HomeMy WebLinkAbout653 COVE ST - Building Permits(714) 754-5273 • Fax (714) 754-4856 • wv+w.ci.costa-mesa.ca.us 77 FAIR DRIVE, COS7A MESA, CA 92626
BUILDING PERMIT
Job Address: 653 COVE ST
Suite:
Vicinity: ROOF
Parcel Number: 42223105
Applicant: SAMPABLO, MIGUEL
Address: 653 COVE ST
COSTA MESA, CA
Owner: SAMPABLO, MIGUEL
Address 653 COVE ST
COSTA MESA, CA
Convactor: O W N ER-B U I LDE R
Address:
Zip:
Arch :
Address:
Phone:
Zoning:
Phone: 94&646-2537
Zip: 92627
Phone:
Zip: 92627
Phone:
License: 000000
Eng:
Address:
Status: ISSUED
Applied: OZ13/2003
Issued: 02/73/2003
ISSUED BY: D
Phone:
Zip: License: License:
SCOPE OF PERMIT
TEAR OFF EXISTING ROOF. INSTALL 30 YEAR, COMPOSITION SHINGLES, AND REPLACE SHEATHING AS NEEDED. 20 S�UARES INCLUDES
RESIDENCE AND DETqCHED GARAGE. WORK TO BE COMPIETED SIMULTANEOUSLY.
Plan Check: $0.00
Permit: $97.25
SMIP Res: $0.50
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: 597.75
SETBACKS
MAIN STRUCTURE Front 0- 0
ACCESSORY Front 0-0
PARKING Existina: o
Rear 0- 0
Rear 0-0
Re uired: 0
FEESUMMARY
PLANNING & ZONING
Left 0. 0
Lek 0- 0
Pr000sed: 0
Calc Valuation:
Claim Valuation:
Right 0- 0
Right 0- 0
sa.000.00
sa,000.00
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, § t, 12-21-92)
EXPIHATION: This pertnit shall automatically expire and become void if work is not commenced within 1B0 days, or it work is suspendad or abandoned
for a period of 180 days.
�� INSPECTIONS: In order for the work authorized under this permit ro be considered legal, such work must comply with all applicable codes, and all
�' required inspectfona end finel approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
I FOR INSPEC710NS CALL: (r14) 7545626
!aasae (saol
WORKERS'COMPENSATION DECLARAnON: ���
I hereby ettirm under penalty of perjury one of Ihe lollowing tleclarations:
❑ I heve end will maintain a certificete ol wnsent to self-Insure br workers' compensetion, es pmvided for by section 3700 ot the Labor Cotle, br the pedortnance of tha
work lor which this pertnit is Issued.
❑ I �ave end will malntain workers' compensalion insurance, as required by section 3700 of ihe Lebor Code, for the peAortnance ol the wwk for which Nis pertnit is issuetl.
My workers' compensatlon Insurance carrier entl policy number are:
Cerner: Policy Number:
(Thls section need not be completetl i/ fhe permit is �eluetl ef one huntlretl dollars ($100) or less.) . . ,
❑= I certify that in ihe peAormence ot the
' compensatlon laws ot Calitomia, and
comply with thesa provisions.
ApPliCen� Signeture: �
WARNINO:'FAILURE TO SECURE WORKERS' CC
Ti1CM15AND DOILFRE (5100,000), IN ADDRION Tf
hich t�is permit is Issuetl, I shall not employ eny person in any manner so as to become sub�ect to the workers'
i� I shoultl become su6�ect to Ihe workers' compensetion provislons of Seclion 3700 of ihe Labor Code, I shall forthwlth
Oate: �/��/' � 7
iN COVERAGE IS UNLAW FUL AND SHALL SU&IECT M! EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FlNES UP TO ONE HUN�REA
OF COMPENSATION, OAA4IGES AS PilOVIDED FOR IN SECiION 3108Of THE UBOR CODE, IMEREST, AND AiTORNE`f5 FEES.
LICENSED CONTRACTOfiS DECLARATION:
I hereby eHirm that I am licensed undar provisions ot Chapter 9(commencing with Section 7000) of Division 3 oi the Business and Pmfessions Code, entl my license is in full
torce antl eflecL Lla • Class tl
Conirector's Signature: Date:
CONSTRUC710N LENDING AGENCV:
❑ I �ereby aRirtn ihat there is e construction lending egency for ihe performance of the work tor which Ihis partnit is issuetl. (Sea 3097, Civil Code).
