HomeMy WebLinkAbout324 COSTA MESA ST - Building Permits� � '�
(714) 754-5273 • F� (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, GOS7A MESA, CA 92626
BUILDING PERMIT
Job Address: $24 COSTA MESA ST
Suite: B
Vicinity: UNIT B (GARAGE AREA)
Parce1 Number: 42629215
Applicant: RYAN, ROBERTA
Address: 268 MORNING CANYON RD
CORONA DEL MAR, CA
Owner: RYAN, Cf2AIG M TR
Address 268 MORNING CANYON RD
CORONA DEL MAR, CA
Contractoc OWNER-BUILDER
Address:
Zip:
Arch :
Address:
Phone:
Status: ISSUED
Applied: 11/28/2001
Issued: 11/28/2001
Zoning:
ISSUED BY: '
Phone: 949-760-6232
Zip: 92625
Phone: �11
Zip: 92625 �� � T� �
D� g q �a
Phone:
License: 0
Eng:
Address:
Phone:
Zip: License: License:
SCOPE OF PERMIT
CONVERSION OF A ILLEGAL THIRD UNIT BACK TO A GARAGE. DEMOLITION OF INTERIOR NONBEARING WALL &
REINSTALLATION OF A GAR4GE DOOR.
REF:C01-2205
Plan Check: $15.28
Permit: $23.50
SMIP Res: $0.50
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $39.28
SETBACKS ,
MAINSTRUCTURE Front 0-0
ACCESSORY Front 0-0
PARKING Ezistinq: a
NOTES:
Rear 0- 0
Rear 0- 0
Required: 0
FEE SUMMARY
Calc Valuation: 3soo.00
Claim Valuation: 5soo.00
PLANNING & ZONING
Left 0- 0 Righ[
Left 0- 0 Right
Proposed: 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, 72-21-92)
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
requlretl inspectlons 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) 7545626
244&48 (fl�00)
WORKERS' COMPENSATION DECLARATION:
I hereby attirm under penalry ot perjury one of ihe following declarations:
❑ I hava antl will maintaln a certAicate ot consent b self-Inswe for workers' compensation, es pmvided tor by section 3700 of ihe Lebor Code, tor the peAormence of ihe
work for which this permit is issuetl.
❑ I have antl will maintain workers' compensation insurance, as required by section 3700 of the Lebor Code, for the peAortnance of t�e work tor which this pertnit is issued.
My workers' compensatlon Insurance cerrier end policy number ere:
Carrier: Policy Number.
(This section neetl not be camplefed it the permit is veluetl a( one hundred dollars ($700) ar less.)
❑ I certity that in the pertormance oi the work tor w�ich this permit is issued, I shall not employ any person in eny menner so as to become subject to t�e workers'
compensetion laws of Califomle, and egree ihat If I should become subfect to the workers' compensation provlsions oi Section 3700 0l the Labor Code, I shall forthwith
comply with these provisions.
Applicent Signeture: Date:
WARNING: FAILURE TO SECIIFE WORNERS' CAMPENSATiON CqVERAGE IS UNLAWFUL ANO SHALL SU6IECT PN EMMOYER TO CPIMINAL PENALTIES PND GVIL FlNES UP TOONE HUNDRED
TFqUSAND DOLLARE (5100,000), IN ADDITION TO THE COST OF COMPENSATION, �AMAGES AS PROVIOED FOR IN SECTIIXJ 3lOfi OF THE LABOR CODE, IMEREST, ANO ATTORNEV'S FEES.
LICENSED CONTRACTORS DECLARATION: ��.
