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Home My WebLink About210 COSTA MESA ST - Building Permits(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.@�tLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job nddress: 210 COSTA MESA ST Suite: Viciniry: ROOF ' Primary Occ: R3 Dwellings/ Cong Res <10 Type of Construction: V-N Parcel Number: 42627221 Zoning: Applicant: BERBER, ISRAEL Address: 1615 S MINNIE ST SANTA ANA, CA owner. CASILLAS, CONSUELO Address 210 COSTA MESA ST COSTA MESA, CA Contractor: R B ROOFING Address: 1615 S MINNIE ST SANTA ANA, CA Zip: � 92707 Arch : Address: Zip: Phone: License: Phone: 714-836-8384 Zip: 92707 Phone: Zip: 92627-2208 Phone: 714-836-8384 License: 772680 Eng: Address: Stalus: ISSUED Applied: OS/23/2006 Issued: 05Y23/2006 /✓J / �• � Phone: License: SCOPE OF PERMIT TEAR OFF EXISTING ROOF. INSTALL 30Jt FELT, 30 YEAR TIMBERLINE, COMPOSITION SHINGLES AND REPAIR/REPLACE SHEATHING AS NEEDED. 9.50 SQUARES. � Plan Check: Permit: SMIP Res: SMIP Com: Other: Inspection: Total $0.00 $9725 $0.50 $0.00 $0.00 $0.00 $97.75 SETBACKS MAIN STRUCTURE Fronl 0- 0 ACCESSORY ,. Front 0-0 PARKING Exis�in : 0 FEE SUMMARY PLANNING 8 ZONING Rear 0- 0 LeN 0- 0 �' Rear 0- 0 . Left 0- 0 Reauired: 0 Pr000sed: .0 Calc Valuation: Claim Valuation: Right 0-0 Right 0-0 $3,300.00 $3,300.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requiremenis under Califomia statutes and reiated regulations. (Ord. No. 92-28, § 7, 1241-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 1 BO days, or if work Is suspendatl or abandoned for a period of 180 days. . INSPECTIONS: �n order for Ihe work authorized under ihis permit to be considered legal, such work must comply with all applicable codes, and all required Inepectiona and final approval must be obtained. Failure to obtain inspections and final approval will result in the ezpiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 tasae (e�oo� WORKERS'COMPENSAnON DECLARAnON: 1 hereby aNirm untler penalry of perjury one oi the tollowing declaraUons: . � �. , ❑ I have and wlll maintain e certificate of consent to self-Insure for workers' comNansetion, es proviaetl for by section 3700 of ihe Lebor Code, for tha peAormence of the work tor which Ihis permit is issuetl. - - ❑ I �ave end vriil maintain workers' compensa�ion insurance, as required by section 3700 of Ihe Labor Cotle, Por Ihe paRortnance ol Ihe work for which Nis pertnit is issuetl. My work pensation InsuranceqI� rrier and policy number are: p Carrier. �j�Q� C �V `nC� � Policy Number: � SiDD ! S 7' Z00 6 (76is sectian need not be completed i/ the pemutls valued et one huntlied tlollars ($100) or less.) ❑ I certity ihat in iha pertormance ol ihe work tor which Ihis permit is issued, 1 shall not employ any person in any mannar so as to become subject to the workers' compensetlon laws of Calilomie, antl agree t�at II I should hecome sub�ect to ihe workers' compensation provisions oi Section 3700 oi the Labor Code, I shall torthwith comply with these prov ions. �J ApplicaniSlgnaWre: �i�� Oe�„o1� Date: �-.�.�-� 6 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLFWFUL AND SHP1L SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND GVII FlNES UP TO ONE MUNORED 7HOUSNND DOLLAflE ($100,000�, IN nDDfTION TO iHE COST OF CAMPENSATION, OAhNGES AS PROVIOED FOR IN SELTION 3�06 OF THE UBOR CADE, IMEREST, AND ATTOHNEY'S FEES. LICENSED CON7RACTORS DECLARATION: I hereby aHirm Ihat I am licensed under provisions of Chapter B(commencing wilh Section 7000) of Division 3 of the Business end P�olessions Cade, antl my license Is In tull �orce end aNect. uc. a%7 2 Co Class x C—� S q' CONrectors Signeture: ��.o..