Lentler'S Neme: Lenders Address:
Signature: Date:
OWNER-BUILOER DECLARATIONS: �
I hereby affirtn thet untler penelry of perjury Ihat I em EXEMPT FROM THE CON7RAC70RS LICENSE LAW for ihe following reason (Sec. 7031.5, Business and Profes5�ons
Code: Any ciry or counry which requires e permit �o construct, alter, improve, tlemolis�, or repair any structure, pnor to its issuance, also requires ihe epplicant for such permit
to lile a signed siatement that he ar she is Ilcensetl pursuant to the provlsions of the Cantrectors License Ww (Chapter 9(commencing wlih Sectlan 7000) of Division 3 0l t�e
Business end Pmfessions Gode) or Ihet ha or spe is eaempt therefrom and Ihe basis for the elleged exemption. Any doletion of Section 7031.5 by any epplicant for e pertnit
sub�ects the applicant to e civll penalry oi not more than tive hundred dollers ($500).):
❑ I, as owner of the property, or my employe9s with weges es their sole compenutlon, WILL DO 7HE WORK, and tha sWCNre Is not intenOed or otteretl for sale (Sec.
7044, Business an0 Professions Code: Th9 Contracbrs License Law does not apply to an owner of Droperty who builds or improves thereon, end who tloes such wo�k
himsetl or harselt or ihrough his or her own employees, provided that such imD�ovements are not intended or oHereA for sale. If, however, the building or improvement is
sold within one year ol completion, Ihe owner-builder will have �he burden of proving ihat he or she did not build or improve for purpose of sale.). �
❑ I, es owner ot the property, e EXCWSIVELV CONTRACTING WITH LICENSED CONTRACTORS to consimct the pro�ect (SecJ044, BuSiness and Professions
Code: The contractors Llcens Lew does not epply �o en owner ol p�operty who bullds or Improves Ihereon, and who contracts tor such profect wlth e contrector(s)
license pursuant to iha Contr tors License L.ews.).
I am exempt untler sec. Business and Professions Code for this reason:
sig —ture: � � / oate_ i4 —1 3 -B5
-Owner ID verifiad by dnvef ic se. Yes ❑ Na �Driveis License No. � Ezpirw:� 9'29� 0%i-
Verificetlon ol Ownership by' e of tlwu e i.a. - property t� bill or tleed):�
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I heraby certify that no excave�ion five (5) o� more Ieel In depih into which a person Is requiretl to descend, will 6e mede In connection wlth work euthorized by ihis
permit, antl Ihat no building siructure, scaHolding, talsework, or demolition or dismantiing t�ereof, wiil be more Ihan �hirty�six (36) teet high. (Chap. 32, Grp 2, Art 2, Sec.
3d1, TIUe 8, Cali}omia Administretive Cotle). .
❑ As owner-builder, I will not employ enyone to do work which would reduire e permit irom the Division of Industriel Sefety, es noted above, unless such person hes e
permit to tlo such work from the division.
Signature:
Division ot Industrial Satery Pertnit Number.
Date:
MIZARDOUS MATERIALS AND EMISSIONS CEHTIF{CATION:
1 W III t�e epplicant or present or fuNre buildin9 occupent need to file end cetlity a Business Plan tor emergency response to release or threetened releese of e hezardous
metariel7 ❑ Ves ❑ No
(Saction 25505 of lhe CeliFornla Health antl Setery Cotle requires, wit� some exceptions, Ihet e Business Plen 6e filed with Ihe Costa Mesa Fire Department by e�ery
business which has at any one time during a reported year a quantiry ot haiardous matenals equal to or greater then a weigh� of 500 pounds, or a volume o155 gallons,
or 200 cu�ic feet of compressed gas at standartl tempereture and pressure).
....................__...................._......................._....'_'_'_'._............_.....__....................._.........................__..........................._._..............................................................._................................ _........._..................._..............._
2 Does or will the appliwnt or present or Futur� builAing occupant neetl to tile a re8istretion lorm tor acutey ha�rtlous materials? ❑ Yes ❑ No �
(Section 25533 0l the CalHomla Heelth antl Safety Code, with some exceptions, reqNres registratlon with t�e Coste Mesa Fire Depanment Dy each business w�ich et eny
one time has on hand e Quentity oi ecutery hazardous meterials equal to or greeter ihan a weight at 500 pauntls, or e volume ot 55 gallons, or 200 cubic teet o1
compressed gas at stentlartl tempereture antl pressure).
