HomeMy WebLinkAbout2138 UNION ST - Building Permits CITY OF COSTA MESA
app•eg BDILDJNG DIVISION
�,,,� .. DEVELOPMENT SERVICES DEPARTMENT P IT NUMBER
ilailTriet
F I i�.�,."�� PERMIT
• B05-01701
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesaBiiit PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 2138 UNION AV Status: ISSUED
Suite: - + Applied: 09/26/2005
Vicinity: LIVING ROOM AND KITCHEN "i/^..- Issued: 12/27/2005
Primary Occ: R-3 Dwellings/Cong Res<10Type of Construct -"r
Parcel Number: 42244101 Zoning.
Applicant: RICARDO ARIZMENDI / II
Address: 2138 UNION AV il
. Phone: 949-650-0318 ISSUED BY. VI
COSTA MESA,CA Zip: 92627 F
Owner DOMINGUEZ, RICARDO
Address 2138 UNION AVE
Phone: 949-650-0318
COSTA MESA,CA Zip: 92627-4025
Contractor: , OWNER-BUILDER .
Address:
Phone:
Zip: License: 000000
Arch : Eng: HOSSEIN ZANDHOSSEIN ZAND ASSOCIATES
Address: Address: 5175 CHAPALA DR
Phone: Phone: 909-784-2424
RIVERSIDE,CA
Zip: License: 92507 License: C035721
•
SCOPE OF PERMIT
ADD 371 S.F.TO EXISTING S.F.D.WORK TO INCLUDE:EXTEND EXISTING LIVING ROOM AND KITCHEN.ALSO INCLUDES REFRAME ROOF
OVER EXISTING FAMILY ROOM AND KITCHEN.CONSTRUCT 64SF PATIO COVER.ALSO INCLUDES REROOF OF EXISTING STRUCTURE.
4 BEDROOM,2 BATH S.F.D.TO REMAIN THE SAME.
FEE SUMMARY
Plan Check: $385.94 Calc Valuation: $44,480.48
Permit: $593.75 Claim Valuation: $o.00
SMIP Res: $4.45 -
SMIP Cam: $0.00
Other: $0.00
Inspection: $0.00
Total: $984.14 •
PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front 20-0 Rear 16-0 Left 14-6 Right 0-0
ACCESSORY \ Front 0-0 Rear 0-0 Left 0-0 Right 0-0
PARKING Existing: 0 Required: 0 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, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned'
for a period of 180 days. 1 /
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes,/and all
required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(WOO)
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
�
(This section need not be completed/f the permit is valued at one hundred dollars($100)or less.)
r
.I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
—compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these ions. (A7 0
1rApplican6Signature:-- ettt (Gf a.//r iU✓r,N / Date: /2 - A,g- -0 (�
`WARNING:.FAILURE'TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($103,000),IN ADDITION TO THE CCIST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES.
' LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Lic.# Class It
Contractors Signature: Date:
.
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
_ sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). '
( g Cas owner of the property.am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
• Code:The contractors License Law does not apply to an owner of properly who builds or Improves thereon,and who contracts for such project with a contractor(s)
_license pursuant to the Contractors License Laws.).
AI am,exegapt,under sec. Business and Professions Code for this reason:
Signature:Th nuclj, �
Expires: c •—.24-O
Verification of Ownership by(type of docu ;• ,i.e.-property tax bill or deed):------'
DIVISION OF INDUSTRIAL SAFETY PER IT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a
permit to do such work from the division.
Signature: Date.
