HomeMy WebLinkAbout246 ROSE LN - Building Permits(714) 754.5273 • Fax (714) 754-4856 • www.ci.costa-mesa.BUILDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 246 ROSE LN
Suite:
Vicinity: ROOF
Primary Occ: R3
Parcel Number: 42614312
Applicant: MARTIN ARROSAGARAY
Address: 2508 BOWDOIN PL
COSTA MESA, CA
Type of Construction: V -N
Zoning:
Phone: 714-556-8867
Zip: 92626 -
Status: ISSUED
Applied: 09/15/2005
Issued: 09/15/2005
ISSUED BY: kJ
Owner: MARTIN, PAUL J TR
Address 246 ROSE LN
Phone: P
COSTA MESA, CA Zip: 92627 P.
Contractor: MARTIN ARROSAGARAYS ALL SEASONS ROOFING
Address: 2508 BOWDOIN PL
COSTA MESA, CA
Zip: 92626
Phone: 714-556-8867
License: 622480
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
TIO EXISTING SHINGLE ROOF AND BUR AND INSTALL NEW 30 YEAR ASPHALT SHINGLES AND TORCH APPLIED MODIFIED BITUMEN OVER
FLAT ROOF, APPROX 2400 SF ATTACHED HOUSE AND GARAGE. REPAIR AND REPLACE SHEATHING AS NEEDED.
FEE SUMMARY
Plan Check:
$0.00
Permit:
$125.25
SMIP Res:
$0.54
SMIP Com:
$0.00
Other:
$0.00
Inspection:
$0.00
Total: $125.79
Calc Valuation: $5,400.00
Claim Valuation: $5,400.00
PLANNING & ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 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.
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) 7545626
2aa64e tsrool
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.
xq,I,f have and will maintain workers' com nation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this Permit Is Issued.
M work rs' Go ensa6o urance order and policy number are: _ _ Z '>^
-to -L-1 F/ V p Policy -Number._ .[83D zS
1—(This section need not be crompleted it the permit Is valued atone hundred dollars ($100) or less.)
❑ 1 certitythat in the performance of the work f which this pemlit Is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of C yorria, a9b agreoyffuvt If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these i ns. / 4
Applicant Signature:- e'er Date: l �— O✓
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERA $ UNLAWFUL AND SWILL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARS ($100.000). IN ADDITION TO THE COST OF COMPE TION, DAMAGES AS PROVIDED FOR IN SECTION Was OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under pr visions of apter 9 (commencing with Section 7000) of Division 3 of the Business aAd Prays Ions Code. and my license is in full
force and effect. Lk. x Class a
Co tors Signature: rDatei M� — —OS—
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affimt that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cade),
Lenders Name: Lender's Address:
Signature: Date:
OWNER- R DEC .,q ATIONSi4, 1 , +& tN
1 hereby affirmahat unc!441nalty of,pe�uq,t I am E E,IjAPTFROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Processions
Code: Any city or county which requiV9s a,permit to �u Salter, 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 Ilcensetl rsuenl'-G 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, 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 exempt Under sec. Business and Professions Cade for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation live (5) or more test 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? ❑ 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 tocried 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).
............................................................................................................_................................................................................rati....................................................rdo.............................................................................................................................
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ 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).
........................ .................................................................................................. ........................ .................................................. .......................... ................................................................................................................................................. I ...........
.
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 on RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
...4..........e..nR.MPP.... ........................................................................ -.......................................................................... ... .................... .............................................................
......................................................................................................
is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No
...........................................................................................................................................................................................................................................................................................................................................................................................
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication 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? Yes N0
(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 pan 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
...................................................................................................................................................................................................................................................................-................................................................................
attach certlflcate 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 for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Sig a Of L at Owner(s) � D a
And/Or Authorized' !cant- rDate =,.J
CODE It, INSPE0011 TYPE 11,1711141. COVEll INSPECTION TYPE BETE INTITIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Roof `z7 l— 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
O
_e
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
CITY OF COSTA MESA r CONSTRUCTION PERMIT
Project Address 246 ROSE LANE .--
Applicant's Mailing Address
Owner's Name MR -&MRS MARTTN �Phone_650-15.2
Address 246 ROSE LANE
Arch/Eng. —N/A License No.
Address
Contractor's Name% -L. RAI SERMAN AIC Phone 526-332
Address(mailing)_808 X11, COM_MONWEA7. H — UL ..RTO.
City License No. 0 3 8 7 0 7
LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Charter 9 (commencing
with section 700u01) of Division 3 of the Business and Professions Code, and
my license is in fVLd and effect. 478762
License Class lam/ L LiLkb.