........................................................................................................................................................._................................................................................................._........................................................................................._.................._..........
3 Does or will Ihe applicanl or present or fuWro building occupant need to prepare en RMPP (Risk Management end Prevention Program tor acutely hazerdous metenals)9
❑ Yes ❑ Na
(Section 25534 ot Ihe Califomia Health and Selety Code pmvides ihat ihe Coste Mesa Fire Department may require Ihe preparation, certificaiion and filing with the Fire
Depertment of an RMPP by businesses whiCh are required to regisler acutely hezardous materlels with the Fire DeDartment.
...................._".....................__.................................................._...._..__...................................._.....................__............................_..................................._._._.."'.... ....._................. ........._......_........._....................._.........._
4 H en RMPP is presen�ly requireq has Section 25534 0l Iha Celifomia Health end Selery Code been tully cromplietl wit�7 ❑ Yes ❑ No
.......................................................................................................................................................................................................................................................................................................................................................................................
5 Does or will Ihe applicant or present or future bullding accupent require br t�e work whlch is the subject ot this a..ppllcation a gerznit for such conslruction or motlilicetlon
trom the South Coest Alr Ouellry Menagement Distdct or Irom eny other air polNtion wntrol district or agencyt u Yes �,J No
(Seciion 65050.2 of the Calilornia Govemme�� CoOe requires t�at the requestetl inlormetion be fumishetl on applications tor non-resitlen�ial Duiltling permits).
6 W III any patl ot �he facility to 6e consiructed under ihis permit be within 1000 feet Irom Ihe outer 6oundanes of e school? ❑ Ves ❑ No
(II yes", the faciliry must meet ihe requirem8n� ot Sec�ions 25534 and 42303 of the Celitomia Health antl Safery Cotle).
........................................................................................................................................................................................................................................................................................................................................................................................
7 If a permit fmm the South Coesc Air Qualiry Menegement DisMct or other elr pollution control district or agency is repuired fo� Ihe woAc which Is the subject of this
applicatlon, have all of the disclosures prescnbetl by Calitomie Health and Salery Coda Section 42303 been metle7 ❑ Ves ❑ No
.......................................................................................................................................................................................................................................................................................................................................................................................
B (If'yes', anach certifiwte oi compliance from iha aDGropriate air Oollution conirol oNicer).
CER7IFICATE OP COMPLIANCE: I certify lhat untler penalry of perjury Ihe infortna�ion given above is correct. I aprae Io comply with all state laws en0 ciry ortlinences
regarding Hazardous Materials and Emissions.
Signamre: Date:
CER7IFlCATE OF COMPLJANCE AN ORI7ATION OF ENTAY: I certify under ponalry of perjury that I have read this epplication and state that ihe information given is
correct. I egree ro comply wIN ell s t aws and ciry ordinances relating to builtling consiruction, antl authonze represematives of the Ciy ol Coste Mesa to enter upon Ihe
ebove-described propeAy tor insp urpose9. � agree not to aapy or aliow occupancy of eny building authorized by this permii until final inspection.
g=_/3��3
ign f Legal.Dwneqs) Daie`—� ,
� �
CODE �. INSPECTONTYPF P� �TI COOEI INSGECTIONTYPE � QAjf, �$
1616 Fixed System Final Fire Prevention 206 Final Mechenical
1266 Poal Spa Finel
200 Finel Re-Root
201 Finel BIocWRe�aining W ell
202 Final Factory Fire Place
203 Final Sign
204 Final Demolition
/L%�/L i � u-.
_ .. /
208
270
212
220
222
250
Final Plumbing
Finel Electricel
Final Ffre PrevBnlion
Final Planning Approval
Final Site
Final Building/Occupancy
(714) 754-5273 • Fax (714) 754-4856 • vnvw.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
!ob Address: 653 COVE ST
Suite No
Vicinity:
Parcel Nunmber: 42223105
Applicant: NOCK, TIM
Address: 11612 KNOTT ST
GARDEN GROVE, CA
Owner: SAMPABLO, MIGUE�
Address 653 COVE ST
COSTA MESA, CA
Contractor: NOCK PLUMBING
Address: 11612 KNOTT ST
GARDEN GROVE, CA
Arch / Eng :
Address:
ISSUE FEE
BackFlow irtigation
BackFlow Preven[er
Balhtub
Clarifier System
Connect Qce,Soda,etc)
Dental Units
Dishwasher
Drain, Floor
Drain, Rainwater
Drain, Roof
Drinking Fountain
Expansion Tank
Gas Earthquake Valve
WATER HEATER CHANGE OUT.
