HomeMy WebLinkAbout3499 SAN MARINO CIR - Building Permits• J��'.
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� CITY OF COSTA MESA
BUILDING DIVISION �
DEVELOPMENT SERVICES DEPARTMENT
PERMIT
(714)754-5273 • Fex(714)754-4856
PLUMBING PERMIT
Job Address: 3499 SAN MARINO CI
Suite No
Vicinity:
Parcel Nunmber: 41205108
Applicant: LORIE GLOVER � � � ' ' ' '
Address: . . ' � � . .- � . . . . � . ..
� �' - � � Phone: � �
., � ' , , � � Zip: .
owner� �N10UZOON,�RIAZ RAY, : � � �
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Address�, 3499 SAN-MARINO CIR-� -
/ . i-_
� �i!i� Phona:
,,,./� �COSTAMESA,CA / 2ip: 92626
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Contractor. COAST ROOTER PLUMBING HEATING 8 AIR COND
�.
� Address: 2737S.CRODDY ;:� �� � ' .
SUITE D � , - �Phone:� 714 241 �1414
.SANTA ANA CA '; . � > : ; � ^ -' Zip: 92704 �. - _
. � ' � � . � License: 529127� -
�ArchlEng:� � �
/ Address, - , _ _ _
� . - , , Phone: . - = . ; . .
.. . . Zip:. . . . . .
� � License: .
� � � - ' SCOPEOF.PERMIT
WATER HEATER CHANGE OUT. _ . � _ � - ,' /
ISSUE FEE
Backflow irrigation
Backtlow Preventer
Bathtub
Clarifer System
Connect (Ice,Soda,etc)
Dental Units ,
Dishwasher ,
Drein, Floor
Drain, Rainwater
Drain, Roof �
Drinking Fountain
Expansion Tank
Gas Earthquake Valve
Gas (1-4 outlets)
Gas (Over 4 outlets)
Gas Repipe
Gas Service
Interceprors (Grease, Oip
Interceptors (Sand Auto )
AMT
$23.50
50.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
QTY
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
FEE SUMMARY
nMT Qrr
Laundry Tub / Washer 50.00 0
Landscape Irrigation � $0.00 0
P-Trap ' " $0.00 0
Pressure Regulator � $0.00 0
Process Piping (per 10�ft) $0.00 0
Receptors 50.00 0
SepticTank �� $0.00 0
Sewer Cap for Demo '$0.00 0
Sewer Connect � $0.00 0
Sewer Private Line � - $0.00 0
Shower $0.00 0
Sink, bar $0.00 0
Sink, commercial $0.00 0
Sink, Floor $0.00 0
Sink, kitchen . . $0.00 0
Sink, service/mop $0.00 0.
Spa (private) . � . �$0:00 � 0
Spa (public) $0.00 0
COMMENTS / SPECIAL CONDITIONS
NUMBER
Vj P99-00483
77 FAIR DRIVE, COSTA MESA, CA 92626
Status: ISSUED
Applied: 0812311999
Issued: 08/2311999
ISSUED BY:
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AMT
Sump Pump $0.00
Swimming Pool 50.00
Trap Primer $0.00
Urinal " $0.00
Vacuum Brkr Bkfiow(1-4) $0.00
Vacuum Brkr Bkflow(5+) $0.00
Wash Basin $0.00
wash Basin Set $o.00
Waste and Vent System $0.00
Water Closet (Toilet) $0.00
Water Heater f vent $12.30
Water Piping (Inst or Rep.) $0.00
Water Re-pipe $0.00
Water Service $0.00
Water Softener $0.00
OTHER $0.00
VIOLATION $0.00
PLAN CHECK $0.00
REINSPECTION $0.00
TOTALCALCULATEDFEES: $35.80
D�
QTY
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
C
NOTICE: The work authonzed by this permit shall comply with all applicable handicap access requirements u�rK,`alitomia statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRA710N: This permit shall automatically expire and become void if work is not commenced within 180 days,-or if work is suspendad or abandoned
fora 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 inepectlona and final epproval must be obtained. Failure to obtain inspections and final approval will result in ihe expiration of this permit.
FOR INSPECTIONS CALL: (714) 75h5626
WORKERS' COMPENSATION DECLARATION:
I hereby eHirtn untler penelry ot pe�{ury one ot Ihe lollowing tleclarations:
❑ I heve and will maintein a certlticate ot consent to setl-Insure for workers' compensetion, as provitled for by sectlon 3700 of the Labor Cotle, for Ihe perfortnence ot Ihe
work far which this permit Is issuetl.