DateG �� Signature `d LARATION'
_
WORKERS' COMPENSATION DEC
hereby affirm that I have a certificate of consent to self -insure or a certificate
f Workers' Comp ed$, tm 11 ran or -a certified copy thereof (Section
.,800, Lab. 'C,7J� `( 7 {{f ,
Policy No. WOw — o,Pany THILL
®Certified copy Is hereby furnished.
Ce III coag is filed with the city BuildinglTv11s{pp.
Date( '��'� Applicant ]ic
EXEMPTION FROM WORKERS' COS 051 1ENSATION DECLARATION -
(This section need not be completed if the permit is for one hundred ($100) or
less).
certify that in the performance of the work far 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.
Date Signature
NOTICE: If, after making this declaration, you should became subject to the
Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit snail be' deemed revoked.
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 (Section 3097 Civ. C.)
Lender's Name
Lender's Address
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Section 7031.5 Business and Professional 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/she is licensed pursuant to the provisions of
the Contractor's License Law (Chapter 9(commencing with Section 7000) of
' ivision 3 of the Business and Professions Cotle) or that he/she is exempt
erefrom and the basis for the alleged exemption. Any violatiomof Section
131.5 by any applicant for a permit subjects the applicant to a civil
6enalty of not more than five hundred dollars ($500).
LJ 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 (Section 7044, Business and Professional Code: The Contractor's
License Law does not apply to an owner of a property who builds or improves
thereon; and who does such work himself/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 com-
pletion, the owner will have the burden of proving he/she did not build or inn.
prove efor the purpose of sale).
❑ I, az owner of the property, am exclusively contracting with licensed con-
tractors to construct the project (Section 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property. who
builds or improves thereon, and .who -contracts for such projects with a con-
tractor( license pursuant to the Contractor's License Law). I am aware that
proof o their Worker's Compensation insurance should be provided to me.
❑ 1 am exempt under Section B. & P. C. for this reason
Date Owner
I hereby -certify that I have rea
information is correct. I agree to
and state laws relating to buildir
sentatives of this city to enter
inspection ur poses. �a
Signature
Drivers' Lice se or SS -
Pink - Accounting; Goldenrod - Assessor
PLUMBING
Showers
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors -
Solar Piping
Solar Tank
Swimming Pool w/Spa
Urinal
Water Closet '
Water Heater
Water Service
Auto -Wash
Laundry Trays
Issue Fee
AANICAL
Hood or Type ❑
Canopy Type 11 ❑
Refrigeration System t
00-100,0009TU 0100,00081
System Repair/Alteration
Fire Dampers
Registers
Issue Fee 4W I
FEES
A.P. #
S Main Building:
E
T Front
B Rear
A
C Right
K
S Left
Ping. Ref. #
Planning Notes:
Zone
Accessory Building:
Z'
O,
N
I
P N
G
R.
Parking Req./Provided - E.
Q
M.
S
ELECTRICAL FEES
Automatic Washer
Construction Pole Sub.
Transformer ❑ 15-50 KW
I ❑50+KW
Cooking Unit '?
Meter ❑up to 100 amps
Dishwasher ---
Meter ❑over'100 amps:
Dryers ❑Gas E]Electric
i
Sub Panel
Fan
Motors 110-1 HP 1:11'f.-8
F.A.U.
Inc. Solar 119-15 HP 016-15+ Q
Fixtures
Microwave
Device Boxes
Pole Light
Outlets
Range
Switches
Sign
Garbage Disposal
Standing Sections
Generator ❑0.5 KW ❑5.15 KW
Trash Compactor -
$ 3
FEES Reinspection Fee
DEVELOPMENT SER VI
Zoning Approved By_
Building Approved By i
$41
$15 ' I Issue Fee
REQUIREMENTS:
01
ca
'SUMMARY OF
BUILDING PERMIT
$
PLAN CHECK
$
Uy
PLUMBING
$
-F%•
PLAN CHECK 25%
$
ELECTRICAL
$
PLAN CHECK 50%
$
-
d�'• U�
MECHANICAL
$
PLAN CHECK '25%
$
01
ca
SMTP
$
PERMIT
ISSUANCE
- $
ENERGY P.C.
$
GRADING
$
MICROFILM
TOTAL FEE
$
$
CV
CONSTRUCTION AND PLANNING
Date
APPROVALS Permit #
Inspector
POO. ;PA
APPROVALS Permit #
Date
Inspector
1. Temporary Electrical Service or Pole
52. Pool & Equipment Location
,
2. Soil Pipe-Undrgrnd.
53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd.
-
54. Forms
,
4. Electrical Conduit-Undrgrnd.
55. Electrical Bonding
`
5. Steel Reinforcement '
•c?