AMT
$23.50
50.00
50.00
$0.00
50.00
$0.00
50.00
$0.00
$0.00
$0.00
$0.00
$0.00
50.00
$0.00
PLUMBING PERMIT
Phone: (714)895-1246
Zip: 92841
Phone: 949-646-2537
Zip: 92627
Phone: (714)895-1246
Zip: 92841
License: 707775
Phone:
Zip:
License:
SCOPE OF PERMIT
FEE SUMMARY
QTY AMT
Laundry Tub / Washer $0.00
0 Landscape Irngation 50.00
0 P-Trap $0.00
0 Pressure Regulator 50.00
0 Process Piping (per 10 ft) 50.00
0 Receptors 50.00
0 Septic Tank 50.00
0 Sewer Cap for Demo 50.00
0 Sewer Connect 50.00
0 Sewer Private Line $0.00
0 Shower $0.00
0 Sink, bar $0.00
0 Sink, commercial 50.00
0 Sink, Floor $0.00
QTY
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Status: ISSUED
Applied: 02/27/2003
Issued: 02/27/2003
SumpPump
Swimming Pool
Trap Primer
Urinal
Vacuum Brkr Bkflow(1-4)
Vacuum Brkr Bkflow(5+)
Wash Basin
Wash Basin Set
Waste and Vent System
Water Closet (Toileq
Water Heater / venl
Water Piping (Inst or Rep.)
Water Re-pipe
Water Service
AMT
$0.00
50.00
50.00
$0.00
50.00
50.00
$0.00
50.00
$0.00
$0.00
$12.30
$0.00
50.00
50.00
QTY
0
0
0
0
0
0
0
0
0
0
7
0
0
0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 9248, § 1, 12-27-92)
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
requlred Inapectlona end flnel approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
2anGa818�00)
WORKERS'COMPENSAnON DECLARAnON: '
I hereby eHirm under penalry of perjury one oi the following declareiions: '
❑ I have end will maintein e certificate of consent to self-Insure for workers' compensation, es provitled for by section 3700 oi ihe Labor Code, lor ihe pertormence of the
�work lor w�ich I�is permit is issuetl. �
I have entl will mairnain workere' compensatlon Insurance, es requiretl 6y section 3700 of ihe Labor Code, for the performance of the work for which this pertnit is issuea.
My woTrkers'Wc�n pe��/ysation Insurance cerrier d poll um6er a`re`� (�
Cerrier: J-`� /V/ �� P � W 7� R PolityNumber: �7��M �Z �
(This secflon need nof be comp/eted i/ t e permi s velued et one hund tl tlollars ($100) or less.)
❑ I certity that in the peAo ance oi the Ac 1 r which ihls pertnit is issuetl, I shall not employ any person in eny manner so as to become subject ro the workers'
compensation laws of IFomia, and ree et II I shoultl become subject to the workers' compensatlon provisions ot Section 3700 of Ihe���ppp or Code, I shall torthwith
cromply with these pm n �_ � �
Applicent Signeture: Date:
WARNING FAIIURE TO SECU FS MPENSATION COVERApE IS UNIAWfUL AND SHALL SUBIECT rW EMPLOYER TO CRIMINAL PENALTIES PND GVIL FMES UP TO IXJE HUNDRED
THOUSMID OOLLARE (5100, IN DRIIXJ TO THE COST OF WMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3IOB OF THE UBOR CODE, IMEREST, PND ATTORNEV'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby attirm thet I am license nde m'si s ha r 9(commencing with Section 7000) of Divislon 3 of Ihe Businas�n rofjssions Cotle, and my licensa is in full
force and eflect. Lic. q Class a Ci �-�
CoNrector's Slgnature: Date:
CONSTRUCTION LENDING AGE CY:
❑ I hereby aHirm �hat there is a construction lending agenty br ihe pertortnance oi t�e work tor which this pertnit is iuued. (Sec. 3097, qvil Code).