� I have and will maintain workers' compensation insu2nce, as requiretl by section 3700 0l Ihe Lebor Code, for Ihe peAortnence of Ihe work for which this pertnit is issued.
My wo ers' compeA se�,tion Insurance carrier and policy number are: pp
Cerrier. ��'`(/1� ) M Policy Number. NO ) D,� C1 p ��
(This section need naf be com letetl i! fhe rmit 15 velued et one hundred ddlars ($100) or less.)
❑ I certify thet in Iha peAortnance of Ihe work for which thi5 pertnit is issuetl, I shall not employ eny person in any menner so es to become subject to Ihe workers'
compensation laws of California, anC egrae Ihet if I shoultl bacome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions. (�
ApplicantSignature: � ��� _ Dete: [1�a3�g
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBIECT AN EMPLOYER TO CRIMINAL PENALTIES AND dVIL FINES UP TOONE HUNORED
THOUSAND DOLLARE (4100,000), IN AODITION TO THE COST OF COMPENSATIIXJ, �AMAGES AS PROVIDED FOR IN SECTION 3'IO60F THE LABOF COOE, IMEREST, AND ATTORNEYS FEES.
LICENSED CONTRAC70RS DECLARATION:
I herehy aHirtn Ihat I am licensed under provisions of Chapter 9(commencing with Section 7000) of Division 3 of the Business end Profassions Code, and my license is in full
lorce and ettect. Lic. k r�- Cless N C3 <O
Contractofs Slgnature: Date: -r� �� i �'i
�
CONSTRUCTION LENOING AGENCV:
❑ I hereby eHirm ihat there Is a constmction lending agency for the pedormance ot the work tor which this permit Is Issued. (Sec. 3097, Civil Code).
Lenders Name: Lenders Address:
Signature: Date:
I OWNER-BUILDER DECLARA710N5: �
1 hereby attirtn ihat untler penalry of perjury ihat I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business antl Professions
Code: Any ciry or counry which requires a parmit to construct, alter, improve, tlemolish, or repair any simcture, pnor to Its issuance, also requires the applicant for such permit
to file e signed stetament thet he or she is licensetl pursuant ta the provisions of �he Contrectors License Law (Chepter 9(commencing with Section 7000) of Divlsion 3 0l Ihe
Business anC Pmtessions Code) or that he or s�e is exempt iherefmm and ihe basis lor the allegeA exemption. Any dalation of Sectlon 7031.5 by eny applicant for a permit
subjects the epplicant to e civil panelty ot not more than five hundretl tlollars ($500).):
❑ I, as owner ot Ihe property, or my employees with wages as iheir sole compensation, WILL DO TME WORK, antl the structure Is not intended or oHeretl for sale (Sec.
7044, Business and Professions Code: The Contractors License Law tloes not apply to an owner of property who builds or improves thereon, and who does such work
himsalf or herself or through his or her own employees, provitletl Ihat such improvements are not intended or ofterad for sale. If, however, ihe builtling or improvement is
sold within one year of completion, the avner-Duiltler will have Ihe burden ot pmving Ihat he ar she tlitl not build or improve for purpase of sale.).
❑ I, as owner of Ihe properry, am EXCLUSIVELY CONTRACTNG Wf7H LICENSED CONTRACTORS to consiruct ihe project (Sec. 7044, Business and Professlons
Cotle: The contrectors License Law does not epply to an owner of properry who 6uilds or Improves thereon, entl who contrects for,such project with a comractor(s)
license pursuant to the Conirectors License Laws.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID venlied by tlriver's license. ❑ Yes ❑ No Dnvels License No. Expires:
Venfication of Ownership by (type ot document, i.e. - property tax bill or deetl):
DIVISION OF INDUSTRIAL SAFETY PERMI7 CER7IFICA710N:
❑ I hereby certify ihat no axcavation five (5) or more feet in tlepih into which a person is requiretl to tlescentl, wlll be made in connection with work authorized by this
permit, end ihat no building simciure, scaHoltling, falsework, or demolition or tlismentling thereof, wlll be more then thirty-si: (38) feet high. (Chep. 32, Gry 2, An 2, Sec.
341, Title 8, Celitomie Atlminisiretive Code).
❑ As owner-builtler, I will not employ anyone to do work which would require e permit from the Division of Industrial Satery, es notad ebove, unless such person has a
permit to tlo such work from Ihe division.