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes ❑No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency/ 0 Yes LI No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property formation pu oses.I a ree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
LSignature,Of.Legal w33 --- - Date
And/Or Authorized Applicant Date
CODE I INSPECTION TYPE PATE INTRIALS CODEI INSPECTION Type DATE INT7Al5
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site -7
204 Final Demolition 250 Final Building/Occupancy 3/Z3//
01►J-,- CITY OF COSTA MESA
t BUILDING DIVISION
4- , DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER
1. 1 4 PERMIT
,rF 05-01359
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 2138 UNION AV Status: ISSUED
SuiteNo Applied: 12/27/2005
Issued:Vicinity: ssusued: 12/27/2005
Parcel Nunmber: 42244101 ‘41
Applicant: DOMINGUEZ, RICARDO _ cX)11._
Address: 2138 UNION AVE • ; ISSUED BY:
Ph•'T3�i • .50-03
COSTA MESA,CA Zip • . -025
Owner: DOMINGUEZ, RICARDO
Address 2138 UNION AVE
Phone: 949-650-0318
COSTA MESA,CA Zip: 92627-4025
Contractor: OWNER-BUILDER
Address:
Phone:
Zip:
License:000000
SCOPE OF PERMIT
ADD 371 S.F.TO EXISTING S.F.D.WORK TO INCLUDE:EXTEND EXISTING LIVING ROOM AND
KITCHEN.ALSO INCLUDES REFRAME ROOF OVER EXISTING FAMILY ROOM AND KITCHEN.CONSTRUCT
64SF PATIO COVER.ALSO INCLUDES REROOF OF EXISTING STRUCTURE.
EXISTING 4 BEDROOM,2 BATH S.F.D.TO REMAIN THE SAME.
ELECTRICAL TO INCLUDE: 14 LIGHT FIXTURES, 15 OUTLETS,AND 11 SWITCHES.
FEE SUMMARY
Quantity Quantity
ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0
Temp service test $0.00 Busway/100 ft $0.00 0
Res.a/c package $0.00 Standing Section $0.00 0
New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0
New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0
Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0
Lighting Fixts $15.40 14 up to 50 kva/kw $0.00 0
Recept Outlets $16.50 15 up to 100 kva/kw $0.00 0
Switches $12.10 11 over 100 kva/kw $0.00 0
Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0
Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0
Service to 200a $0.00 0 Misc.Conduit $0.00 0
Service to 1000a $0.00 0 Misc.Conductor $0.00 0
Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0
Motors to 1 hp $0.00 0 Circus(mech ride or lights) $0.00 0
Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0
Motors to 50hp $0.00 0 Fireworks Stand $0.00 0
Motors to 100hp $0.00 0 Other Electrical Fee $0.00
Motors over 100hp $0.00 0
Communication drops $0.00 0 Investigation Fee $0.00
Sub panel to 200a $0.00 0 Plan Check Fee $0.00
Pole Light Pkg $0.00 0 Reinspection Fee $0.00
Sign Circuits $0.00 0
Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $67.50
Intermed Pole $0.00 0
COMMENTS/SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord. No.92-28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this: if.
FOR INSPECTIONS CALL: (714)754-5626 Crsr"/
2446-46(6100)
' • I
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations: •
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑ I have end will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance Garner and policy number are:
Carrier: Policy Number:
(This section need not be completed If the permit is valued at one hundred dollars(5100)or less.)
ci Lee' t11 aAt in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
nUtion laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these• ••-ions.
actafi ignaturei, ?�> L..i.I Date:.��2 —v2`I 'O 5
WARNING_FAIL'URETO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT EM MPLOYERTQ' IMINAL PENALTIES AND GVIL RNES UP TOONE HUNDRED
Tl15AND DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SE4 THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Lic.4 Class x
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement Is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
( • " I,a3 wner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
C :The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ am •, sec. Business and Professions Code for this reason:
Signature --'ii i 4 -:
O -Jr ID verified by driver's license. ❑Yes 0 No Drle s License No�+�� -/// Urgii;t&f69.'- —.'6—DF
Verification of Ownership by(type of document,i.e.-property tax bill or tl
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2.Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,es noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a, ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes Li No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No
8 (If yes-,attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and ci ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described properly f. 2pection purposes. agree not to• upy or allow occupancy of any building authorized by this permit until final inspection.