I hereby aflirtn that I am licensed under provisions of Chapter 9(commencinq with Section 7000) of Division 3 of the eusiness and Professions Code, and my license is in full ,
force antl ettect Lia tt Class q
Coniractor's Signemre: Date: '
CONSTRUCTION LENDING AGENCV: �,
❑ I hereby aHirm that there is a constmction lending agency for the pertormance of ihe work tor which ihis permit is issued. (Sec. 3097, Civil Code). �,
Lendefs Name: Lender's Address: �
Signawre: Date:
OWNER-BUILDER DECLARATIONS:
I hereby aHirtn thet under penalty oi perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the tollowing reason (Sec. 7031.5, Business end Professions
Code: Any city or counry which requires a pertnit to consimct, alter, improve, demolish, or repair any siructure, prior to its issuance, also requires iha applican� for such permit
to file e signetl statement that he or she Is licensed pursuant to ihe provisions ol the Coniractors License Law (Chapter 9(commencing with Section 7000) oi Division 3 of ihe
Business and Profe4sioo5 Code) or thet he or she is exempt Iherefmm and the basis for the alleged ezemption. Any vloletion of Section 7031.5 6y any epplicent tor a perrr+.
subjeGts the epplicant to a'civil penalry of no� more than tive hundretl tlollare ($500).):
,,,/ n.�
�,y I, es owner ot ihe property, or my employees with wages es Iheir sole compensation, WILL DO THE WORK, antl the sWdure Is not Imentletl or oHered for sale (Sec.
7044, Business and Professions Cotle: The Contractore License Law does not apply to an owner of property who builds or improves ihereon, an0 who does such work
himself or herseN or ihrough his or her.own employees, provided that such improvemenis are not intended or oflered tor sale. If, however, Ihe 6uilding or Imp�ovement is
sold within one year of completion, ihe �owner�6uiltler will have ihe 6urtlen of proving Ihat he or she did not build or improve for purpose of sale.).
❑ I, as owner oi the property, am EXCLUSIVELV CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contrectors License Lew tloes not apply to en owner of property who builtls or Impmves thereon, and who coniracts tor such project with a contractor(s)
license pursuant to the Contrectors License Lews.).
❑ lam
Siqnature:
Owner I�
by dnver's licensa. ❑ Yes
❑ No
Business and Professions Code tor this reason:
Date: /�'Z��D/
Drivar's Licensa No. Expires: 3-2/-03
Verlfication of Ownership by (type ol documenL i.e. - property tax bill or tleatl):
DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION:
❑ I hereby cenity that no excavetion five (5) or more feet in depth into which a person is raquired to descend, will �e made in connection with work authonzed by this
permit, and ihat no building structure, scallolding, falsework, or demoli�ion or dismantling ihereot, will be more then thirly-six (36) feei �igh. (Chap. 32, Grp 2, Art 2, Sec.
341, Ttle 8, Celifomia Administrative Code).
❑ As owner-builtler, 1 wiil not employ anyone to do work which would require a permit from the Division of IndusViel Setery, as noted ebove, unless such person has e
pertnit to do such work from ihe division.
Signature: Date:
Division of Indusinel Safery Pertnit Number:
CER7IFlCATE OF COMPLIANCE AND AUTTIORIZATION OF ENTTiY: I cehify under penalty of perjury that I have read this application antl state thai ihe iniormation given is
correct I agree to comply with all state lews and ciry ordinances relating to building construction, end authorize representatives of ihe City of Cos[a Mesa to enter upon the
above-descnbed properry tor ins/�p non purpos/e �. I ag—ree not to occupy or allow occupancy ot any 6uildinq authonzed by this permit until tinal inspection.
�h//.i:�L /✓ �� 2�-�/
Si nature Ot Legal Owner(s) Daie
AnNOr Authorized Appllcant Date
COOE1, INSPECTIONTYPE
1616 Fized System Final Fire Prevention
1266 Pool Spe Finel
200 Final Re-Roof
201 Final BIocWRetaining Wall
202 Final factory Fire Place
203 FinalSign
204 Final Demolition
Qdj[ INTRIALS LOUEI INSPECTIONTYPE
206 Final Mechanical
208 Final Plumbing
210 Finel Electrica�
212 Final Fire Preven�ion
220
222
250
Final Planning Approval
Final Site
Final Building/Occupancy
� It�
324 Costa Mesa Street �8
Rear Building Demo Plan .