Lentlefs Name: Lenders Atltlress:
Signeture:
OWNER-BUILDER DECLARATIONS:
Date:
I hereby eHlrm that under penalry ol perjury ihet I em EXEMP7 FHOM THE CONTRACTORS IICENSE LAW lor ihe tollowing reason (Sec. 7031.5, 8usiness and Professlons
Cotle: Any ciry or counry which requires e permit to construct, elter, improve, demolish, or repair eny sirucWre, Onor to its issuance, also requires t�e epplicant tor such pertnit
to Nle e signed statemant t�at ha or she Is Ilcensed pursuam to the provislons of the Coniractors Llcense Law (Chapter 9(commencing with Sectlon 7000) of Dlvision 3 ot the
Business antl Professions Cotle) or ihat he or she Is exempt therefrom and the basis tor �he allegetl exemption. Any violation ot Section 7031.5 by eny applicant for a permit
sublects the epplicent to e civil penelty of not more Ihen five hundred tlollars ($500).):
❑ I, es owner of the proparry, or my employees with weges es iheir sole compensetion, WILL DO THE WORK, end the sirucWre Is not Intantletl or ottered for sale (Sec.
7044, Business end Protessions Code: The Contractors License Law tices not ep01y to an owner of property who builds or improves ihereon, antl who does such work
himsell or herself or through his or her own employees, provitletl that such improvements ere not Intended or oftered for sale. It, however, the building or improvement is
sold within one year ot completion, the owner�builder will have ihe �urden of proving Ihat he or she did not build or improve for purpose of sale.). '
❑ I, es owner of the property, am EXCLUSIVELY GONTRACTING WITM LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contrac[ors License Law does not epply to en owner of propehy who builds or impmves thereon, end who contracts for such projad w1th e contractor(s)
licanse pursuant to ihe Contractors License Laws.).
❑ I em exempt under sec.
Signature:
Owner ID venfied by dnvers license. ❑ Yes ❑ No
Business and Prafessions Code for this reason:
Vanficatian oi Ownership by (type ol dxumem, i.e. - pmperty tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMITCERTIFICA770N:
Ddver's Litense No.
Date:
Expires:
❑ I hereby certify Ihat no excavetion five (5) or more feet In depih iNo which e person is required to descentl, wlll be made In connection wlih work eut�orized by this
permit, and thet no building strucWre, scaHolding, falsework, or demolition or dismantling ihereot, will be more than Ihirty-six (36) leet high. (Chep. 32, Grp 2, Art 2, Seq.
341, Title B, Celifomia Administretive Code).
❑ As ownerDuiltler, I wi0 not employ anyone to tlo work which would require a permi� from the Division of Industrial Safety, es no�ed above, unless such person has e
pertni� �o do suCh work tmm the divisian.
Signature: Data:
DivLsion ol Indusirial Safery Permit Numher:
CERTIFlCATE OF COMPLIANCE AIfTHORVA OF ENTTiY: 1 certify under penalry of perjury ihat I have read this application end state ihat the information given is
correct. I egree to compty with all �e laws end rdinances relating to building wnstruction, end authorize representatives ot the Ciry ot Costa Mesa �o enter upon ihe
above-tlescribed propetly tqr ins ion purpos . I ree not to occupy or allow occupancy of eny building amhonzed by this pertnit unlil finel inspection.
COpE 1, INSPECTIONTYPE� V I
7616 Fired System al Fire P�
1266 Pool SOa Fina
200 Finel Re-Root
201 Finel BIocWRetaining Wall
202 Final Factory Fire Place
203 FinalSign
204 Finel Demolition
OpTE
� p,@te � � C).�
� �/ /
' Dare
INTRIALS f�QQE1i INSPECTIONTYPE -
206 Finel Mechanical
20B Final Plumbing
210 Final Electncel
212 Final Fire Preventian
220 Final Planning Approval
222 Final Site
250 FinalBuilding/Occupancy
�a '1:.
• � ��
�
��
OWNER j-jAR$�u FSTATES � DATE 7_iR_5[
JOB ADDRESS 653 �ove Street BUILDING PERMIT NO. lri�ih
GENERALCONTRACTOR Dike & Cole�rove VA W E$ B��jQn.�Q
�or lpq BLOCK rencr iqR(, Residence �d Gar2ge
GROUP I
INSPECTIONS
Footing Trench
Foundation Forms and Grade to
Rough Framing
-C
Plumbing, Rough to SIaE �y,�
Plumbing, Rough Complete i��
Temporary Pole
Wirinq. Rough �
ig, Final /�
, House Sewer, St.