�-.. 6•-,. Date: ti- 2�-O F CONSTRUCTION LENDING AGENCV: ❑ I hereby affirtn ihat lhere is a construction lending agenty br the pedormance of ihe work Por which ihis permit is issued. (Sec. 3097, Civil Code). Lender's Nema: Lentler's Address: SignaNre: Date: OWNER•BUILDER DECLARATONS: I hereby aifirm �hat untler penalty ot perjury ihei I am EXEMPT FROM TME CONTFACTORS LICENSE LAW for ihe following reason (Sec. 7031.5, Business end Professions Coda: Any ciry or counry which requires a permit to construct, elter, improve, demolish, or repair eny structure, pnor to its issuance, elso requires the applicant for such pertnit co lile a signed stetement thet he or she is licensed pursuant to the provisions of the Contractors LJcense Law (Ghapter 9(wmmencing with Section 7000) of Division 3 ot the Business antl Professions Code) or ihat he or she is axempt iherefrom and the basis for Ihe ellegetl ezemption. Any violation oi Section 7031.5 by eny eppliwnt for e pertnit subjects the applicant to a civil penalty of not more than tiva hundred dollars ($500).): ❑ I, es owner of the property, or my employees with weges as their sole compensation, WILL DO THE WOFiK, and the structure is nat intentletl or oHeretl for sale (Sec. 7044, Business and Professions Cade: The Coniractors License Law dces noi apply to an owner ot property who builds or improves ihereon, end who does such work himsetl or hereetl or through his or her own employees, provided that such improvemenis are not intended or ottered for sale. If, however, ihe building or improvement is sold within one year oi completion, the owner-builder will have ihe burden of proving Ihat he or she did not build or improve tor purpose of sale.). � ❑ I, es owner oi the property, am EXCLUSIVELV CONTRACTING WITH LICENSED CONTRACTORS to consiruct the project (Sec. 7044, Business antl Professions Code: The wntractors License Law does not apply to an owner of pmperty who bulltls or improves thereon, antl who contracts for such pro�ect wiID a contractor(sj license pursuant �o the Contractors License Laws.). ❑ I am exempt under sec. Business antl Professions Code for this reason: SignaWre: Data: Owner ID venfied by dnvefs license. ❑ Yes ❑ No � Driver's License No. Verification of Ownership by (type of tlocument, i.e. - property tax bill or deed): Etpires: DIVISION OF INDUSTRIAL SAFETY PERMR CERTIFICATION: ❑ I hereby certity that no excavation five (5) or mora feel in depih into which e person Is required to descend, will be made in connection with work authorized by this permit, and that no building stmcNre, scattolding, falsework, or demolition or tlismantling thereoi, will be more than ihirty-six (36) tee� high. (Chep. 3.2, Gry 2, Art 2, Sec. 341, Title e, California Adminisirafive Code). ❑ As owner-Duiltler, I will not employ enyone to do work which would require a permit from the Division ot Indusirial Setety, as notetl aDove, unless such person has e pertnit to do such work trom the tlivision. Signature: Date: Division ot Intluslrial Safeiy Permit Number: CERTFICATE OF COMPIJANCE /WD AUTHORVA710N OP ENTRV: I cenity under penelty