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Home My WebLink About989 DAHLIA AVE - Building Permits� li (714) 754-5273 • Fax (714) 754-4856 � www.ci.costa-mesa.$�LDING PERMIT 77 FAlfi DRIVE, COSTA MESA, CA 92626 � _ �"��,,� Jobnddress: 989.DAHLIAAV `�"4 � /+t,� Slatus: ISSUED ' �Suite: � � -� � ' •� , . . . y1„" y.'i v Applied: 10/18/2006 Vicinity: - . � � r � � , � Issued: 10/18/2006 Primary Occ: R3� Dwellings/ Cong Res <10 Type of Construclion: V-N- • � � � •� Parcel Number: 41218116 Zoning: R1 , . npp�icant: STVE JANOSIK , �. t. ,. •'`•'�=�'a� `��', Addfe55: ` � �... +_ ; , .� � _ ..�:lJ�`r-:^_.. {,Jy.i�'_.!a..�„��„i{_ � � . '- � ' , . . Phone: 774-349-2182 ISSUED BY: � Owner: GRIFFIN, Address � 989 DAHLIP Address? � -1621 ESTANDREW;PL"^= ' av ( `� �///�•-�' ,.. . ; � SANTAANA!CA Q� /i%.. 92705�� . ' . � n IA�� _ /Address — ) r�`� � Phone J •��^• J �V �c�' 1'� �'" fr' Zip:,�% � � +� License�o��y1`` Ut ��.(.J�� h � .�� V-�,�'�j .�f Q``.,,=-_=- I , , c,rv ��RE7ROFIT 10rIW/iND WS R P�CP`CE O DOOR SLIDERS. � J $0.00 ' j $167.25 � I �0.8� � �o.00 !; �0.�� ,; $o.00 �, $168.06 00 � � « l � ' �,`` _ ,�\ �.� ,� _ �� zs� �%,: `�\�.:,c � �r��„ T �',�%ti� `�} ) i Phone: 714-259-5120 �'G\� '�� ( � ., ��Q��. � �'.� �,_� . License: 523043 � 't�A �� V'� \ � �� G� . Eng:� �iAAV / -,� � , ' � Address' _ � �� \� \ . ^; �� , R / / `, \t �� < <oc" ('�� ` �Phone:, �•, + � � � ,. ri �v� l. � � V� �I �- . �, �'`.,rt 7`� 1 `�'License: '\�� i .. _ .. �� ,Ati � � �� :OPE OP PERMIT�' �-' }� -�`z;,,t'� � \ �. A :='�,', � ; ' � { '. `_.. �� .. � a�,,1�� i ��4 ��V { i� !.. , -'1 . FEE.SUMMARY�__ _t � ��j°, ,==: �'� ` �vy7/'�y �, T �,r'�'nCalcValuation: �.. '. (�! ; ,_ sa,ioo.00! lL.11 �1L �� t`�1� u :�) Claim Valuation ` �� ' \ $8100.00� ,� � � � —=—��-__=� ��;?j�! '_-=, 'fi, �� '` ; � , �- � � �� `J`/.G�'}� T'�� JI /�'I <`-+ �/ � �� i .� �"'.�.e- '11�; %-- _ ( ,'';1 `t i ��,, ; ;� � � �j'' {`'� . '' � � i U/1 r� 7 %�; � VING&'ZONING I %'%J� �"��,: ) j,�1�' _;:•��.� f,'�i Z ' ( ; ri ;' Front �0-0. Rear.�.^'0 0�°��"��,Left ��0 O,n Right j 0 Oj%�% �` .'�I � �',z o 'Yf• . � �r, � . � � �l ��?� . n%.hS�"� 6 <+' / �Front 0�'0��=t+i�ReaJ�_,�"�� „�� "a o . � r '( u'�rv ar'`"" � r' i [ ' !, . �_ ,� Left � 0 .0 �- Right 0 �0 � - ; � � 1��i � ' 'o Otl p� jlls4(j„��o o� 'v >j5� -� / �Existin��Reauired� �O,��o„ �.. �.. °�..s�"�� %�� . � Proposed:i �'0' f � �j�, � / 0 ��`.,,��.,_-�� a0 0 9 '="c`-.c,o�rf �,•�'�Li�C`/ �,i \� o /�,� �� .oc�� ",%,'' ��,J��/.��,ri `J . a �/�� ' �2 C1 ''� `"� ;� % �..� �1_rl , i ��--� ,,��i � ; . -, �, :�� , .. ;a �. ��, ,. ,_ , ;, �,?'+,G� z �i G._+-_�_:::�.�- _�, "1 NOTICE: The work authorizad by this permit shall comply with all applicable handicap access requirements under Califoinia 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 ii work is suspended or abandoned for a period of 180 days. . . INSPEC710NS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspeetlons 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 � . . ��a�„i. � � . . ... . . . . . ., . . , . . . . WORKERS' COMPENSATION DECLARATION: ' - � � -° ' . . � - � I hereby eflirm undecpenelry of peYury one ot the following tlecleratlons: � ' _ � ,�� • _ �'I heve end will maGteln e certificate af consent m selbinsure for woikers' compensation, es provitlad for by section 3700 af the Labor Code, Por the pertoimence ot ihe. work far which ihis permit is issuetl. �•- � ,� I have and will maintain workers' compensation Insurance, as requiretl by section 3700 of Ue Labor CoUe, for the pedortnance oF ihe work for which this pertnit is issuetl. My workers' compensatlon Insurance wrner and palicy number are: � /� ,pp O C�, Certier. t�� G ii�� / Policy Number (SO � �� T � (This section neetl not be comp/et i/ Ihe permit is ve/ued at one hundred dollars ($ 00) or less.) . � .. _ . ,.. , . _ . .. . . . .. . � ❑ I cetlity ihet in the pertorrnance oi Ihe work for which this pertnit is issued, I shell not employ any person in any mannei so as to becwne subject to ihe workers' compensatlon law f alifomia, and egree that it I sh d become subject to the workars;compansation provisions of Section 3700 of the Lebor Cotle, I shell forthwith comply with the ia 6� n Appllcent Signeture: Data: I D' IO �� WARNING: FAILURE TO ECURE W ERS' PENSATION COVERAGE IS UNLAWFUL AND SW1LL SUBIECT AN EMPLOVER TO CRIMINAL PEWILTIES AND GVIL FlNES UP TOIXJE HUNDRE TFIOUSAND DOLLARE ($100,000), IN DITI O THE COST OF COMPENSATIIXJ, OAMAGES AS PROVIDED FOR IN SECiION 3M OF THE LABOF CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRAC70RS DECLARATION: � I hereby effirm that I am Ilcensed under provisions of Chapter 9(wmmencing with Section 7000) oi Division 3 of the Business�nd Protessions