56. Rough Plumbing &Pressure Test
'
6. Electrical LIFER Grnd.
57. APPROVAL TO COVER-GUNITE
7. Footings
r
58. Electrical Conduit-Undrgrnd.
8. Foundation
59. Gas Pipe, 0 Undrgrnd., Test
9. Water Pipe-Undrgrnd. -
60. Backwash Lines, P -Trap, 0 Undrgrnd.
10. Structural Floor System
. C
1
61. APPROVAL TO DECK
11. Property Sewer Line & House Connection
62. Backwash & Receptor -Final
12. Sewer Cap
63. Heater & Vent -Final
13. Roof Drains
64. Plumbing System - Final
'
14. Rough Plumbing
65. Electrical -Final
15. Rough Electrical -Conduit
66. Solar System -Final
16� Rough Electric Wiring -.
6 Fencing & Access Approval
1747Rough Wiring Sign
68. APPROVED FOR PLASTERING
1A;'Rough Electrical -T Bar Ceiling
69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning's
FIRE DEPT. REQUIREMENT
APPROVALS Permit #
20. Rough Factory Fireplace
21'% Ducts, in Structure
70. Underground Hydro
22. Ducts, Ventilating -
71. Product Piping 0 Gas El Oil
23. Gas Pipe -Rough &Test
-
72. Underground Flush
24. Roof Framing
73. Undergrnd. Storage Tank El Gas 0Oil
25. Roof Sheathing .. :'
74. Overhead Hydro
26. T -Bar Ceiling (Structural) & Monocoat
75. Dry Chemical
27. Frame and Flashing
76. Dry Standpipe
28. Lathing &Siding
77. FIXED SYSTEM FINAL
29, Insulation-'
78. FIRE PREV. FINAL
30. Drywall Nailing
HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat
79. FINAL INSPECTION
32. Electrical Power Meter -Final
80., FOOD CERTIFICATE ISSUED
-
33. Final Electric
F17/(V
&,60
Notes:
34. Final Heating & Air Conditioning
7 g0
0 _
35. Final Gas Pipe -Test
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing
39. Water Service -Final
`
40. Gas Service -Final
-
41. Solar Domestic -Final
42. Backflow Preventer
'
-
43. Backflow Irrigation
-
44. Landscape Irrigation System
45. Sound Attenuation
j
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING
r
48. Special Requirements Completed
49. Electric Release to Edison
-
•i'
50. Gas Release to Southern California Gas Co
-`
51. CERTIFICATE OF OCCUPANCY
No. Date
OWNER DTiCF & COLEGROVE DATE 12-15-5
JOBADDRESS 246 Rose Pane BUILDING PERMIT NO. 2172
GENERALCONTRACTOR Dike & Colegrove VALUE S 8.500.00
97_ BLOCK TRACT 2562 Residence & Garage
GROUP I & i TYPE v ZONE RL FIRE DISTRICT 2195
INSPECTIONS
DATE
SUBCONTRACTOR
PERMITS ISSUED
DATE
NUMBER
Footing Trench
Foundation Forms and Grade to Garage
Rough Framing
Plumbing, Rough t✓fS ab G
/.3-
g_Plumbing,
h
Plumbing,RougComplete
,r
,..n.�.�
i,-..
Temporary Pole
Wiring, Rough
Heating, Rough
Sewer, Sewer, St.
Septic Tank o Cesspool
L 1g, In 04
1
n
Plastering2—
Plumbing, Final, Fixtures Complete /f / „p
Plumbing, Final Gas Test /,�d%' � '
Wiring, Final
Occupancy
Fnrm 21n (1_H 15001-55
to Mesa Building Department
ttt EAST 20th STREET
COSTA MESA, CALIFORNIA
FOR APPLICANT TO FILL IN
Building
Address 2146 Rose Lane
Costa Mesa, California
Nearest
cross St. 21st St. & Orange Ave.
rss 1419 E. 17th St.
Tel.
Costa Mesa No. Li.
itect or Lic.
neer Cnrlcnr R. MirtAloh,nNb.
-_ itractor Dike & Colegrove No: 27C
Address 419 E. 17th St., Costa Mesa
(Attach Metes and
Size of Lot 82, 5
Use of
Existing Bldg.
Setback Line from
New I X
Lljl 5
Wall
t Side Yard
V OF WORK
n I I Additig4/d
Demolish
of
5ms 6 Stories 1
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 Laws regulating
building construction.
Signature of
Permittee Dike and Cole rove
Authorized Agt.
lValizationAPermitFees'•Plan Check s 1U•$ 5500.00Total /� y
Fee S v7,y, 0�
FORM 204 S -BP 2M 6.55
APPLICATION FOR PERMIT
19� BUILDING
FOR OFFICE USE ONLY
Receipt No. Permit No.
a172 -j
ReceV by Date Reo'd. Date Issuet
Building
Address
Costa Mesa, California
Nearest
Cross St.