Slgnature: Da�e:
Division of Intlustnal Safery Permit Number:
1 Will the applicam or present or fuWre 6uiltling occupant neetl to file antl certity a Business Plan for emergency response to releese or threatened release of e hazartlous
matenal7 ❑ Yes ❑ No
(Section 25505 of ihe Califomia Health and Safery Code requires, with some exceptions, �hat e Business Plan 6e filetl with ihe Cwta Mesa Fire Department by every
business which has at any one time during a reportad year a quantity of hazartlous ma�eriels equel to or greater ihan a weight of 500 pountls, or e volume of 55 gallons,
or 200 cu�ic feet of compressetl gas at siantlartl tempewture and pressure). �
2 Does or will the applicant or present or future building acupant need to file a regisiration fortn for ecutely hazar0ous materials? ❑ Yes ❑ No
(Section 25533 oi the Celifomia Heelih and Salery Code, with some exceptlons, requires registretion with the Cwta Mesa Fire Department by each 6usiness which at any
one time has on hantl e quantiry oi acutety haiardous materlals equal to or greater Ihen e weight of 500 pounCs, or a volume oi 55 gallons, or 200 cuDic teei of
compressatl gas et stantlard tempereture end pressure). �
3 Does or will the applicant or present or future builtling occupant neetl to prepere an RMPP (Risk ManegemeN antl Prevention Program Por acutety hazardous matenals)?
❑ ves ❑ No
(Section 25534 of Ihe Celifornia Health and Salery CoOa provitles that tha Casta Mesa Fire Depariment mey requlre the preparation, certification antl filing with the Fire
Departmem ot an RMPP by businesses which ere required to register acutely haiardous matenals wit� Ihe Fire Depariment.
4 If an RMPP is o�esentiv required �as Section 25534 of the Califomia Health antl SafeN CoCe been fullv comolied with7 ❑ Yes ❑ No
uoes or ww me eppucem or presenc or mwre ounaing occupam reqmre ior me wonc wnicn is me sm�ect oi Inls a pllcatlon a permn ror such construcuon or
from the Sout� Coast Alr Oualiry Management Distnd or trom eny other air pollution conirol tlisirict or egencyt � Yes u No
(Sedion 658502 Of Ihe Celilornia Governmen� Code requires ihat ihe requesletl inlormation be turnishetl on epplications for non-residenliel building pertnits).
WIII any pert of tha facility to be constructed under this permit ba within 1000 feet irom the outer bounderies ol e school? ❑ Yes ❑ No
(If'yes", ihe lacllity must meet Ihe requirement ot Seclions 25534 and 42303 of ihe Calitomla Healih end Safery Code).
or agency is requiretl for Ihe work which is Ihe sublec� of �his
en made9 ❑ Yes ❑ No
8 QY'yes", ettach certiticate oi complience from the appropriate air pollution contml oflicer).
CERTIFICATE OF COMPLIANCE: I cenity ihat under penalry of periury the Information given above is correct. I egree to comply with all state laws entl city ortlinances
regerding Hazardous Materials end Emissions. -
Signeture: ' " Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZA710N OF EN7RY: I cenify untler penelty of perjury that I heve read this epplication and state ihat the information given is
wrrect I agree to comply wlth all state laws and ciry ordinances �elating to building construdion, antl authodze representatives of Ihe Ciry of Costa Mesa to emer upon the
ebove-describetl property for inspectlon purposes. I agree not �o occupy or allow occupency ol any building authorized by this permit umil iinal inspection.
i re Ot Legal Owner(s) Date
�,.�`�� 8-� 3 � �
And/Oi Auihorized Applicani Date
CODE r. INSPECTIONTYPE
1616 Fixetl System Final Fire Prevention
7266 Pool Spa Final
200 Final Ra-Roof
201
202
203
20a
244&a8
Final BIxWRetaininq Wall
Finel Factory Fire Place
Final Sign
Final Demolition
P9IE INiIiIpLS
CODE�
206
20B
210
212
220
222
250
INSPECTION TYPE
Final Mechanical
Final Plumbing
Finel Electrical
Final Fire Preven�ion
Final Planning Approval
Final Site
Final Building/Occupancy
� INi1TIAL5
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OWNER HELTZER E�terprises Cossta Mesa
JOBADDRESS 3 99 San Marino Circle
GENERAL CONTRACTOR Georae J. Heltzer
AP No.