/-I(Ql/L✓/3/(rA` C:'L� �� — tel --� 5_
Slgnaturel0115101 Ow nom) •_1/±. }7- - r;Dattr -"
And/Or Authorized Applicant Date
CODE# INSPECTION TYPB PETE INTIRALS CODE( INSPECTION TYPE PATE KOLE
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing ���
200 Final Re-Roof 210 Final Electrical CC/'••YLy
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
,1t! CITY OF COSTA MESA
4 '
BUILDING DIVISION
> : ,� DEVELOPMENT SERVICES DEPARTMENT P IT NUMBER
ag
PERMIT 05-00766
a '
Juno
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
MECHANICAL PERMIT �-
Job Address: 2138 UNION AV Status: ISSUED
Suite No Applied: 12/27/2005
Issued: 12872005
Vicinity:
Parcel Number: 42244101
ISSUED BY:
Applicant: DOMINGUEZ, RICARDO
Address: 2138 UNION AVE
Phone: 949-650-0318
COSTA MESA,CA Zip: 92627-4025
Owner DOMINGUEZ, RICARDO
Address: 2138 UNION AVE
Phone: 949-650-0318
COSTA MESA,CA Zip: 92627-4025
Contractor: OWNER-BUILDER
Address:
Phone:
Zip:
License:000000
SCOPE OF PERMIT
ADD 371 S.F.TO EXISTING S.F.D.WORK TO INCLUDE:EXTEND EXISTING LIVING ROOM
AND KITCHEN.ALSO INCLUDES REFRAME ROOF OVER EXISTING FAMILY ROOM AND KITCHEN.
CONSTRUCT 64SF PATIO COVER.ALSO INCLUDES REROOF OF EXISTING STRUCTURE.
EXISTING 4 BEDROOM,2 BATH S.F.D.TO REMAIN THE SAME.
MECHANICAL TO INCLUDE: 1 REPAIR/ALT COOLING/HEAT,RELOCATE FACTORY FIREPLACE
AND 1 HOOD W/MECH EXHAUST.
FEE SUMMARY
Quantity Quantity
ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0
Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0
Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00 0
Repair/Alt Cooling/Heat $13.70 1 Evaporative Cooler $0.00 0
Inst/Rep.Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0
Refrig Sys<100 k BTU $0.00 0 Domestic Incinerator $0.00 0
Refrig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems
Gas Piping $0.00 0 Up to 3 hp/100 k BTU $0.00 0
Factory Fireplace $10.65 1 3 To 15 hp/500 k BTU $0.00 0
Hood w/Mech Exhaust $10.65 1 15 To 30 hp/1,000 k BTU $0.00 0
VAV Box $0.00 0 30 To 50 hp/1,750 k BTU $0.00 0
Vent Fan/Single Duct $0.00 0 Over 50 hp/Over 1,750 BTU $0.00 0
Appliance $0.00 0 Boilers
Fire Dampers $0.00 0 Up to 3 hp $0.00 0
Smoke Dampers $0.00 0 3 To 15 hp $0.00 0
Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0
Air Handlers< 10000cfm $0.00 0 30 to 50 hp $0.00 0
Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0
Floor Furnace $0.00 0 Other Mechanical Fee
Floor or Suspend Heater $0.00 0 Investigation Fee $0.00
Plan Check Fee $0.00
Reinspection Fee $0.00
TOTAL CALCULATED FEES $58.50
COMMENTS/SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord.No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, a
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this
FOR INSPECTIONS CALL: (714)754-5626
244646(6/00)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued,
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
<y certify t• in the performance of the work for which this permit is issued.I shall not employ any person in any manner so as to become subject to the workers'
tion laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply wit sr ns. / y
_l�opllcant*Signature -v 14aatc/(7 47/?.r�vr
g��-(/ Date q� —�// — U e7
,..WgRii�[[JJCC Ltlp ITO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMP-LOYERTOORIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED
LTHOGSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Lic.11 Class 8
Contractor's Signature: _ • Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097.Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that t am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business end Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages es their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement is
s--old within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
I k I, owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044.Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am e : pt under ec. Business and Professions Code for this reason:
ign`atur ter' 'c. ai• . s . '
- Expires QiN —t7
Verification of Ownership by(type of document,i.e.-property tax bill or deed):'
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2.Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appem it for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Duality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that 1 have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inns purposes.I agree of to occupy or allow occupancy of any building authorized by this permit until final inspection.
C_
SighettTrtif'JiLeaal`-Dwoet(�:u*�ruJe 9�' F ,-Date • '
And/Or Authorized Applicant Date•
�J
CODE t INSPECTION TYPE DAIS INTITIALS CODER INSPECTION TYPE 17SIE VtJirJ�i
1616 Fixed System Final Fire Prevention 206 Final Mechanical s/�r r! )
•
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Root _ 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
•
204 Final Demolition - _ 250 Final Building/Occupancy
'-` 'S CITY OF COSTA MESA
4r ►'° BUILDING DIVISION
F•' AI DEVELOPMENT SERVICES DEPARTMENT PER NUMBER
PERMIT
J
%boears,'et P05-00986
-u.