Tank or Cesspool
Out
Plumbing, Final, Fixtures C
Plumbing, Final Gas Test /
Wiring, Final
Occupancy j�
Form'l10 G-H 1500 1-55
DATE
�
■
20NE
SUBCONTRAC70R
FI
PERMITSISSUED
DATE I NUMBI
■ Ad
Size
Use
■ New
I ■ use
a esa g epa en
111 EAST 20th STREET
COSTA MESA, CALIFORNIA
iR APPLICANT TO I� ILL IN
653 Cove Street
Costa, Mesa,, California
19th Street
Iarbor Estates
419 East 17th Streets
Tel.
Costa Mesa No.LI 8-11
Lic.
`�arlson& Middlebrooldo,
Gazden Grove
,. Dike & Colegrove NoY ����1301
Metes and
B
Alteration � � Addition
Stories
APPLICATION FOR PERMIT
�,��5� �UILD,LNG '�
� FOR O�'FICE USE ONLY
I hereby acknowledge that I have read this Application
and state that the above is correct and agree to comply
with all City Ordinances and State I.aws regulating
building construction.
Signatureof
Perm�ttee Dike & Cole�rave
Authorized Agt. . li
Add ress '�
Costa Mesa, California
CORRECTIONS
APPROVALS
Foundatlon Loeation Inspector
Forms, Materials,
Under-Pinning
Frame: Fire Stops,
Bracing, Bolts
Lath.lnt.
Lath. Ext.
Valuation Permit Fee $ � . D o
$ 8t5�•�� TotaCheck $ Bond
Fee $ ���� FINA
O
�
�
2
D
r
d
J
a
0
�
a
IStreet
PLOT PLAN
.Show IOcation and disGinces from
property line and between bufldings
�\ r '
'JL 18-5 cosra � �.`*,
�2P�uEsd�F28a -25.f0
�
'
f' ��
`1`! \) _ • � . ~I �
.... _. :> ._ " +�-
� '... � .' �•��� c-
d06 ADDRESS
AP No. 115-�F�
INSL'LCTIONS
TRACP
_ g �
PIRIs 7.ONG
DA'I'L•' I GROUP
nA7'E 2-
VALUE
3SCR[PTION OP \VORK det
TYPE V 7.ON� R1
SUBCONTRACTOR
�. � 16413
CO,STA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 917 COBTA MEBA. CAI.�FORNIA
For Applieant fo Fill In Complefely
TYPE OR PRINT
COSTA MESA CALIFORNIA
� MAIL
u`c". eEia. 70 (o �/(o NEo -2SS
61ZE / � � I No. OP B1D08.
OF L[fT (OS X I�� Mew nu �nt
U6E OF
EX187'ING BLDG �
66TBACK LIN6 PNOM
DESCRIPTION OF WORK
�� I%� II e� TcweTnN I' II AODITIO
G NO. OF
�QX9(� ROOM6
GWAL�/UL�Q. I COVEP
iU1LDING AND WORK TO �
/�C�,( 20 � �{APAb�� _
�..�._/ n__`�.',
'- CP17.4��-
1 HEqEBY A NOWLBDGE THAT 1 HAVB R TXIB APPL) `TION
AND BTATE THAT TH8 ABOVE IB COR�R AND AGPEe 'f0 COM-
PLY WITX ALL CITY OHOINANCEB ANO �ATH LAWB OULATINO
6UILDINO CONBTRUCT�,Ory., � /���^n�
SIGNATURE OF �Ni . 5��
� AUTHORIZED AGENT
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fE8 141968
FINANCE DEPT.
CITY OF COSTA MESA
APPLICATION FOR PERMIT
BUILDING
For Office Use Onl y
I HHC8IPT NO. I PEryM¢ N�/
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BUILDING /_S � %1_ �
ADDRESS �O �P'!"•C� �'.
COSTA MESA. CALIFORNIA
ZONING
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� THE�M0IJNT BXOWN UNOER VALWTION 19 FOR THE
PURP08E OP E9TABL19HING A PERMIT FEE ONLY.
VALUATION �
S j PERMIT FEE $ �� �
S �� �� PLAN CNFf_K A .T