INSPECTION
SOIL
GAS
W ATER
ROUGH PLOMBI
PROP. SWR. LI
SPRINKLING SV
MISCELLANEOU
ROUGH HEATIN(
TEMPORARV SE
UN�ERGROtINO
ROUGN WIRING
TRENCHES �.
FLOOR SYSTEM
BON6 BEAM �
SHEATHING
LOT
AIR CONOITIONING
OR POLE
POWER I I
STEEL REINFORCE
FRAME AND FLASHING
LATHING - IN OUT
PLASTER, BROWN COAT
STRUCTURAL, FINAL
HEATING, VENT., REFRIG. AN� A.(
PLUMBING, FINAL AND GAS TEST
FINAL
ELECTRIC, FINAL
RIIII fIIIJ!'. GII.1�1 /
DATE 2_$_72
BUILDING PERMI
WORK Res.w%
VAWE $ 24_60
SUBCONTRACTOR
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, 34113
� COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 7200 COSTA MESA, CALIFORNIA 92626
For qpplicant to Fill in Completely
ADIDRESS 3499 San Marino Costa Mesa
OWNEF Heltzer Enter rises Costa Mesa
MAIL
ADDRESS 740 N. La Brea Avenue
TEL.
cirv Los An eles No. 937-21
CONSfRUCTION .
BRANCH Main Office
aooaess 600 So. S rin St. Los An eles
ARCMITECT TEL.
ORENGINEER David Freedman NoFiS'i-3A5�
ADDPESS 113 N.San Vicente, Beverley Hil
CONTiiACTOR George J. Heltzer
ADDRESS 740 N. La Brea Avenue
TEL.
ciTv Los AnQeles No.937-2171
� c No. 3144 uc�No. 1900
512E NO. OF BLOGS.
OF LOT NOW ON LOT
USE OF �
EXISTING BLDG. � � �-yc'1.e
SIZE OF NO. OF
EMERIOR WAL�
AND WORK TO BE PEFFORMED
��
�. -�-7��,";-;;.'00 305# *** 129.00
APPLICATION FOR BUILDING PERMIT
RECEIVEDB. OATERECEIVED ...r��ew���.
A.P. NO.
BUILDING
AODRES�
TRACT
FIRE
20NE
APPROVED
PERMIT NO.
�! ci-o�L1 i'�6����+-O
o(c3 '
LOT BLOCk
� P
��
GJ �
�'' VA�US G,� �
O
TYPE� GROUPI �
DATE
�� ..
NO.OF
PLANS ,
VARDS APPROVED
MAIN BUILDING
DISiANCE BET
MAIN BLDGS.
VAR. #e
I noroby eeknowletlpn Net I have reatl this ap0licallon and rtate D �
that No ebove ��}ormotion is correct antl apreo to comply with
all laws rogulatinp buildin8 �onrtruction, antl I shall not employ
eny perwn In v�olation of the workman's compensallon laws of
the State o( Cal�(ernia. 2
1 �areby cartify xhat 1 am properly licansetl as e contraetor untler " D SQ. FT.
tha State of Cel�fornio Businezs end Profassions Cotlo, Divisicn 3, THE AMOUNT SI
Cheptar 9, end thet such li ensae are In full force antl Btfeet, or I THE PURPOSE OF
m oxampt from tho slons o( tha Stete of California Businass VALUATION
ontl Profassions Cotlo, i ision 3, C�epror 9.