Code, and my license is in full force end ettect. Lic. # 3 � Class F � _� Contracrors Signeture: Date: 1 Q�- 1 � CONSTRUCTION LENDING AGENCV: ❑ I hereby aHirtn that there is a construction lending egency for tha performance oi the work tor which this permit is issued. (Sea 3097, Civil Code). Lenders Name: ' Lendeis Address: Signature: Date: � OWNER-BUILDER DECLARATIONS: I hereby aHirm Ihet under penalry ot perjury that I am EXEMP7 FROM THE CONTRACTORS LICENSE LAW tor ihe following reason (Sec. 7031.5, Business end Professions Code: Any ciry or county which requires e permit to conslruct, alter, improve, demolish, or repair eny siructure, prior to its issuance, also requires the epplicant for such pertnit to tile e signed statement Ihet he or she Is licensed pursuant ro t�e provisions of ihe Contradors License Lew (Chapter 9(commencing with Section 7000) oi DlNsion 3 of tha Business antl Professions Code) or �het he or she is eaempt theretrom end tha besis for the elle9ed ecemption. Any violetlon of Section 7031.5 hy any applicant for e permlt su6jects Iha applicant to e civil penalty c� not more lhan five hundretl dollars ($500).): . ❑ I, as owner of the property, or my employees wlth wages as thelr sole compensation, WILL DO THE WORK, antl the siructure Is not intended or oHaretl for sale (Sec. 7044, Business antl Professions Code: The Coniractors License Ww does not apply to an owner of property who builds or improves thereon, and w�o tloes such work himself or herself or throuqh his or her own employees, provided that such improvements era not intended or ofleretl for sale. If, however, ihe building or improvement is soltl wit�in one year of completioq Ihe owner-builtler will heva Ihe burden ot proving ihat he or she did not build or improve for purpose ot sale.). - ❑ I, as owner of the property, am E%CWSNELY CONTRACTING WITH LICENSED CONTRACTORS to constmct the project (Sec. 7044, Business and Protessions Code: The contractors Llcense Lew does not apply to an owner oi propetly who builds or Improves thereon, and who coniracts tor such project with a contractor(s) license pursuam to the Coniradors License Laws.). ❑ I am exempt under sec. Business antl Professions Cotle for this reason: SignaNre: � Date: Owner ID verified by tlriver'S license. ❑ Ves ❑ NO - Driver's Licensa No. Expires: Verification of Ownership by (type ot dwumem, i.e. - properry tax bill or tleetl): DIVISION OF INDUSTRIAL SAFETY PERMIT CER7IFICATION: `- ' � , ❑ I hereby cetlify ihat no excavation five (5) or more teet in depth into which e person is required to descend, will be made in connection with work authonzetl by Ihis pertnit, and that no building sWdure, scaflolding, talsework, or demolition or dismamling ihereof, will be more ihan ihirry-six (36) feet high. (Chap. 32, Grp 2, Art 2, Sec. 341, Title B, Calitomia Adminisiralive Code). -. ❑ As ownervbuilder, I will not employ anyone to do work which would requiro e permit from tha Division of Indusinal Safery, as noted above, unless such person has e permit to do such work Irom the division. . Signature: Data: Division ot Indusinal Satery Permit Number: CER7IFlCATE OF COMPLIANCE AND AIJTHORIZATON OF ENfRY: I cenify under penalry of perjury that I have read this epplication end state that ihe infortnation given is correct I agree to wmply with all state lews end ci�y ordinances relating to building construction, and authonze representetives of the City of Cos1a Meu to enter upon the ebove-descnbetl property for inspection purposes. I agree not to acupy or allow occupancy of eny building authorized by Ihis permit until final inspection. Lil GOpE t. INSPECTIONTYPE � 1616 Fixed System Final Fira Prevention 1268 Pool Spe Final , . . 200 Finel Re-Roof 201 Finel BIocWRetaining Well • , �- 202 ' Final Factory Fire Place' ' 203 Finel Sign 204 �� Final Demolition ' ' ' ' I�Z�i�l�ltll_1i�'1 (' . , . ` t�:[. . .. CODE� INSPECTIONTVPE 206 Final Mechanical 208, ' Final Plumbing . 210 Final Electrical �ein /D-l�-��o / Date _ Q�IE INTIMLS 212 � . Final Fire Prevention . .. . 220 Final Planning Approval � � : 222 Final Site � � . 