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EtiC�ST� W ��� 7'� i3�
/�'�iMu ��'
CITY OF COSTA MESA
PLANNING DfV. DIVIS10Iv O:''$�iLGiiv;� SAFETY
SUBJECT TO BLDG. DEPT. REG. CITY OF CbSTA McSA
A PROV�U
BY �'Z DATE , (� ✓�,��,,� ��. � �
/ u!—,_s!!/.lL1 Dafe
Tii; sa; rd pIM.� e,nd sGrodticelion: MUS� kepi on ihis job at a� tYnes and d'o udawlul to
�, make any r�w�gn a s�er�ion on esne xip�uul xniH�i pe�missbn hom tlre av'sbn of Buddug
.-'�. .�]i±l}',C�fO'.r10516N:i8. �U/—Q / �i� �
I V O T� '� • rn3 slam�i�g o! Ihis plar. e�d :FaiEration; SH;J.L I�CT he hald lo �ertnil or to De an approval
'� of Ihe viclaGon ci eay umv;;i�as c� zny L'!t� ui Casl; Pdese Crdirancv anCbr Slete law.
ADDITIONS, [�ELETIOPiS, 0�� CORi ECTIONS SHALL �hsxp:an;antlpsrt�i :i�a8expiretyr:m�i��ior.andarc�mmenu7and�.roidNiMbuikl�go�
BE APr"ROVED BY THE PLAiJi!!h!G DIViSiON "'0r"�����4nnerrc�uzr�manta�5a�:+epuG'&;�,103�ujwitneili�iJa(iofissu�tae.
Jun G6 O� DE1:�Eta Pa^+fiCom �p'.Y '
June `,, 2002
Mr. Eci F�tros
City c1 C��sfiG Mesa
?7 Fair Drive
��osta Mesa, CA 92628-1200
Re: Perrnit Number BOl -0187:i
324 Gosta Mesa Strect
rv1r. Pe,fros:
ft�is is a rey�,�,� for an extensic3n on Buiiding Fermit #BO]-01875
��s I have not yet been able to corr����lete tP�e v✓ork. In uddition
t� having to move my com��an>>, a rr�aj��r ember.zlement by my
former controlier, litigation �Nith th�� I�cinks over resoonsiL•�ility for
11��e rc�rc�ec! cF�ecks and trying #a gE�r Irvine F'D fo prosecufe, this
has beE;n a very difficult busir-iess e{�vironment. I have �very
inter��ion of completing the work, jus� neec! a fittle more time to
�oordir�crfe the project and fincl the� money for constructing the
new �aarage doors.
Please consider my request for an extensian. ,4ny assistance
w�ouid bE> greatly appreciat�_�d.
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a�_� ti1. R,y n
2f I�Anrnin�Canyon Road
Corona ciel Mar, CA 92626
� i ��.?5 � .���Goo ext. i �
Counfy of Orange
Building Deparfinent "
Room 322
Court House Annex
Sanfa Ana, California
Phone: KI 2-6211
APPLICATION FOR
PERMIT
PfiRMIT NO. �` � � [ `�- ^
_��%/y('s_,✓. ,1 r' , lv �_„ P,J
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l. OWNER'S NAME!` � _ '����� �e�'t'�`�' � — PHONE:
MAILINGADDRESS`���,�%'�'�����'���^ �'` `� CIT'Y �v'""�d� ���'"���
(Stteea or P. O. Boz NoJ
✓ P �../ }, p..,r]�r
F R��'F�} 1 {' ,z 1 F" �+ '�
NAME NAME�- �•�-�- � � '�F- �-
(Archiee<e or Hneineec) • • � �(C/onvn�cmr or Builder) �
ADDRESS— ADDRESS�LL � - 'y% � � /
CITY i.ITY �//� ��� Z
Scate Lic. N� Phone _ Sta[e Lic. Nol� 9� _� PhonP��"� ✓����%
�j� /�J���9 i �p �,�,f
2. JOB LOCATION� � T" I,i i�"'s�c G�f �� � � Cr ""o""... �t.''V� 3.I �`
(Houae No.� (Name of Sneee� �' / (Town or School D'urcitt�t
3. LEGAL DESCRIPTION: Lot e� � Bloek�{ Tracr w3 �
4. Meets and Bound, Description — Use Reverse Side of This Form. .
5. CORNER LOT () INTERIOR LOT ('�) THROUGH LOT () SLOPE OF LOT
� THIS AFPLICATION CANNOT BE PROCESSED UNLESS LEGAL DESCRIPTION •
IS ACCURATE AND COMPLETE.