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 4 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
<kz,
Job Address: 2138 UNION AV Status: ISSUED
Suite No Applied: 12/27/2005
_I1a;47,.Y Issued: 12/27/2005
Vicinity:
Parcel Nunmber: 42244101 / j
• 3.44. r/
Applicant: DOMINGUEZ, RICARDO ISSUED BY: 4
Address: 2138 UNION AVE
Phone: 949-650-0318
COSTA MESA,CA Zip: 92627-4025
Owner: DOMINGUEZ, RICARDO
Address 2138 UNION AVE
Phone: 949-650-0318
COSTA MESA,CA Zip: 92627-4025
Contractor: OWNER-BUILDER
Address:
Phone:
Zip:
License: 000000
SCOPE OF PERMIT
ADD 371 S.F.TO EXISTING S.F.D.WORK TO INCLUDE:EXTEND EXISTING LIVING ROOM AND
KITCHEN.ALSO INCLUDES REFRAME ROOF OVER EXISTING FAMILY ROOM AND KITCHEN.CONSTRUCT
64SF PATIO COVER.ALSO INCLUDES REROOF OF EXISTING STRUCTURE.
EXISTING 4 BEDROOM,2 BATH S.F.D.TO REMAIN THE SAME.
PLUMBING TO INCLUDE: 1 GAS(1-4 OUTLETS), 1 GAS PIPING, 1 KITCHEN SINK AND 1 WATER
PIPING.
FEE SUMMARY
AMT QTY AMT QTY AMT QTY
ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 Sump Pump $0.00 0
Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0
Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0
Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0
Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0
Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0
Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0
Dishwasher $0.00 0,• Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0
Drain,Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0
Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $0.00 0
Drain,Roof $0.00 0 Shower $0.00 0 Water Heater/vent $0.00 0
Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $9.80 1
Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 0
Gas Earthquake Valve $0.00 . 0 Sink,Floor $0.00 0 Water Service $0.00 0
Gas(1-4 outlets) ' $6.15 ,1 Sink,kitchen $9.80 1 Water Softener $0.00 0
Gas(Over 4 outlets) $0.00 0 Sink,service/mop $0.00 0 OTHER $0.00
Gas Repipe $9.80 1 Spa(private) $0.00 0 VIOLATION $0.00
Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00
Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0
Interceptors(Sand Auto) $0.00 0
TOTAL CALCULATED FEES: $59.05
COMMENTS /SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord.No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all; '"
required Inspections and final approval must be obtained.Failure to obtain Inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
•
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
O I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
O I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(�T/his section need not be completed if the permit is valued at one hundred dollars($100)or less.)
yI certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with then isions. /
Applicant Signature: _ ye- D (,ut4..L:LFr.L N fL( Date: /a— 2 7-0 C
WARNING:FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Lic.#_ Class#
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
o I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
O I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
Ri I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
I am e' t under sec. Business and Professions Code for this reason:
Signature: X/C(Mr t7 G Date: /.2-Q 3'6a
Owner ID verified by driver's license. Yes 0 No Drivers License No. Expires: '— G'"07
Verification of Ownership by(type of docu ,i.e.-properly tax bill or deed): .,
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes ❑NO
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be tiled with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at Standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes U No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑No
(If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑No
B (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE MID AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described propertyspection ��rfi ypurposes/.II�gree not to occupy� or allow occupancy of any building authorized by this permit until final inspection.
f2ro-tc/ (an 7if. 42- - 2 9 'U6
Signature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
CODE 0 INSPECTION TYPE PAT INTRIALS CODE✓r INSPECTION TYPE PAIS jNtt11AL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing crZJ/7
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
JOB ADDRESS COX2138 Unon Avenue
GENERAL CONTRACTOR Owner-Builder
BUILDING PERMIT NO. 25881
DESCRIPTION OF WORK Altereie Garage
Al' No. 115-412-01 LOT TRACT FIRE ZONE VALUE 1,246.00
ZONE R-1
(� INSPECTIONS Signature Date GROUP 3 TYPE V
V Soil PERMITS ISSUED
Gas SUBCONTRACTOR I Date I Number I Signature
Water Plumbing
Rough Plumbing
Prop. Swr. Line 0 House Con.0
Sprinkling System
Miscellaneous
Rough Heating and Air Conditioning
Temporary Service or Pole
Underground ❑ Power C _
Rough Wiring Heating and Vent.