250 Final Builtling/Occupancy -- � - : � 1 ! gOB SITE: �� ZIP CODE �Z C��. L �`i` ' � fNTRY DIN LIV [HJ i 10 DABLIA AVENUE Loca(ions Require Tempered Glass i Doors i Windows Within 24' From Doors And <Than 60' High Within 5 Feet From Pool Or Spa In Windows At Shower Or Bathtub & Stair Landings �han 60' Above Floor ction Shall Comply Wilh The 2001 Cal. Building Code. 5 Are Rated And Certified For 20 Ibslsf Of Wind Load. is Meet UBC sec. 2406 For Safety Glazing. is Meet UBC sec. 7203 For Light And Ven6lafion. ws Meet Z005 Energy Cade Repuirements - ! not more than 0.67 I Gain Coe�cient = not more Ihan D.40 irms In All Bedrooms. ns Must Have At Least One Window / Door Opening Directly erior- It Mus! Meet The Following Criteda: Nidth = 20' Min.Clear Height = 24' = 5.7 Sq. FL Maz. Sill Height = 44' eakout-Provide MoistStop Flashing Around All Windows, Doors. chuthane At Olher Neetled Loc. Such As Inlersecling udion Surfaces, Small Exl. Shelves And At Exl. PenetraUons. icco Shall Comply With Chapter 25 UBC. Min. 60 - Minule Bldg. =xteria SNoco. =rench Door Swing Out 7 YES NO ing Door Musl Open Over A Landing Not More Than 1' Below srSurface �g Must B6 At Least As Wide As The Door(s) And Extend 'he 7hreshhold The Distance Of The Doors Outswinging Arc rl' �. � - ; � -- � ��$ Jaeu+ne+rt Spa�cla►lsb JJING r' ' � ,. ,. �r DNISION OP 131.)ILDING Si11�1: fY CITY OF COSTA MESA AI'!'i:OVh;l) �- �.,�. �� 1,��6i�� This et ol ola�s zn; ;> er,lfications ��UST 6c kepl on thi; joG �: ali tim�:, antl it is unlavdul lo make any cn�. nos �.� %Iterz'�on; on same v�ithcut written �r.rmis�ian Ircrn ;n� �rm ion of Building [nd dI91�. Ci:,l4� CG'.id �A^:a. The amping of In��e pinn antl spscilicationc SHALI I IOT G^, hnld lo pc�rmil or tr; G� an approvsl of ih violatlon o4 any prUvisi�,n> ol any C'uy ot r,u�ta tl,esa Ordinhncs nndlor Stalc lav+. Thes plans and p�rmd shall cipire Gy Iimiln�ir,n ar�7 Gecorr�e null znd void ii Ine buil;inq or work s nol commenced and maiNained aclive per U2C �303 (d) vmhin 1c� day� of i;.uanc�: Owner DARLENE GRIFFIN Address 989 DAtji1A qVENUE City,Zip COSTA MESA, 92626 Phone 714-751-8122 Prepared By: Steve Janosik Contractor Address 1621 E. St. Andrew Place Santa Ana,92705 714-259-5120 All New Windows and Doors Have Dual Glaze, Low - E Glass Unless Otherwise Stated LEGEND XX Slider - Slider AWN Awning Window XO Slider - Fixed � DH Double Hung Window GW Garden Window SH Single Hung Window CST Casement RBA Renewal By Andersen PIX Pic[ure Window J0B:18224 cg SCOPE OF WORK: RETROFIT l O WINDOWS WITH ANDERSEN RENEWAL WINDOWS REPLACE 2 PATIO DOOR SLIDERS WITH ANDERSEN PATIO DOOR SLIDERS NO OPENING MODIFICATIONS NO HEADER CHANGES �o � o00 ��c��ru� 00 �� Wlndows & Doors Energy Efficient Windows & Doors www.dia4onewi ndows.com 1. i 4 1ZF • _.. 4�.�.. Request Reporting o�� CA _ Cifv nf Requested Inspect Date: Friday December 08, 2006 Site Address: 989 D,QHLIA AV CM A/p/D Information ' Activity: 606-01761 Type: BLD SUB Sub Type: ALT_RRIP Status: ISSUED ConstType: V-N Occupancy: — Use: Insp Area: Owner: GRIFFIN DARLENE A Applicant: SNE JANOSIK Phone: 714349-2182 Contractor: DIAL ONE WINDOW REPLACEMENT Phone: 714-259-5120 SPECIALISTS Description: RETROFIT 10 WINDOWS, REPLACE 2 PATIO DOOR SLIDERS: Requested Inspection(s) Item: 18 FRAME & FLASHING Requestor: Camments: 7�929-2705 PM Assigned To: Action: Time Exp: In�pection Historv Item: 1 BLDG PLAN CHECK Item: 6 SLAB Item: 8 STRUCTURAL FLOOR SYSTEM Item: 10 ROOF FRAMING Item: 16 SHEAR PANEL Item: 18 FRAME & FLASHING Item: 20 LATHING & SIDING Item: 22 INSULATION Item: 24 DRYWALL NAILING Item: 26 PLASTER BROWN COAT Item: 31 NPDES/BMP Item: 150 MISCELLANEOUS INSPECTION Item: 220 FINAL PLANNING APPROVAL Item: 220 FINAL PLANNING APPROVAL Item: 250 FINAL BUILDING / OCCUPANCY Requested Time: 08:00 AM Phone: Entered By: KELLY_N K r � �� I2� � � � REPT131 Run Id: 3062 JVJ L!'91�Y1A' llY PNOJECTRODflESS: GRIFFIN DARLENE A awxeesNarne: ggg DAH�IA AVE . aoueess: COSTA MESA, CA ' (714)751-8122 � AHCHIENCINEEH: . nooxess: DARLENE A. GAIFFIN PEPMITTEE: 989 DAHLIA AV aooeess: COSTA MESA � � r�� UNIT: 92626 � � BEG.NO.: � ' UNIT: (714)751-8122 CA 92627 LICENSED CONTHACTOB OECIAPATION: I �ere�y aifirm I�a� I am fcensed untler pmvisions ol Chap�er 9(commencing wiU Sec�ion 7W0) ol Oivision 3 of the Business antl Pmf�Sions Code, antl my license is in full fome an0 eflect. . CITY LIC.: STRTE LIC.: CIASS: � oate: � Signature: WOflKEBS' COMPENSFTION OECIAHATION: I hereDy at�irm �hat I have a cehificate ol consen� t0 sel4insure or a cerli�icate ot Workers' Campensation Insurance, or a cetlilied, copy Ihe�eol (Section 3800. LaD. C�. POLICY N�.: E%P. UATE: COMPPNY: ❑ Cenilied copY is AereOy Wmishetl. ❑ CenifieA copy is filed with the ciry BuilOing Uivision. Oate: ApPlicant E%EMP110N FNOM WOXREflS'COMPEN54TION OECIAPATION: Qhisse� o neeA notbecompletetlil�he permitisforone �untlretl(8100)orless). I cerlity Ihat in I�e pedormance of t�e work tor which I�is permi� is' si �4 I sh nol employ a ersan in any man er so as ro ecome subleci lo the Workers' Compensalion Laws of Calilomia. , Oate�. ��' �' �7� - Signature'. NOTICE: II. afler making �his aeclara�ion, you shoultl become su6lect lo Ihe rkers' Compens mvisions of ��e la0or CoOe. you mus� IOMwi�h comply wi�h such pmvisions ar Ihis