6. PROPOSED WORK: New Building ( ) New Strucmre ( ) Addition ( ) Repair ( )
Alcerations ( ) Mov�� ( )��ilmolish ( ) Conversion ( )
r i , � _ ,�!t'i�.-ah ..�,. . —i ..�8' . /.� .,
7. PROPOSED
8. SIZE OF
9. CEILING
10. NO. LIVING
AREA
NO. OF STORIES
SIZE OF KITCHEN
11. EXTERIOR WALL CONS^��T=J('T���i7:' Bcick O Concrete Tile O Monolithic Concrete O
�� Wood Frame ( ) Steel Frame ( ) Concrete Frame ( )
12. WALL COVERING: Wood O Metal O Stucco O Other_ •�
�
13. FRONT YARD SETBACK FROM CELVTERLINE OF STREET ���-�� s`� �
14. DISTANCE TO PROPERTI' LINE: Side Yard Rear Yard _
15. SHOW ON PLOT PLAN EXISTING BUILDINGS NOW ON LOT, STATE USE OF EACH.
16.
17.
18.
DISTANCE IN FEET FROM PROPOSED BUILDING TO NEAREST EXISTING BLDG.�
VALUATION OF PROPOSED WORK: Induding A(1 Labor, Plumbing, Electrica( Wiring, Heating, Fire Sprink-
lecs, Painting, Sewage Disposal y8 � O v, ,
I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE INFORMATION
IN THIS APPLICATION IS CORREC'I' AND THAT THE CO[�ISTRUCTION WORK WILL CONFORM
TO ALL LAWS OF THE COUNTY OF ORANGE AND THE STATE OF CALIFORNIA APPLICABLE
THERETO.
Plan Filed.
Date �/x �*Z � BY
/ '
FOR DEPARTMENTAL USE ONLY
19. GROUP__„�_ TYPE � nISTRICT MAP �^+�' NO. �
PERMIT FEE $ �-�—G RECEIPT NO. �� 2�' PAID TO �+�� DATE S�-7 �% -Jsi
CHECKING FEE $ RECEIPT NO. PAID TO DATE
PERMIT GRANTED JUN 5 1950 lq �' `1V�����I�F COU�Tc BUi�oi�
PLAIVS CH$CKED BY.
D_PUTY
APPROVEQ BY:
HEALTH DEPT.
STATE FIRE MARSHAL
STATE DIV. OF HOUSI[VG
sM—�z-as
APR 9 �962 � -� w��
OWNER HT?MI'4TN�SRNi A. R. ��p R t962 DATE 10-2-61
JOB ADDRESS 'j?�, Costa PTPsa StraPt BUILDING P�RMIT NO. 155B7
GEN�RAL CONTRACTOR p�Pr-builder VALUE $ ']a080.00 Far.to res.
AP No. 117-172-05 LOT TRACT FIRL ZONE llESCRiPTtON OR WORK Add guest hse.
7NSP�CTIQ�S� j„(�Ial7'�o/ I Signaturd DA7'Is GROUP I& JTYPE p ZONE .•fC
° L _v_/ ?�/.�2 PEFjMITS ISSUED
n_ ��.. __. . � , n.ti.. �e-r�.z .� .:, f.i •. _. � SU6CON7'RACTOR .,.,,,., .....,.,...,
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OCCUPANCY
�neM eua.sm —
.
• ', :�_��S�a
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 917 C08TA MEBA. CALIFORNIA
For Appllcanf fo Fill In Complefiely
TYPnE OR PRINT
BUILDING // C O
AD�RE88 '1
COSTA MESA. CALIFORNIA
I I STATE
USE OF
EXI6TING BLDG
96TBACK LINH FROM
FEE RECEIVED °
SEP�91�1 p f,t!— �
FINANCE DEPT. �' '
CiTY OF COSTA MESA ��o�
APPLICATION FOR PERMIT �' � ��
BUILDING � � s-�;
��� �For Office Use Only �
flECHIPT NO. PCNMIT NO C
�� s� , �
1' Re�V�. eY I Y�2J-/�'veo I o��(/
NO. - UILDING � � �C i""��� ��,'
ADORE55 t'Q�
7EL. , �OSTA MESA. CALIFORNIA
NO.