91 Zone 12 1 No.of I Type Group
CORRECTIONS
I
r I
0 APPROVALS I
Frame: Fire Stops,
Bracinc. Bolts
Plaster, Ext
Masonry Reinforced
Date
PIAT PLAN
Show location and distances from
property line and between buildings
rosTr
SPD> FSFA 2 .g ° t': *33.00
tr
c
v
J
�
J'
4
�
- 6
a
o
-- '- - a`
Street
PIAT PLAN
Show location and distances from
property line and between buildings
rosTr
SPD> FSFA 2 .g ° t': *33.00
tr
1
OWNER MARTIN, PAUL DATE 2-7-62
JOB ADDRESS 21F6 Rose Lane BUILDING PERMIT NO.1 376
GENERAL CONTRACTOFTOr Const. VALUE $ 3,06� 00
AP No11&M-08 LOT TRACT FIRE ZONE _ DESCRIPTION OF WORK Add Fam.Rm-to
INSPECTIONS SignaturE
DATE GROUPI TYPE V ZONE Rl Res
SUBCONTRACTOR
PERMITS ISSUED
DATE
NUMBER
Water
Rough Corn. Refrig. ❑ Air Cond. ❑
_
Rough Heating i
Rough Plumbing
a.
Zhl:.._�•5`�'*4c¢t�it..0
���✓=G7__�d�7
Miscellaneous
Prop. Swr. Line ❑ House Con. ❑ St. Swr.
Sprinkling System
Construction Pole
Underground ❑ Power ❑
Rough Wiring
Trenches 2' Forms Steel Reinf. E 401y
-/�j �t,y
Floor System
Bond Beam ❑ Steel Reinforce ❑
Sheathing a —_
Frame and Flashing /3
/,
Lathing — In ❑ Out ❑ -
1 -
__
Plaster,
Plaster, brown coat
>�
-ig. ❑ Air Cond. ❑ Final
I ng, Final — -
- -
Plumbing Fixtures, Final
Final Gas Test
Electric Fixtures, Final
Building, Final
.V
�l�\
OCCUPANCY
FORM aU4 - 5M — 7 -GI I bi7b
4 16376
COSTA MESA BUILDING -SAFETY DEPARTMENT
P. O. BOX 917 COSTA MESA. CALIFORNIA
For Applicant to Fill In Completely
TYPE OR PRINT
BUILDING
ADDRESS f /✓ G
COSTA MESA. CALIFORNIA
FEE RECEIVED
FEB 7
FINANCINEPT.
CITY OF COSTA MESA
APPLICATION FOR PERMIT
BUILDING
For Office Use Only
BF'
RECEIPT NO.
Peg
OWNER L —
yO 6
//Il//,•
MAIL �2
RECEIVED BY DA RE�jIVEEff
DATE IBSUHO
ADDRESS /�- OSY
n TEL.
CITY ` O _ T J,,# — NO.
BUILDING
ADDRESS
ti{
COSTA MESA. CALIFORNIA
ADDRESS
FIRE
ZONE TYPE GROUP
AP //
BY DATE(/
7„ �l
/ Z -
CONTRACTOR GIlT LC d.I
J�
ZONING
ADDRESS 0
ADDRESS
ZONEF N8W
UU8HILOIN
P�G
ANCITY
IC75!I 7�
LEGAL
�i
. NO. N NO. /
DESCRIPTION
A. P. NO. /^ D
I O� 57,
OF SIZELOT '/ S' I NO. of 8LDG8. I
NOW ON LOT (
USE OF /�
YARDS EVES
EXISTING BLDG.
APPROVED ALLOWED
SHTBACK LIN. FROM
/7—
(CENTER LIN. ST.)
CENTER OF STREET REAR YARD
FRONT .FT
IN.
SIDE YARD I LEFT
I RIGHT
R. SIDE FT.
L. SIDE � FT.
i1N.
6 IN.
DESCRIPTION OF WORK
NEV I I ALTERATION I I ADDITION
REAR / FT.
GIN.
I II I I
REPAIR MOVING DEMOLISH
APPROVED I PATE
411
BUILDING } NO. 0S
3
f
SIZE / ROOMS STORIES
EXTERIOR WALL '/`eCO I
COVERING COVERING D
US OF BUILDING AND WORKTO BE PERF MED
(✓ ✓ 0 O
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
THE AMOUNT SHOWN UNDER VALUATION
18 FOR THE
RECT AND AGR COM.
PLV WITH ALL CITY OSTAT WBUILDINGCONSTRU.
AND STATE THAT THES'Emz:
PURPOSE OF ESTABLISHING A PERMIT
FEE ONLY.
VALUATION
PERMIT FEE $PERMITTEy,/J
SIGNATURE OFCl,?
V
��
OIl' O/t�S G C ti'
$ /
PLAN CHECK S
AUTHORIZED AGENT
TOTAL FEE Sv
BF'