permi� shall be tleemetl revoke0. ' CONSTflUCTION LENDING RGENCY: I hereby atlirm �ha� Ihere is a constmtiion IenOing agenty �or Ihe De�armanCe oi �Ae work for which this permit is issued (Sec�ion 3097. Civ. C). LENDEN: ; — AOONESS: ' " . OWNEB BUILOEN DELLANRTION: I hereby affirm t�at I am exempi Imm lhe Coniractors' S�a�e license Law tor the following reason . (Seclion 7031.5 Business and Pmlessional Cotle'. .Any ci�y oi coun�y w�ich requires a De�mit �o cons�mcl, alter, impmve, demolish, o� re0air any s�mc�ure. Orior �o ils i55uance, also requires th¢ applican� for such permi� �o �ile a signeA s�a�emen� �ha� helshe is licensetl pursuam m ihe pmvisians ot ��e Contraclors' Slaie License Law (Chapter 9(commencing with Sec�ion 7000) ol Division 3 0� Ihe Business � anA Pm�essions Cade� or Ihat he/she is exempt thereimm anA Ihe 6asi5 for ��e alleged eKemD�ion Any violation oi Sec�ion 7031.5 6y any applicanifor a permit SubleCis Ihe applitant �o a civil penalry ol n0� mOre lhan hve hunOfeO tloltars (5500�� I. as owner of ihe pmDe�y or my employees with wages as �heir sole comDensation, will Oo the work, and ihe ❑ stmcmre is not imentled or oifere0 Por sale (Section 7044, Business antl Pmlessional Code: The Conlractors' State License Law Aoes no� apply �o an owner ot a pmperty who builtls or impmves �hereon, an0 who tloes such work himself/�ersel� or ��rough �is or �er own employees, pmvitleJ IAa� suc� improvemems are nol in�en0etl or ofleretl �or sale. I�, Aawever Ihe builtlinp ar impmvement is soltl wrthin one year o� completioq ihe owner will have the buraen o� proving he/she did no� hui10 or impwve lor t�e purpose ol sale), ' . . I. as owner of lhe pmpeny, am e�tlusively contracling with licensed contractors to consimct Ihe prolect (Section 70.14, Business ❑ antl Pm�essions Cotle: TAe Conlracbrs' S[ate License Law does not appty ro an owner o� OroDe�Y w� bwltls or improves ther¢on antl who contracls lar such D�olects with a conVactor(5)license pursuant�o �he ConUac�ors' State License Law),I am aware x ��ai pmol oi Iheir Worker's Cariqex6atipp usurance 5hou10 be D�ovitletl Io me. - bY/V94 � I am exemDt untler ^.��en: OWNER I I� PLMPLOY $ � � for �his reason'. Dale �� Z Owner I tlo here�y cenify Ihat I am aware of antl un0erstand the repuiremenis of Calilomia Heallh anA Safety Coee Sectia , 25533, antl . '25534 and �hal I or anY �ulure builaing occupant willlwill not (circle one) neetl �a comply with saitl s�aie co0e5 an Quiremen�s lor a permit br con9mction or modilication Irom Ihe Air Ouality Management Disirict. Fesieential consimction applications are exempt irom , Ihese pmvisans. , � � �ate'. - ApP�icam: _ I hereby ceriity�hal Ihave reatl Ihis applitalion anA Siale Iha�IAe 'ortlinances and slatelawsrela�ingio Duiltling constmction and herel pmperly lor inspeclion D�ur0+ase5. Oale: � � 3 / � '�la' � � Driver's License or Social Securiiy a: is correct.l �he i64L46 White-Bwlainp; Green—Code EnlorcemenL CanarV—Aoolicanl Pink—Revenue: Goltlenrod—Assessnr anA � .-. - CITY.OF COSTA MESA — BUILDING PERMIT PERMIT NO; � B 060194- ' ' PLAN ,CHECR NO; N CONSTRUCTION TYPE; 5—N '' PERMIT TYPE: STR JOB DESCRIPTION e T/O EXIST, SHAKES / RESHEATH 6 REROOF CLAIM VALUE: 2,900.00 CALC—VALUE; �2,400.00 2 O N I N GS ERTEH�AUCIKRSE M,E N � � PURP.OSE; ALT SQ FT: 2,400 ' GROUP OCC: R-3 /M-1 F THE UBC *r*�tit*�r*�e�******�t*�e*r�r S � �----------- HAIN 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' PARRINC, REQ• " PROV:, PARCEL: 41218116 ZNE: .. REF NO:- � PLANNING NOTES>' ' � If if iE if ff #�t if fF 1E 1F iF �E if 1f iE �f 1E 1f �f IE 1k fF �flf IE iE IflF M �tif 1t if �f 1E if 1E if it �E �E 1t IF 1F �F1k MIFlF If if It *1f fElF 1Fif 1F iF IE M IE �f !k If ik ik11� iE1F 1EiklElF 1f iF 1t . 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;YT._ S , ZONING APPROVED BY DATE; .=--. L`/" � BUILDING APPROVED HY : DATE; �`i APPLICATION ISSUED BY; � DATE: -Z � *�r**�r*****�*�e�r*�r�e*�**�r *�e**�r�r��rre* �.;. ��r il�fififlflf�fit�fikMkifkMkMlF!!k!tlfkMkMikMikkkMkifk�flflfklflFitlFitMkiFff iFM1klfitkflk�FltltifNiFiFifklFiFMifiFltiFiFiFltifiF LEGALIZA2ION;N . F E'E fS U M M A R Y STRUCTURAL SEGMENT:Y _ HLDG PMT PLUMBING ELECTRIC MECHANIC FIAE SMIP/RES GRADING PERMIT 59,00 ,SO PLAN`� . ISSUE FEE ' BUILDING—DIV—> PERMIT'- ISSUE TOTALS----> '. 54:50 0.00 REVENUE DIVISZON TOTALS--> BLDG PMT PLUMHING ELECTRI 54,00 I N D I V I D U TYPE QTY D E S C R I P T I SFR 2400 REROOF BY VALUE R , Gx� � ��CDX ci— �G t A �1 � � �'E PLAN—CHECK 3 � 0.00 SMIP/NON—RES TOTAL PAID DUE 54.50 � 54.50 ,00 54.50 OVER/SHORT: .00 FIRE SMIP/TS�T GRADING PLAN—CHECK if k 1t if �f iF 1F�F 1F iE3f k�kk ik k iFlf if M iflf iklflf ik k iF iF 1f �tlf iF 1F iflF iF iF if 1F ik �k �k 1„ F E E B R E A R D O W N 1 � Njj UNIT COST TOTAL COST DENTIAL�_NOZONE 1,00 2,400,00 Y • ,4 I y:'r.