of perjury i�at I have read ihis application and state ihat the infortnetion given is correct. I egree lo comply with ell stete laws end ciry ordinances rela�ing to �ullding cronstruction, entl authodze represemetives ol Ihe Ciry oi Coste Mesa to enter upon the above-descnbed property tor inspection purposes. I agree not to occupy or ellow acupancy of eny building aulhorized by ihis pertni� unlil finel inspection. ��Signat Of Lega1 er(s) — Date � ,//I1�f � �n/ i 5-G��"�� And/Or Aut�orized Applicant Date 1616 Fixed System Final Fire Prevention 7266 Pool SDa Final 200 Finel RB-Rooi 201 FIneI Block/Reteining Well 202 Final Fectory Fire Place . 203 Finel Sign 204 Finel Domolition P�g IMRI�LS � � COOE� INSPELTIONTYVE 206 Finel Meclianical 20B Finel Plumbing 210 Finel Electricel 212 Final Fire Prevention 220 Finel Planning Approval 222 Finel Site 250 Finel Building/Occupency PAg � IN�fID�ELi � AOPIIcant lo till In all spaces exce0� �nose within heavy Cortler Iinos anC sign all a00/opriate Oeclarations. CITY.OF COSTA MESA CONSTR UCTI N PERMI / n/1. PER T NO. TRACT NO. LOT NO. UNIT NU. � Pfoject Address �� [�% A C�i ��VIX "/ � ��J /I_ TVPE OF CONSTRUCTION NEW ADD ALTERATION REPAIR Applicant's Mailing{F�� dr/e,ss1 // d.'� � HTWL�[L. � PhOne � CONVERSION ❑ DEMOLISH ❑ OTHER q,p, q� Zone Owner's Name DESCRIPTION OF WORK/USE OF BLDG. � Address SRmc- S Main Building: Accessory Building: E Z Arch/Eng. License No. TVPE OF PERMIT GRADING�l �FOUNOATION STRUCTURnL T Front p Addre25 ❑ THERT � ELECTRICAL L—f'PLVMBING ❑ MECHANICAL A Reaf N Contractor's Nam %��+ Phone ' PROJECT DESCRIPTION 5(l. FT. oCCUPANCv C Aight �`1 Address (mnilin3) �� A CONSTRUCTION TYPE VALUATION $ $ G Left R City License No �� ' ZONE GRADING CU. VOS. ACRES E LICENSED CONTRACTOR DECLARATION Ping. R¢f. # Pa�king Req./P�Ovid¢d 1 hereb aHtrm that I am licensetl untler. rovislons of Chart¢r 9 commencin C � Y P ( 9 Remarks' �S�'�CC C D C�i� T / Plannin9 Notes: M �`A with section 7000) ot Division 3 of tho BuSinezs antl Protessions Cotle, antl T my licenze is in full to e eHect. n/�� ^ . ' S LICenS¢CI � li n5 OLY J Date � — Signature PLUMBING FEES WORKERS' COMPENSATION DECLARATION Bar Sink Showers � ELECTRICAL FEES I hereby alfirm that I have a certlticate of consent to self-insure or a certificate ' Workers' Compensation Insurance, or a certlfietl c�opJy tnenreot (Section gackflow Preventer Service Sink Automatic Washer Transtormer � 15-50 KW Q 0, Lab. CJ /� _�j/ � I"/LOJ �/ � ❑ 50+KW � olicy No. �-� J(� Company Backf{o�„� Irngation Sewer Cap Construction Pole Sub. • �, �rtifietl copy is hereby furnish¢tl. LS�'Cert fiep� oRy� tiletl with Ihe <ity euj� i DI�/ sio /^/ Ba[htubs $ewer Connection Cooking Unit � Meter �up to 100 amps � - Date � [Cd `�� APPlicant / •� (��+� . - EXEMPTION FROM WOHKERS' COMPENSATION DECIARATION Cld�ifiQ�s S013t COII¢Ct0�5 Di5hwd5h¢� Mete� �OVC� 1002m�5 (Thi55CCtion neetl not be completetl ii the pGrmit is tor One huntlretl ($100) or - Iess). Dishwasher Solar Piping Dryers ❑Gas ❑Elec[ric Sub Panel . - I wrtity Na[ in the perlormance of [be wO�k fo� whlth Uii perm�t is i55uetl I � shall not employ any person in any manner so as to bocome zubjeci to the Drinking Fountains Solar Tank Fan � Motors �0.1 HP �1 h- 8 Worker5' Com0en5alion Lawz of CalifOmia. Date Signature Floor Drains Swimming Pool w/Spe F.A.U. Inc.Solar �9�15 HP 016-15+ ' NOTICE: It, after making thiz