f i_.Permit # - 20:rRoi(gh F,�ctory F`replace u + d _ - ` + 21?Dubs, in Stryctuvte -' y < 470. lnderycolnd Hjidro * " _ 22. Ducts, Ventilating S� •71. Productrffping EBtGas ❑Oit 23:-Gas Pipe;Rough &'Test _ 72. Under Found Flush' - 24. Roof Framing 5'=r t. - \v, 73.cUndergrnd.StorageTank.,DGas ❑Oil ` 25. Roof Sheathing- 5 9 `: .� L7 �'74,-Overhead Hydra_ 26.,,,T-Bar Ceiling (Structural) 4onocoat 'u _ 75.-Dry Chemical 27s•-Frame and Flashing u' 76. Ery Standdipe '-_28`Lathinq& Siding 77; FIXED SVSTEM,F.INAL •�-29. Insulation " "" ' { '•'T ` 'r 78 'FIRE PREY. FINAL *•: _ -30. Drywall'Nailing + w HEALTH-DEPT. R EQUI R:EME NT X31. Plaster Biown, Coate79yFINAL INSPECTION �-.32; Electrical Power Meter-Finals .� ;_ ii.' •'- 80.,,F00D CERTIFICATE ISSUED , 33aFinal Electric Notes: ;34.-Firial Heating &Ai, Conditioning; -•!; , , �� A t p� ,,; _ 35.. Final Gas Pipe-Test, -c - r 'a _ .• a + + �_ " "' �� i .c •� 36: Hood orzCanopY • v , .. , 7 a, : �, Vis, x :t qr+• 37:'Final Factory Fireplace - ^ ^ ^• t '�+." - ' •T ! Y 38. Final Plumbing w � •• - ' 't �r ' - y, r X39. Waier Service-Final, a +- `t r _ = r � ;40. GasService-Final �, �` • „ ;� �'r - v'41. Solar Domestic-Final- I 1, 42.'Backflow Preventet 43. Backflow Irugation4- ir•< n . -- -c: r- - J -• _44. Landscape ItrigatigZSystem ;� =` j45 _Sound Atter}uatiort :'46.`Handicap Regulatio{ts. �,,iO =; 1 x - - - -47.--FINAL ST R,UCTURE"& OtiDING •• �I�13•�jll � .-_ ~48;`FINAL _ PLANNING._ ''�'"' ``•`' ct �' `.-1 ;': ._. c ease 49. ElectriRelto=EBi - } �t 50. to Southern California Gas Co ,Gas,Release r51. CERTIFICATE OF•'OCCUPANCY No. Date OWNER FAIRVIEW ASSOC. DATE 8-16-79 JOB ADDRESS 185 FaiTwindc T.n tr..it r BUILDING PERMIT NO. 47R4n AP No. 141-711-24 LOT TRACT iu-�IccFIRE ZONE VALUI II 'CTIONS Signature I Date RTYPE GROL $G. SUBCONTRACTOR GAS W -AT Plumbing ROUGH PLUMBING - PROP. SWR, LI-E4USE CON. SPRINKLING SYSTEM MISCELLANEOUS ROUGH HEATING AND AIR CONDITIONING TEMPORARY SERVICE OR POLE UNDERGROUND POWER ROUGH WIRING— I-2 — Heatingand Vent. TRENCHES I] FORM$ STEEL REINF. FLOOR SYSTEM BOND BEAM._ STEEL REINFORCE SHEATHING t FRAME AND FLASHING sA00 rA PLASTER BROWN GOAT S_TR"FTURAL, FINAL H G, VENT., REFRIG. AND A.C., FINAL A 4=i / PLUm SING. FINAL AND GAS TEST ELECTRIC, FINAL C _ RUII Illuo Flusi I S lnLeQ/ skeAa ,aAt� aRt(av� S 3�aY•90 ¢-��- "�, COSTA BOE A BUILDCOSTING-SAFETY G- SAFETY DCALIFOEPART NIA E T APPLICATION F TRyfffyy* PERMITP.- g6s97 T�) m RECEIVED BV PERMIT ImJP 6(J For Applicant to Fill in Completely — Use Ink Only BUILDING NO. — 2 ADDRESS185 )DSA.P. OWNER OR �/ASS'f ADDRESS r lI� BUILDING I SAjpoga) TENANT OC UNIT OR MAILING ZF- SPAACF_Gnl. ADDRESS T .NO. LOT BLK. r TE L. 213 CITY LL l r7 p% NO. NEW ADD ALTER IREPAIR MOVING DEMOLISH CONSTRUCTION LENDER BRANCH OWNER ADDRESS VALUE ARCHITECTTEL.ZI3 USE &5 E OR ENGINEER C a� ADDRESS ZONE TYPE GROUP. CONTRACTOR C, f APPROVED BY DATE ADDRESS TEL. 2 CITY I-IrS Z NO. STATE CITY APPROVED SETBACKS LIC. NO. LIC. NO. SIZE NO.OFBL I—�ju (FROM C/L STR ) OF LOT NOW ON LO RONT USE OF EXISTING BLDG. �R. SIDE 36�FT. ALZ2�4 Separate permits are required for L SID VZ` FT. electric, plumbing and heating work. ,Or REAloor USE OF BUILDING AND WORK TO BE PERFORMED PLANNING/ACTION �7Q APPROVE Z® APPRO -DATE BY I hereby acknowledge that I have read this application 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 the State California. /!/ y0 home r' '] / SO. FT. ✓CCJG a __5/ /5 I hereby certify that i am properly II ensed as a contractor under er the State of Cel' o is Business end ofpssions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter B, and that uc •li n$as e I full force end effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt fr the r i ns f ha tate of California Business VALUATION PERMIT FEE E and Profession Cotl Di is n PLAN CHECK E SO Signature of Permlttee / ��{ S /r/ /� TAX s or / v Authorized Agent Date / TOTAL PAID E m 9 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely — Use Ink Only BUILDING ADDRESS sss�� W• C. OWNER OR�n� TENANT MAILING L.� ADDRESS(cjF. llU ui%dCITY lti/NO. .1(�11\f BRANCH ADDRESS ARCHITECT TEL. ADDRESS CONTRACTOR ADDRESS TEL. CITY NO. STATE CITY LIC. NO. LIC. NO. SIZE NO.OF BLOCS OF LOT NOW ON LOT USE OF EXISTING BLDG. Separate permits are required for electric, plumbing and heating work: USE OF BUILDING AND WORK TO BE PERFORMED APPLICATION FOR STRUCTURAL PERMIT C,U/�X Pw,jnen Ng bfi# A.P. NO. BUILDING I ADDRESS UNIT OR SPACE NO. s TR.NO. LOT NEW I ADD 1ALTERTREPAIR I hereby acknowledge that 1 have read this application 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 the State of California. I hereby certify that I am properly licensed as a contractor under the State of C.l;,ft6—rnbk Business and Professions Code, Division 3, Chapter 9, and hat su h licenses ar n full force and affect, or I am exempt fro the p ision/f t State of California Business and Profession Code, sio 3 ter 9. Signature of Permittee or Authorized Agent Date OWNER VALUE USE $ ROVED APPROVED SETBACKS PLANNING ACTION DATE APPROVED APPROVED 10 TL m i m SQ. FT. smv 7 THE PURPOSE FSHOWNETA UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. m VALUATION PERMIT FEE $ N fw� /y PLAN CHECK $ TAX E LL V TOTAL PAID S h '/