�E�,�"c�• , �y � ��i 1f, �. 0 C. 0 9J �U129:t)r.•QQ3�9•i'35 '! Y}"I 4;ii; I<"iL��/S2 7Ii;�; 1�=°b 0 � J r,o`d CITY OF COSTA MESA BUILDING DIVISION OWNER-BUILDER VERIFICATION A city or county, which is required to give notice pursuant to Section 19830, shall attach to such notice, and, as a condition precedent to issuing a building permit, require the campletion and require the return of, an owner-builder verification. Attention Property Owner: An 'owner-builder' building permit has been applied for in your name and bearing your signature. � Please complete ahd return this information in the envelope provided at your earliest opportunity to avoid unnecessary delay in processing and issuing your building permit. No building permit will be issued until this verification is received. 1. 1 personally plan to provide the major labor and materials for construction of the pro- posed propeRy improvement. �Q Yes ❑ No 2. I(have/have not) �q�C signed an application for a building permit for the proposed work. 3. I have contracted with the following person (firm) to provide the proposed construction: Name Address Ciry Phone ( ) Contractor's Lic. No.. 4. I plan to provide portions of the work, but I have hired the following person to coordinate, supervise antl provide the major work: Name Address City Phone ( ) Contractor's Lic. No.. 5. I will provide some of the work but I have contracted (hired) the following persons to pro- vide the work indicated: Name Address Phone Type of Work I hereby affirm that I have received a copy of the information set forth in Section 19830 of the State of California Health a�Satety Code and have co pleted the above information to the best of my per- sonal knowledge, in pl' nce wi h t Stat . Signed: Date: /a��f 9 Z Name: �'N� � � � (Printed or Typed) C.D.L.NorS.S.N ,oez<s 754-5273 CITY OF COSTA MESA BUILDING DIVISION ROOF COVERING CERTIFICATION Permit No. _/�'7 v ��/ �% I i I � . i � •..- �.. - r i. i r �i e — i • If i I � i[ l Contractor (J � � State Contractor License Number Classi ica io I hereby certify that I have installed, or caused to be installed, a minimum Class C roof covering at the above address in conformance with Chapter 32, and Section 1704 of the latest adopted edition of the Uniform Building Code, as amended in Section 5-17 Title 5 Costa Mesa Municipal Code, and the installation instructions of the manufacturer. � I further certify that I am the owner of the property. (Owner-Builder permittee only). ❑ I further certify that I am: ❑ Owner of sole proprietorship company ❑ Full partner of the company ❑ Limited partner of the company ❑ Officer of the corporation I certify that as an authorized officer or agent of the company or corporation, I am empowered to make this certification, which shall be binding on all successors or assigns of the company or corporation. I shall deliver a copy oi this Certification to the above listed owner, after submittal of form to the Building Division for acceptance. Received by Building Division By: .��r,>%�/% i�/-3/ci.2 � Inifial � Oate W90d6 W�ile-Boildmg Div; Canary-Conlractor, Pink-Ownar Company or CorpOrate Name 9,9�? �i A�l� Address s � a6�6 ignaW re Date .CL'�(/Gs �P-1 i - 3- � Prinfed or ryped name 9 M e @ : , f J - �pmm � (714) 754-5273 • Fax (774) 754-4856 Job Address: Suite No Vicinity: Parcel Nunmber' 989 DAHLIA AV 41218176 Applicant: NOCK, RON Address: 11612 KNOTT ; Address: �`�/ � Backflow Preventer � Bathtub �`c\ Clanfier System� Connect Qce,Soda;etc) � Dental Units � Dishwasher � Drain, Floor Drain, Rainwater Drain, Roof Drinking Fountain Expansion Tank Gas Earthquake Valve Gas (1-4 outlets) Gas (Over 4 outlets) Gas Repipe Gas Service Interceptors (Grease, Oil) Interceptors (Sand Auto ) CA CITY OF COSTA MESA BIIILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT 77 PLUMBING PERMIT ' �`-.�"". --_, - t -• �. �� 1 i ` ;� �� `,l; �-� n / �� 1 Phone: 774 895-1246 //� (!^� ��_5 { "Zip- _92841 U `-J � ^\� ��_._ -_��/�� ic_'--`•-`-_'``�,�ti��.�\� ,_` - =_- Phone: Zip: 92626 PERMIT NUMBER DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 07/01/1999 Issued: 07/01/1999 BY: t, , tj` I , _ '--, PLUMBING y�� ., . . � � �� No'T-7�sT'} r�, ,r''�'F��: a.�l� ,1 i, 1 � � � ��F�O�r��,\ Ptione , 714 895 1246,'j.: �� l + J GROVE.�CA�7v � "� Zip� 92841 - '.��`' �//- ��f.>-"'x"%� License: 707775 '�"`,-�� v � �'�1 ��li � �`,� ��r 1�CPhone � (n i'(� ii ��i �.:i �' � i�\ ;;1�1 ,�� /r ��;!'14iA�'IJ _ - �� . - . ''_- -- =- � Z�p � - -- - --" " --t � � i License y�, ' ' r, l n , , , �„-�,. r, - ��:1 n 1 /..l1 _ _ . � �� _-. . _ �� HEATER CHANGEOUT $0.00 $0.00 $0.00 $0.00 $0.00 so.00 $0.00 >.' _'_ � � • _ FEE SUMMARY- - " ' AMT QTY QTY,� .