Trenches gyp-- Forms Steel Reinf. 0 M`L���- — -
Floor System _
Bond Beam 0 Steel Reinforce 0 -- //
Sheathing =% ' Y/Y46
Frame and F1ash',;l -1' a _ �' 5-4/ G6
Lathing —In ffuil�i�ut L'
Plaster, Brown oat /i+!�q/ ,f" fe• di • _
Structural, Final„ Electric
Heating, Vent., Refrig. and A.C., Final ((7M x yt/-id/../S-, 9-5-6 6 <96/X6' /
Plumbing, Final and Gas Test 0 // 2-2 -Ls-2279'o
Electric, Final A 25t.//6 me41sW6t/
Building, Final ,yh C. fR /Z/6,W
25831 3****13.50
M -5-66 00 115A_
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 62626
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
Bu1LDINQ ^ /)I For Office Use Only
BUILDI 8 .211 6 (/h Joh
RECEIPT NO. PERMIT NO.
COSTA MESA. CALIFORNIA c5 5-0 PF/
��/J) .{j/j L / EEC V[D BY 7R6C[IV[D6 _ - UG
OWNER len A-9 2 !• cox- JJLL�- GG 7 I
MAIL /�
{. �I BUILDING
ADDRESS 2/,} p 0»/oh ADDRESS // ifri
/+ L[ 1 . TE ZONE TYPE 1 GROUP
cITYt_ c+a Ms 58 NO.,J� -Q+};!2
ARCHITECT TEL C AP /�
OR ENGINEER OW 11 C). NO. Ion a BY / JJJ DATE J —
ZONING
ADDRESS /?/yYIL 'as ORW///yY/}/ry� 7- y MB No.01 - / uB[01 N[w(jl"(llo
CONTRACTOR o *'4' e (l/` /V/�J� 1 PLANE V BUILDING "/,��yVA��A,,V
LEGAL �t l� �41 (�1j '1 _
ADDRESS DeBCRImoN I/' / /1 l/
A.P.NO. i /''7 " r /p - V j
CITY ! '{LL
NOTE: NO SAVE OVERHANG SHALL BE LESS THAN
STATE TEL. EO'TO SIDE a REAR P.L
LIC.NO. NO,
SIZE !'y`' / (0 [ I NOO.ON•LOT ,/ ALLOWED (U.B.C.REQUIREMENT)
OFLOT 68 •Y 1 x O
USE OF J'/� YARDS APPROVED YARDS APPROVED
EXISTING BLDG. TLS.L(l 5 MAIN BUILDING ACCESSORY BUILDING
i FROM C/L STREET)
SETBACK LINE FROM FRONT PT. FT.
CENTER OF STREET REAR YARD
SIDE YARD LEFT RIGHT R.SIDE FT.
DESCRIPTION OF WORK L.SIDE �(l -h-f FT.
`
NEW V ALTERATION ADDITION / REAR Y) Fi. PT. ,
DISTANCE OR. BUT.MAIN O
REPAIR MOYINO „QEMOLUJN MAIN BLDQ4, ACCESS.BLOCS.
BUILDING r�Iv A Ai NO OF VAR.# DATE
SIZE '4n A otl) ROOMS / STORIES / C.U.P.# APPROVED
EXTERIOR WALL ROOF /' // 1 ) APPROVED G L/)
COVERING (Tin COVERING anile• ,�/I////(((' BY lM/U/ DTE �I !p�
USEj, OF BUILDING AND WORK TO BE PERFORM W 0 r iP.
'FDF g HhD14-< +)-d[nbAl slap Si; PP
ui
kd'2 SQ.PT. So
I HEREBY ACKNOWLEDGE THAT I NAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE j
AND STATE THAT THE A E IS CORRECT AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT PEE ONLY. JDR,
PLY WITH ALL CITY ORDI CES AND STA LAYYY(((S RE MATING VALUATION O
BUILDING OFIUCTI N � �
SIGNATUREPERMITTHF OF �. cJ/ 023 PERMIT FEE 5 '/ D
S 2 PLAN CHECK S 7��� wC
AUTHORIZED AGENT _ 5 Z
TOTAL FEE S /�1