tleclaratlon, you shoultl become subject to [he workers' Compen5ation provisions oi tne Labor Cotle, you must torthwith Floor Sinks Urinal Fixtures Microwdve ' comply wilh suc� provisions or [hi5 p¢rmil shall b¢ tl¢emetl revoketl. CONSTRUCTION LENDING AGENCV GasService Outl¢LS Wet¢fCIOS2t ' ' I neretiy a(firm that there is a construction lenain9 agency tor tne periormance /� Device Boxes Pole Light of the wOrk fOr wblcn this pe�mit is ISsuatl (SeClion 309] Civ. CJ InterceptOrs WdtC� H¢dIE� p( �utlELS R2ng¢ LEntle�'s Name ' Lentlar4 Atltlress Kitchen Sink Water Service Switches g�y� . � OWNEii BUILDER DECLARATION I hereby afnrm tnat I am exompt from tne Contracror's License Law for me Lavatories Auto-Wash Garbage Disposal Standing Sections lollowin9 �eason (Section 7031.5 BuSiness anU Pratessional Cotle: Any cily or county which requires a permlt to construcq alter, improvo, aemolish or repair P—Trap Laundry TraVs Generator 00.5 KW �5-15 KW any slructure, prlo� lo ils i55uance, also �equireSlhe ap0��cant tor SUGh pe�mil T/d5h COmp2ct0� lo fiie a signetl stalement [hal he/sne IS Ilcen5o0 pu�suant lo Ih¢ Provision5 01 ROOf D�ains tho ConVactor•s License law (Chapter 9(commencin9 with Sectlon ]000) of Division 3 0( the Business antl Prolossions Cotle) or that he/she is exempt ' •pfrom antl lh¢ basls tor the allCgetl exemption. Any vlolatlon ol Sectlon , .5 by any ap0�iwn[ tor a permit subfects lhe applicdnt to a civil .Ity ot not more than live nuntlretl tlollars (ES00). S 3 � L� I, as owner of the property or my amployaes wltn wagos as thair sole ReinspBetion F9a $15 IRue Fea <ompeniation, will tlo Ihe work, antl th9 SIrUCW�e IS not inten0etl or of/ere� RBinSPBctiOn FBB $1$ ISTue F88 $ 3 ior sale (Section 7044, Business antl Professional Cotle: Tne Contractor's MECHANICAL FEES LiCCnm I�w tloes nol apply t0 an own¢r ot a pro08rty who builUs o� imprOv¢s thereon, antl who tloes such work nlmseH/horsalt or through hls or her own DEVELOPMENT $ERVICES RE�UIREMENTS: � employees, provitletl that such �mprovaments aro not Intentlotl or offeretl ior Boiler Hood Or Typ21 ❑ Sale. I1, howevo�, the bull0ing or Improvemant I5 soltl wilhln on0 Yea� ot com- CdnOpy Typ¢ I I ❑ ZOnin9 App�Ov¢d By Date plotion, tho owner will Itav¢ the bur0on ol prOving hC/She UIG not builtl or im- Duct � Under Ground BuildinB APProved By Date p�ove fOr the purpose of Sale). ^ ❑ 1, a5 owner oi the prOpe�ty, am axtluSively conl�acting wilh Ilcensetl cOn- Duc� -$tfuCtU�dl Retrigeration System Applit'atiOn IssuBd By Dat9� lracto�sto Consttuct Ihe Droject (5¢CtlOn 7044, Busineii antl PrOteStionS Cotle: The Con[ractor'S License Law tloes not apply to an owner of Property who Duct- Ventilating ❑0-100,000BTU ❑1�,�� BTU bulltls a. imo�o�ez thereon, antl wha contracts 1or such orojectt with a con- SUMMARV OF FEES bactor(sl �icense oursuant to the ConVactor's Lic¢nze Law). I am aware that Exhaust System ❑ Multiple 0. System Repair/Alteretion BUILDING PERMIT $ SMIP $ pf001 O( thoir Worker's Compenwtion insuranca snoultl be provitlatl to mn. PLAN CHECK $ PERMIT � I am exempt untler Sectian e. & P. C. Por this reason Firepl/FecL BIL ICBO # Fire Dampers PWMBING 5 4,�� UANCE 3' Date Owner Heating System & Ducting egisters PLAN CHECK 25% 5 ENERGV P.C. S i her y hat I have reaa thls appiicat on a at the above ❑0�700,000 BTU �100,0006 ELECTRICAL $ GRADING S i mation Is correcL I agree to