-� . Laundry Tub�gWa her ,,�,`_5- $0.00 0 0� Landscape�lrn9ahon o�� $0 00 0 ��0' �PTrap�'�ij� "�i��$000�'-ey0 � �o�� PressureRegulator�?,��'� $0o0��-O�ti�� 0� �!?,Process Piping (per 10 ft) , $0 OO�o �` 0 , � 0 �� Receptors� t� �� .�� $000 ;-0 ,� � 0 \��SephcTank�tj �-��" $000-� 0`�� 0� �:.;�Sewer Cap for Demo � c� $0 00 --�0 l,. �0�� . SewerConnect�='i� `-�`$0:00"_��0' `� 0� � �Sewer Private Line =-..�=- $0.00 0 .- � �0�,.:/�( �` �Stiowec . $0.00� 0�;'\.'� �0 ''' `` Smk;,bar �';� ! -�l f=-�'=$0;00'�01_.� � 0 �� _Sink, commeFcial� �/ � � -� �i $0.00 `�,p�-�J 0��` `��Sink, Floor--` �-�� -� �- $0.004 0 _ ->X a " 0 0 0 0 0 Spa(private)--'"'--`$0.00 0 Spa (public) $0.00 0 COMMENTS / SPECIAL CONDITIONS � �� f� � �� Somp Pu p� �u� $0�00 t`Swimmjng"Pool 1 i$0;00 Trap Primer � y ��i$0.00 y _ � Unnal � �-� �ni $0.00 q., �. Vacuum Brkr Bkflow(1 4)�/ �$0.00 y�iVacuum�BrkrBkflow(5+)' $0.00 ij� Wash Basin�% / � $0.00 Wash,Basin Set /J� $0.00 •l�\ Waste'and Vent System $0.00 -��VVaterCbsef.(Toilet) $0.00 �-WatecHeater'/vent $17.00 Water:Plping pnst or RepJ $0.00 �' /�N/ater Re-pipe $0.00 �Ji. Water Service $0.00 - Water Softener $0.00 OTHER $0.00 VIOLATION $0.00 PLAN CHECK $0.00 iEINSPECTION $0.00 TOTAI CALCULATEO FEES: $33.00 NOTICE: The work authorized by this permit shell comply with all applicable handicap access requirer regulations. (Ord. No: 92-28, § 1, 12-21•92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 for a period of 180 days. � INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work mu requlred Inspeetione and final epproval must be obtained. Failure to obtain inspections and final approval FOR INSPECTIONS CALL: (714) 7545626 QTY 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 under Califomia statutes and related or if work is suspended or abandoned comply with all applicable codes, and all II result in the expiration of this permit. WORKERS'COMPENSAnON DECLARAnON: I hereby aHirm under penalry of perjury one of the following declarations: ' � � . � ❑ I �a e and will maintain a certificate ot consent to selt-Insure tor workers' compansation, as provitled for by sectlon 3700 ot Ihe Lebor Cotle, for the pertormence of the for which this pertnit is issuetl. I have antl will maintain workers' compensation insurenca, as requiretl by section 3700 of the Labor Code, for the performance ot the work for which ihis partnit is issuetl. Myworkers'compensation�ln/su��renc�ec rrierandpolicynum�ber.�a}}�� ,�_)�t�,� ��s�Q Carder... ��`� % //G. /�� . + (r�� . . , Policy Number: l(l T `i � (This sechan�nee n'ot e�efed r/ the permif is valuetl at one hundred dollers ($100) or less.J -� — ❑ I cartify that In Ihe pertormance of ihe work tor which ihis permit is issued, I shall not employ any person in eny manner so es to become subject to Ihe workers' compensation laws oi California, and agree Ihat if I shoultl become subject �o ihe workers' compensation provisions of Section 3700 of ihe Labor Code, I shall forthwith comply wi�h �hese provisions. Applicant Signature: Date: WARNWG FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNIAWFUT AN� SHALL SUBJECT AN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (510D,000), IN ADDITION TO THE COST OF WMPENSATION, OAMAGES AS PROVIDED FOR IN SECTION 3]O60F THE LA00R CODE, IMEREST, AND ATTOFNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aHirm that I am licensetl untler pr^`� torce and eflect. Lic. # � � ContracroYs Signature:—� with Sec�ion 7000) of Division 3 ot the Business and Professions Code, and my license is In full _ ClassN G �j.�+ . Date: �7 —i—S 4 CONSTRUCTION LENDING AGENCY: ❑ I here6y e8irm Ihat there is a constmction lending egency for the pedormance of the work fo� which ihis permit is issued. (Sec. 3097, CiWI Code). Lender's Name: Lenders Address: Signatura: Date: OWNER-BUILDER DECLARATIONS: I hereby aHirtn that under penalry ot perjury ihat I em E%EMPT FROM THE CONTRACTORS LICENSE LAW tor ihe tollowing reason (Sec. 7031.5, Business and Professions Code: Any city or counry which requires a permit to constmct, elter, improve, demolish, or repair any stmcture, prior to its issuance, also requires the applicaN for such permit to tile a signed statement ihat he or she Is licensed pursuaN to the provisions oi Ihe Contradors License Lew (Chapter 9(commencing with Saction 7000) ot Division 3 ot the Business and Professions Code) or fhat he or she is ezempt iherefrom and the basis tor the elleged exemption. Any violation of Section 7031.5 by any epplicent for a permit sub�ects the applicant to e civil penelty of not more than five hundred dollars ($500).): ❑ I, es owner of