FIRE � ` � . _ �
? a �`a i �' . � `�
TEL. Leoe�
N�• DEBCftIPT
� I NO� OR BLDC�9. ' Z
/
DESCRIPTION OF WORK
./ /� � NO. OF 2
^ /-� R(]OM£�
PXTERIOR WALL ROOF
GOVERING GL� COVEI
USE OP_BUILDIN4 AND WORK TO I
NO. OP �� U86 OF NEW
•L.6NS OUIL�ING
_ ' (CENTER LINH BT.1
�"/'�.J -U;�
EVES
ALLOWED
�� FT.��{A IN,
7 FT. IN�
� ) FT. IN.
FT. r -�L - IN.
� � C_ ( G(�Y� -4
ATE �
.i /�
I�
-�/ _ !
1 HEHEBY ACNNOW��GE THAT 1 XAVB R6AU THIB APPIJGTION }{�g AMOUM BHOWN UNDER VALUATION IB FOH TX¢
AND 6TAT8 TXAT TME ABOVH I8 CORNE4T ANO AOREE TO CON- pYf�OeE OP EBTABLI9NING A v¢pMIT FEH ONLY.
PLY WITN ALL CITY OROINANCEB AND BTATE LAWB REGUui1NG
Bu1tDINo coNsiRucT�oN. � ' VALUATION ,
HIGNANRE OP PERMIT FEE $ hn `
PERMITTE �j ��D �
S ' PLAN CHECK $ � � -�
AUTHORIZED A6ENT 30 ...�
iOTAL FEE
OWNER
GENERAL CONTRACTOR 0
AP No.117-172-05 LOT
INSP�CTIONS
c
G.
I
OCCUPANCY
�ORM BU4-5M — ,
TRACT FIRE ZONE
�Signature� DATE GROUP J
DATE
Ri7TTAiNG PF.RMTT NO.
VALUE $ 101.00
DESCRIPTION OP WORKDemol
TYP� V ZONE R,_
SUBCONTRACTOR
r' �. a���
_ �,
;
COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. HOX St7 C�STA MHBA. CIILIFORNIA
For Applicani to Fill In Complefely
TYPE OR PRINT
BUILDING +(�L %O ^ �
ADDRESS l U
COSTA MESA CALIFORNIA
� STATE
■ BHTBACK LINC PRON
S�
TEL.
NO.
I
FEE RECEIVED
�EP s� 91961•
FINANCE DEPT. � �
CITY OF COSTA MESA
APPLICATION FOR PERMIT
BUILDING
For Ofiice Use Only
NHCEIPT NO. PERM�T yu
/S 5—i(i
—(� ferv D BY I D[�T6 RgCEIVED DATE IBSIIQC
f+S'4 S 1 . %'.�7`(n I •-Z _
NO.M�' �j BUILOING �'Z i/ � �
AODRE55 Z� �� `7-�
NE�' COSTA MESA. CALIFORNIA _
/
NO. OF BLDGB.
NOW ON LOT
DESCRIPTION OF WORK
i NO. OF
EXTBRIOR WALL R
COVERING C
U8E OR BUILDING AND WORK
l
FIRE
Z � INO.OP
% rurve �
LEGAL �; n
(CBNiCR LIN¢ 8T.)
ING '
UBE OF !
BUILDING
'�% 1 ' a
EVES
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1 HEfl6BY ACKNaW�DGE THAT i H�VE HHAD THi9 MPLlGT10N THQ AMOUNT BHOWN UNDER VqLUATION 18 COP THE
AND BTAT¢ THAT TME ABOVE IB CORPEGT AND AGREH TO fAM-
PURPo9¢ OP BHTABLIBN�NG A PERM�T FEE ONLY.