compty wltn all city antl coun ' ances ntl state laws relatin9 to builamg construction, antl hereby autnorize r PLAN CHECK 50% $ MICROFILM S J� sentatives oi this pity to x e ypon tne above-mentionetl property for MECHANICAL $ TOTAL FEE $�vv Inspe[Uon pu�;� / /n ignature _� rp5_� / Date O� qeinspeetian Fee $15 Issue Fae $ 3 PLAN CHECK 25% $ Oriv or SS � � — CMF OB65-46, rev. 30/B4 White - Builtling; Canary - - Acwunting; Goltlenrotl - Assessor �� UW1elL1—U�JULJI.1 B LV 7 ?.Uu _ OATE: D2/03iE� 7IflE: 16:2� CONSTRUCTION AND PLANNING FOOL & SPA � APPROVALS Permit# Date Inspector qppROVALS Permit# Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. E�ectrical Conduit Utility-Undrgrnd. 54. Forms .� 4. Electrical Conduit•Undrgrnd. 55. Electrical Bonding � 5. Steel Reinforcement 56. Rough Plumbing & Pressure�Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-Gl7NITE ,.^ 7. Footings •- 58. Electrical Conduit-Undrgr,nd.� 8. Foundation 59. Gas Pipe, O Undrgrnd., Test^ . 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap,'��,Undrgmd. 70. Structural Floor System 61. APPROVAL TO DECK ��Et� 11. Property Sewer Line & House Connection 62. Backwash & Receptor-Fin�'a�l� 12. Sewer Cap 63. Heater & Vent-Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical-Final 15. Rough Electrical-Conduit 66. 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 20. Rough Factory Fireplace APPROVALS Permit # 21. DuCts, in Structure 70. Underground Hydro 22. Dy�ts, Vent�lating 71. Product Piping OGas ❑Oil 2, Gas Pipe-Rough & Test 72. Underground Flush ' 24. Roof Framing 73. Undergrnd.StorageTankOGas ❑Oil 25. Roof Sheathing 74. Overhead Hydro 26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical � •� 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & 5iding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT �� 31. Plaster Brown Coat 79. FINAL INSPECTION '�• 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED ' 33. Final Electric Notes:2//�j/�i�f G�rC�Q,p• L.�� 34. Final Heati�9 & Air Conditioning 7_Z�.�e� '��T �Gxpl �t,o F�S PC£R- �' �-// 35. Final Gas PiPe-Test U(`�. L.t. i� 36. Hood or Canopy 37. Final FactorY Fireplace . , 38. Final Plumbing 39. Water ServiCe-Final - 40. Gas Service-Final '� ' 41. Solar pomes[icFinal , � ' 42. Backflow Preventer ' '43. Backflow Irrigation � 44. Landscape Irripation System - 45. Sound Attenuation � � 46. Handicap Ragulations � � . . 47. FINAL STRUCTURE & BUILDING ' 48. Special Requirements Completed � 49. Electric Relaase to Edison 50. Gas Release to Southern California Gas Co - � .�' 51. CERTIFICATE OF OCCUPANCY ' No. Date ' • .�� . ;` - . _ . DEC 3 i i��. OWNER SHANKLA� Nina 4irginia DATE ln-7��i7 — JOB ADDRFSS 210 E. CoSta Mesa. St. � BUILDING PERMIT NO. 5822 GENERAL ONTRACTOR ' VALUE$ QQQ�QQ � . o. � LOT ZE3 TC2ACT 1. FiRE ZONE DESCRIP'I'ION OP WORK Alt.c�. l:�..s..e 4.. T.i.,;.... � � ur I INSPECTIONS coat Gas Test ZONE DATE f:[.� I PERMITSISSUED SUBCONTRACTOR DATE I NUMBER 5822 _ � 5848 �COSTA MESA BUILDING DEPARTMENT P. O. BO% 31] i COSTA MESA, CALIFORNIA BUILDING ADDRE55 FOR APPLICANT TO FILL IN .'�i ! D - G n,e..