tha property, or my employaes with wages as their sole compensation, WILL DO THE WORK, antl the siruchre is not intended or oHerad for sale (Sec. 7044, Business and Protessions Code: The Contractors License Law does not apply to an owner of property who builtls or improves ihereon, antl who does such work himseN or herself or Ihrough his or her own employees, provided ihat such improvemems are not intendetl or oHeretl for sale. It however, ihe building or improvement is soltl within one year ot completion, Ihe owner-builder will have �he burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, es owner oi the pmperty, am EXCLUSIVELV CONTRAC7ING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Protessions Code: The contractors License Law does not apply to an owner of properry who builds or improves thareon, and who contrects tor such projecf with a coniracbr(s) license pursuant ro ihe Contrectors License Laws.). ❑ I am exempt under sec. _ Signature: Owner ID venfied by drivers license. Business entl Professions Cotle tor this reason: Date: ❑ Yes ❑ No Drivar's License No. Ventication of Ownership by (type ot document, i.e. - property taa bill or deed): Expires: DIVISION OF INDUS7q1AL SAFETY PERMIT CERTIFICATION: ❑ I here6y cenity ihat no excavelion five (5) or more feet in depth into which e person is requiretl to descen4 will be matle in connection with work authonzed by ihis permit, entl ihat no Duiltling sirucNre, scaHoltling, Falsework, or tlemolition or tlismantling Ihereof, will be more than ihirty-six (36) teet high. (Chap. 32, Gry 2, Art 2, Sec. 341, Title 8, Celifomia Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which woultl require a permit irom the Division of Industnal Safety, as noted above, unless such person has a permit to do such work irom Ihe divisian. Signature: Date: � Division of Industrial Safery Permit Number: CERTIFlCATE OF COMPLIANCE AND AUTHORIZA710N OF ENfAY: I ceM1ify untler penal�y of parjury that I have read this application and state that ihe information given is correct I agree to compty with all state laws and city ordinances relating to building wnstmction, and authonze representatives of Ihe Ciry of Costa Mesa to en�er upon Ihe above-descnbetl properry lor inspection purpases. I agree not to occupy or allow occupancy of any builtling authorizetl by this permit until finel inspection. � Signature Ot Legel Ownar(s) Dale _�7 ti � -�. � - � � AnNOr Aut onzed Applicant Dat�i— �— GOOE �. INSFECTION TYPE 1676 Fixetl System Finel Fire Prevention 1266 Pool Spa Final 200 Final Re-Roof 201 Final BIocWRetaining Wall 202 Finel Fectory Fire Place 203 Final Sign 204 Final Demoli�ian , 2446d6 p,ijf, INTITI�lS �t INSGECTIONTYVE 206 Finel Mechenic0l 20B � Final Plumbing 210 Final Elecincal 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupani PdT� ItID�Lfr .� Vli !�� OWNER LARGIIN DATE SUBCONTRACTOR PROP. SWR. �INE �HOUSE CON. SPRINKLING SVSTEM MISCELLANEOUS ROUGH HEATING AND AIR C0� TEMPORARY�SERVICE-OR POL UNDERGROUND � , POWER ROUGN WIRING� TRENCHES FORMS FLOOR SVSTEM FRAME AND FLASHI �. 'P :.. '+ ..v. .: �. ,. . _ - . . . . . r � ' .- ��' . " . . - `' = ? :� %�i � 4 � �� 3Jr�%r `3 . - Ai� 7_o=73cn;��i 1£30 � 5!.3 . CQSTA MESA BUILDINGSAFETY DEPARTMENT. - • . ' � , � ` ' • �3OLBBt.O. BOX 7200 ;COSTA MESA, CALIFORNIA 92626' � . ' � ' � � .- P IC- ION FOR-6UILDING PERMIT ' ` ' Fo� Applicant to Fill in Completely � , .. . . RE EIV Di OATERECEIVED DAT�E�a E73 . o�oaess � Dahlia� Avenue ' �— � . •. owNeA �� LarNiin Southern California, IIIC. A•P.NO. •, P `1°'i�(1R � MAIL - BUILDING � J% z . �/rJ A aooaEss' ,�.16255 Ventura Boulevard . " AooAEss � a U � . � - �� TEL. ' , TRACT / /��' 'LOT. % BLOCK CITV NO. Z . , . . ' Z Q ;CON5TRUCfION , ' W ADD A R P - o� �eNoea Larwin'Southern Cdlifornia lnc. a� eaon,cH 16255 Venlvra Boulevard_ . �/ . �'JN , ,. . . OWNER /,CU.��N�,� C � /.N� . a W ADORESS Encino `California 2 �p J �-y• %�.� ^� VAWE Jm ARCHITECT � ' ' . TEI. � � SE GJ r// �CT/2— $ ' a OR ENGWEER - N . � UQ . PIRE.- �^ . . " - ^. w,ft AODRESS � .9�00 IIS i e.Blvd �ev II ZaNE - TVPE� GROUP� .- aW ' W Z , ..i. •APPR D � � � J O CONTRACTOR BY 'DATE m-, � .;. . . � ' . : '. ._ . . ��. AooREss 16255 Ventura BI d � w W ` TEL - ' ZO ~� NO.OF USE OF NEw /�J r' UU z'� cirv 'Encino :California No, 986-8890 I P�"S}— e��owc �� - O STATE ' � � - CITV . -"•�ARDSAPPROVED � VAPDS�APPROVED. � ' N� LIQNO. I�I�3��' � �LIC.NO. B�� ` MAINBUILDING ACCESSORVBUILDING _� SIZE . ' NO.OFBLDGS. (FROMGLSTFEET) ' 4. . ' OF LOT '� .(�O X IS '� NOW ON LOT ' FRONT FT. . FT. USE OP " " ' ' _ EXISiING BLDG.. � ' SI�E FT. FT �. F � SIZE OF - � 'NO. OF . " ' ` - ' � - ' Z NEW BLOG�.987 ' �. 