PLY WITX ALL GITY OROINANCE9 AND BTATE UWB P66UlATINO
Bu1tDIN0 CONBn+uCTON. w � VALUATION
SIGNATURB OP PERMIT FEE $ �
PERMITTE � Q-4
S /� / � PLAN CHECK S
AUTHORIZED ACENT �
TOTAL FEE �
JOB ADDRESS
GENERAL C01
'- Vo118-1
ECTIONS
SOIL
ROUGH PLUMBING
SPRINKLING
MISCELLAM
ROUGH HEATING AND AIR CONDITIONING
TEMPORARY SERVICE OR POLE
UNDERGROUNU � POWEq �
ROUGH WIftING
TRENCHES � FORMS � STEEL REINF.
FLOOR SYSTEM
BONU BEAM ❑ STEEL REINFORCE ❑
SHEATHING
FRAME AND FLFSHING
LATHING - IN n OUT
PLASTER, BROWN COAT
'CTURAL FINAL
fING. VENT., REFRIG. AND A.C., FINAL
MBING, FINAL AND GAS TEST �f
CTRIC. FINAL
!J�
DATE 5_i_�?
BUILDING PERMIT N
RIPTION of WORK �(lnvnrrd 1
ZONE VnLUE$ Rnn_n�
)UP TYPE
SUBCONTRACTOR P�
34634
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA. CAIIFORNIA 92626
,+Y-i-��"`'"'00 053� *�*��8.06
�.,-
APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Completely
PECEIVED BV DATE RECEIVED DATE ISSUED
BUILDING �j �p !� � y" r
ADDRESS {j. Q�r J�I� �•
OWNER ' � ' A.P. NO. // '-�7 - Q PER�I 6] A
J `t
MAII BUILDING p� %�_ _ /a {�,�Q�.� ("/ .
ADDRESS i / ADDRESS J lJ�f /I/L � J�
/+ TEL TRACT 7� LOT �� BLOCK
CITV Cp NO.
CONSTRUCTION W �+
LENDER �(
/�
BRANCH
OWNER �ofer-� 4��er$on
ADDRESS �_�✓/C�O VALUg
ARCHITECT TEL. S 2 ��
OR ENGINEER N
F�RE
ADDRE55 ZONE TVPE GROU/-P�•� ��77
APPROVED /-� ,�7
CONTRACTOR BV DATE �� /
ADDRESS
TEL. Z NE NO.OF ^ USE OF NEWn
CITV NO. � P�� oS BVILOING (��%p
STATE CITV YAfiDS,APPROVED YAqDS APPROVED
IIC. NO. LIC. NO. MAIN BUILDING ACCESSORV BUILDING
SIZE NO.OFBLDGS. (j (FROM6/bSTREET)f' L
OF LOT NOW ON LOT �j� FROM FT. FT.
USE OF
EXI5TING BLDG. SI T. FT
SIZE OF NO.OF
NEW BLOG. ROOMS STORIES L. SIDE FT. FT.
EXTEflIOP WA�L ROOF �
COVERING COVERiNG REAR FT. FT.
USE OF BUI�DING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN &
MAIN BLOGS. ACCESS. BLDGS.
' VAF.# DATE
(� e C.U.P. � APPROVE�
APPRLf/C S
�
I hereby acknowletlge [hat 1 have reatl this application and state
ihat the ebove information is correct antl agrea to comply with ��
all laws regulating builtling construetion, antl I shall not employ 7E �
ony person in violallon ot the workman's compensation laws ot
[he State ot Calitornla. �
• b
I hereby certity 2het I am properly licensetl as e contrector under SQ. FT. o
t�e State of Colitornia Business antl Professions Cotle, DivisiGn 3, THE AMOUNT SHOWN UNDEfl VALUA 107J�1$ FO �
Choptar 9, end tnat s�c� licanses are In full force antl af(act, or I THE PURPC6E OF ESTABLISHING A PERMIT E QN� : Q
nm exempt from the provisions of the S[ete of California Businass VALVATION :�C%
antl Professlons Code, Divizion 3, Chapter 9. �/ PEFMIT FEE $ � �
A ]
Sipneture ot �% // T�% `�'�// �_ � � m
Perminee 4���`� y %�/L¢.ay� $ �OO PL,ANCHECK $ E
`o
Autha�izetl Agent �— LL
TOTAL FEE $