�i � �a�,^ COSTA MESA. CALIFORNIA . � // � ' . � cirr y� /�_� nRCHirecr OR ENGINEER CONTRACTOR ADDRE55 LEGAL LC OESCRIPiION N[ � A.P. NO. ! SIZE "�is OF LOT � USE OF EXISTING BLDG. SIDE VARD �o. u c. NO. TEL. NO. / (J (J'�BLOCK R T � — � 9�-� — � � NO.OF BLOGS. X �D� G^� MOW ON LOT waM- � � � G '' �s'G �ET REAR VARD �/ � , RIGHT /�] / LEFT � DESCRIPTION OF WORK NEW ALTERA710N ADDITION REPAIR MOVING OEMOLISH BUILDING � NO.OF SRE 1 X ROOMS STORIES / EXTERIOR WALL ROOF �OVERING COVERING I NEREBV >CICHOWLEOGE TN>T 1 n t��: ♦PYLIC�l10N nO STRTE THRT THE ABOVE IS CORRECT NNO GR TO COMPLY WITM /�ll CITV ORDINRNCE$ /�ND 6T/�TE LwWS AEGVL4TING BUILUtNG CONSTRUC- TION. �A SIGNATURE (3�� • � � PERMITTEF� L�� «� -�� X /�� rEE �ECEIl1ED C� � • -I;- I q +'�—� � , FINARCE DEPT. CITY OF COSiA MESA APPLIC,4TION FOR PERMIT BUILDING FOR OFFIGE USE ONLY pECEIpT NO. VERMIT NO. S�1 � '£CENED BY DATE RECENEO DnTE �SSUED �uv /i� � %f � /n _ 7 -J 90o E'S5 Zi 6 L' C�S � A COSTA MESA. CALIFORNIA F^RE 3 i ijJp(. /c H DATE �U � CORRECTIONS� C:TY OP �� SUEIJEC� 'f0 B� .� R9ESA '?'1'. 6tiFT. REG. �UATION /� GERMiT FEE 5 (/ .�- � �� S FI PLAN CHECK S $ V I TOTAL FEE 5 ' vsrr JOB ADDRESS 210 Costa Mesa Street BUILDING PERMIT N0. .li :CTIONS SOIL GAS .WATER ROUGH PLUMBING PROP. SWR. LINE � HOUSE CON. � SPRINKLING SVSTEM MISCELLANEOUS ROUGM MEATING AND rllft CONOITIONING TEMPORAFV SERVICE OR POLE UNOERGROUN� � POWER � ROUGH WIRING TRENCHES � FORMS � STEEL REINF. FLOOR SVSTEM BOND BEAM � STEEL REINFORCE � SHEATHING FflAME ANO FLASNING LATHING - IN n OUT n PLASTER,BROWN COAT ST 'UNAL, FINAL Ht .G, VENT., fiEFRIG. AND A.C., FINAI PLUMBING, FINAL AND GAS TEST n ELECTRIC FINAL SUBCONTRACTOR � 36679 ;1-T��a��CJ114i" t: tr:.,t5.�o Z . a cWj Z Za N am J � J U7 Q W f� J J m Q U � Za W � aw wz J 0 m Z J � W W � ZH w� N � �O COSTA MESA BUILDING-SAFETY DEPARTMENT P O_ BOX 1200 COSTA MESA. CALIFORNIA 92626 APPLIC TION FOR BUILDING PERMIT For Applicant to Fill in Completely BVILDING RECE D�.E @E 'I DATE ISSVE ADDRE55 � � �/� �� OWNE • v A.P. NO. �z' a S P R IT NO MAIL q ADDR'ESS � � (� �,� �j`TpJ � � ADDRESS o(�� Q� CIT TEL. �`�O TRAC�i �� OT �p BLOCK CONSiRUClION W ADD LENOER �/ i\ BRANCH ,K OWNEF � �/L��%a �LL_i] VALUE /� ARCHITECT TEL $ P��B O✓��- $ ! �Q OR ENGINEER � N FIRE � ADOflESS 20NE � T P GROUP APPROVED � 7J CONTRACTO / �� BV DATE ��I�/% ADDRESS ZONE NO.OF USE OF NEW /j'T( O TEI. p�qry� BUILDING CITV NO. I � C�% f�� STATE CITV �'ARDSAPPROVED VARDSAPPROVED LIC. NO. LIC. NO. MAIN BUI�DING ACCESSORV BUILDING S12E NO.OF BLDGS. (FROM C/L T)_� OF LOT NOW ON LOT RONT �� FT. USE OF EXISTING BLDG. 5 ='� FT FT 512E OF NO. OF NEWBIOG. ROOMS STORIES L SIDE �� FT. FT. EXTERIOR WALL ROOF COVERING COVERING REAR FT. FT. USE OF BUILDING AND WORK TO BE PERFOFMED DISfANCE BET. BEf. MAIN & MAIN BLDGS. ACCF55. BLDGS. VAR.qW DATE C.U.7.qW APPqpVED APPROVED �S �_�f_7 I heraby acknowledpa thnt I have rootl this aDG��cation antl state /, that [he ebova infarmation is correct antl a0rea to eomply wit� atl taws regulaNnp bulltlinB �onsnuction, anC I shall not amploy � eny person in viOlotion ot the workmen'S compensa[ion laws ot tha Stata ot Califomla. T� I hereby tertify Met 1 em properly licensetl as a coniractor untler SQ. FT. the State of California Business entl Professions Cotle, Olvisicn 3, THE AMOUNT SHOWN UNDER VA�UATION IS FOR Chaprer 9, and Ma2 such licenses are in full torce antl effect, or 1 THE PURPO6E OF ESTABLISHING A PERMIT FEE ONLY: am exampt from the provisions ot the Stett of California Business m p antl Professions Cnde, Division 3, Chapter 9. VALUATION �—_ '�� Q O PERMR FEE $ Signatura o �� _ Permittee � ��[ %l�4I 5 PLAN CHECK 5 Authorizetl Apent TOTAL FEE 5 ��