'qOOMS • STORIES 1 ' L SIDE FT. FT. �U EXTERIOR WALL � .ROOF . � - ^ /� T , , , � . COVERING^ � St � COVEftING � �F1EAR,�y�{,y-'FT. FT.� J USE OF BW L'DING AND WORK TO BE PEftFORMED ' . DISTANCE BET. ' BET. MAIN & d � MAIN BLDGS. ' ACCESS. BLDf3S: - . • a _ Q - . . �. . -. _ .. �... . .,,� . ..� , . :..�j � .,, - VAR. # ' � . DATP,. i , �' . ':. , . . 'O g ' C.U.P.� - . . . APPROVED- � . v~i Con'struct Sin le•Famil ResicJ'e�' ' AP?Roveo ��; ,+5 z.; �. p �tiOLD FOR SPEC L REQ I S „U I hereby�acknowledge that�l have reid [his application antl s{ate , ' . „ ' ' � that the above information is correct and agree tdcomply with � _ , ,�� . all' laws regulating builtling �construction, and I shall notemploy � � , � F anµ.person in violation,of.the workman's compensation laws of - - - . y the Sta[e of Calitornia. � ' . • � ' � zI hereby certify that I,im properly,licensetl asacontroctorunder� � SQ. PT. • �� Q ' o the State ot California Business antl Protessions Cotle, Divisicn 3,. THE AMOUNT SHOWN UNDER VALUATION IS FOR �. Chapter 9, antl that such licenses are in full foroe antl aftect, or I THE PURPOSE OF-ESTABLISHING A PERMIT FEE ONLY: � am exempt from't0e provisionsbf the State of Calitornia Business , ^ � ¢' ' • antl ProfessionsCotle, Division 3,�Chapter 9. ,�� - •� VALUATION 7' -� � . m . - /� - � • - �ERMIT FEE .$ � " / � J � SiBnemreof '� /�� D.� Downs� . ' � -�- ' . 7 m Pe�mittee �.l�2%L/!//i!� - $. PLAN CHECK $ ' - E , , �� /fl�. . . .:Authorizetl A9ent � � . � . . s�') 1� . u TOTAL FEE $ f�� . OWNER JOB AD GENER� AP No.l t INSPEC . a SOIL _ � WS � WATER _ ROUGH GI (� PROP_5� � SPRINKLI MiSCELL GEOE�E F. BiHG LINE I � HOUSE CON. ROl1GH NEATING nND AIR CONOITIONING TEMPOR<RY SERVICE OR POLE UNOERGAOUNO � .POWER � - RO�GH WIRING TRENCHES IJ FORMS STEEI RE FLOOR 51'STEM BONO BE>M �� STEEL REINFORCE � $HE/TMING FRqME ANO FLASHING � �ATMING — IN ,i � OUT n- PlASTEP.9ROWH COAT ' STRUCTUA4L. FIN4L ME4TiNG. VENi., REFRIG. �ND A.C�..IFI PLOMBING. FIN4L ANO GRS TES� `� ELECTRIC. FINAI BWLOING. iINAI � DATE 12=14-78 BUILDING PERMIT N( CRIPTION oi WORK Tsgal iaetion E ZONE VALUE S �Oo.i)o YPE GROUP SUBCONTRACTOR _ PE . }, . , . . ' . Y � � . / . . .. ��-fa/►�� n /� % l� C�` . s ' ♦ � COSTA MESA BUILDING•SAFETY-DEPARTMENT ' ' � :; ' �„"�� -• . �' P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 ' ��1 (; , . A P I ATI N�'O��ti�l�'�'{��L,BPERMIT''i.l'4:50� � TL . � For A licant to Fill in Com letel �'''"� "-"° �' � �� PP p y—,Use�Ink Only . RE E DATE flECEIVED ' DATE ISS E BUIIDING ' " � � ADDRESS � � � , / p / 'PERMIT NO. . . OWNER6`e �� 'C`l \l/�_ - A.P.NO. y.I2�••I0I �'�p . . MAIL . - UIL�ING �� ', ��: �-' '� ' . ' . ADDRESS � U� , - . ADDRESS • '��. CIT �,� � C `. „C�jz NpL. SI•.a �'%. TFACT � / I O • � LOT � . B�OCK . . CAN5TRUCTION - ' . ' NEW ADD ALT R P R M , LENDER _ . . „ C' ' � v\ BFANCH � ' . . .. � ' . . ' . • - - WNE .�Y`� ll\/�� ADDRESS � /" � VAWE ,r.y � ARCHITECT . �- TEL. ' ' ` U D ' • Ofl ENGINEER " . ' FIRE ' . � . ADORESS -�� . ZONE TY E GRO P ' � APPROVED ' ' r . ' -CONTRACTOR' ' �BV ' DATE ' � ADDRESS � ' � � � ' � � � � � -, TEL. ZONE , NO.OF q ,USE OF NEW P Tl O� � CITV . .. . .NO. ' RI P�� /�'� BUICDING CUVEQ ' . o-�i STATE . CITY ' � �'ARDSAPPROVED, - VARDSAPPROVED- . LIC. NO: � " j LIC. NO. �� • MAIN BU�LDING ACCESSORY BUILDING � 512E � NO.OF BLDGS (FROM C/LSTREET v.' , -� ' � � �. , OF LOT �Q •%� � U U � NOW ON LOT RONT FT. � a USE OF ' .{— � � � � " � � � ,.�., EXISfING BLDG. � q�,p FT. y . �. , Separate permits are required for � �. sioe S FT. � Fr. , q electric, plumbing.and heating work: . ' REAR :�./ FT. � � FT. � USE OF BUILD�NG AND WORK TO BE PERFORMED E^ OISTANCE BET. � BEf. MAIN & - Q � ' MAINBIDGS.' - �ACCESS.BLOGS. . � � ' VAR.#'. � + - - DATE ' ¢' � C.V.P.� " • .APPflOVED� � �. . • - � , �I• .. . . APPROVEDCwRI� � / �� 7(J � �. a a • .. w � I hereby acknowletlpe thet 1 have reetl this eppllcatlon end state . . . � � , � a ihat the above information Is corract an0 agree to comply with _ m� �+ all laws regWatlnp buildin8 construeiion,'and I shall not employ . , . .. � z. any pe�son in violatfon of Ma workman's campensation laws of - ' � ' ° • � Me State ot California. ' . . . _ , ' • ' ' , ' � m � , 3 I hereby certify ihai l em proDerly ca tl a contracto� under Q. FT. ' ' �v the Stete of nia Business e tl P te sions otl , D islon 3, THE AMOUNT SHOWN VALUATION IS FOF ro Chepier 9 ntl tha such Iicen ar in II forc a e ct, or I, THE PVRPOSE OF, ESTA PERMR FE ONLV: '" � am axem t from th proviSlons teie of Iif n Bustnau � o� � VALUATION PERMITFEE 'g ✓ . antl Prof sslons Cotl Dlvizlon C apter 9 „ ' m -� � � '�� PLAN CHECK $ . o - SigneTv �o -� � % �� Permitt $' /�� .TAX S . � , ( � '..0 . Authoriz d Agent . TOTAL PAID $� ,' '