s�9�ecure o+ /q \
Parmittae L� L 5 �-�j
�3.6o-a-
Avthorizetl Apant
USE OF
BUILDI�
VAR
BET.I
noce
DATE
�
/ �
O
VALUATION IS FOR �
A PERMR FEE ONLV:
¢
� $ � N
K$ 3.�= E
�� � s
$
I
OWNER uFrm�FR Fn PrnricP� DATE 6-14-72
10BADDRE$$ �4Q9 San Marsno [�r�lo BUILDINGPERMITN0.34836
AP No
PP.F�
GAS
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGN HEATING AND NIR CON�ITIONING
TEMPORARV SERVICE OR POLE
UNOERGRDUND � POwER �
ROUGH WIRING
TRENCHES FORMS STEEL RE
FLOOR SVSTEM
BOND BEAM � STEEL ftEINFORCE [
$NEATMING
FRAME FN� FLASNING
LATHING - IN n OUT �
PLASTEft,BROWN COAT
VENT
BUIL�ING, FINAL
FIRE ZONE VALUE $ 650.00
SUBGONTRACTOR
BVIL�II
ADDRE:
OWNER
MAIL
34836
MESA BUILDING-SAFETY DEPARTMENT
)X 1200 COSTA MESA,CALIFORNIA 92626
For Applicant to Fill in Completely
'3�(9c� SL1wf �u�l�►2.lnro �(12ci
, ���-7%�r�c�Q1797': t:•:: 6.�Q.OS
APPLICATION FOR BUILDING PERMIT
fiECEIVED BV DATE RECEIVED pp1E ISSu
A.P. NO.� � ��OS� �
AD�D ��E S � Y9CI SLili
d U CITV '-_ - '` NOL TRACTy�� �
2
2 Q CONSTRUCTION W A D
O N IENDER
am
JN BRANCH OWNER �FyT2
m J ADDRESS�OO /N� �
J m ARCHITECT TEL. S � C.i
a OR ENGINEER N
V Q FIRE
W � ADDflESS ZONE T
d w APPROVED
J O CONTRACTOR f'%pfr/�%�CC U// G� � � V
m¢ ADDRESS . U�/JG �GO U
W W ZONE� NO.OF
� TEL. P�� �
Z� cirr r Ga • ov-c� No. 3�o'r�
w� STATE /f CITV VAFDSAPPROVED
j O IIC. NO.�GQZ L{r '1 S LIC. NO. MAIN BUILDING
SIZE NO.OF BLOCS. (FROM C/L STREET)
OF LOT NOW ON LOT ROM FT.
USE OF
EXISTING BLDG.
� SIZE OF NO. OF
ZQ NEWBIDG. ROOMS STORIES I.SIDE FT.
U E%TERIOR WALL ROOF
COVERING COVERING REAR FT.
J USE OF BUIIDING AND WOpK TO BE PERFORMED DISTANCE BET.
a MAIN BLDGS.
a
Q ` /, , VAR.#
O �j C.U.P.$
y APPROVED / / 1/ fl �
lill 4L!
Z
O
VI hereby acknowledBe thax I have reatl this epplication antl stete
� that Ihe above intormation ii correc[ and agree to comply with
� all laws ragulating builtling co�sttuction, antl I shall not empioy
� any person in violation of the workmen's compensallon lows of
y the State of Calitomia.
ZI hereby cartify that I am properly licansetl es e conttactor untler SQ. FT.
[he State of Celifornia Businegs entl Profazsions Cotle, Divisicn 3, THE AMOUNT SHO�
Chapter 9, and that such licens¢z are in full force antl effect, or I 7HE PURPOSE OF 6
am e>empt from ffie p�ovisions of the State of Calif rnla Business VALUATION
entl Professions Cotle, Division 3, Chapter 9 �p
� � ��
SIB^atura of � �
Permittoe $
Authorizetl Ageni
LOT 'J I BLOCK
�
USE OF NEW,.y'��,'�
BUILDING �L��� L
VAROS APPROVED
ACCESSORY BUILDING
BET, MAIN
ACC65. BL
DATE
m
w
0
�TION IS FOR g
IT FEE ONLV: m
¢
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m
� �� LL
�iCINSPECTIONS
SOIL
�GAS
W�iER
�\ROUGM PLl1MBING
�L PROP. $WR. LINE ❑ HOUSE
1'
SPRINKLING SVSTEM
MISCELLANEOUS
ROUGH NEATING �NO AIR CO!
TEMPOR�RV SERVICE OR POL
UNOERGROUNO � POWER
ROU6H WIRING
TRENCHES FORMS
F100R SVSTEM
BON� BEAM � STEEL RE
SMEATHING
FRAME ANO FLRSNING
LATNING - IN n OUT [
PlASTER, 6ROWN COAT
STRUCTUNAL, FIHAL
HEATING, VENT., REFRIG. AI
PLUMBING, FINAL AND G�51
' EIECTRIC, FINAL
BUILOING, FIN�L
SPEfIAL REOIIIREMENTS
DATE
SUBCONTRACTOR
�t v "L� -
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
�oee�t�E���i�ri�e
�,, .. 6.50
APPLICATION FOR STRUCTURAL PERMIT " n
For Applican[ [o Fill in Completely — Use Ink Only RECEIVED BY DATE RECEIVED D TE IS E ��
ADIDRESS 3�199 .faN k,eiNo C��c�E �j -
OWNER I�ENNETI�' N. TONES A.P.NO. �I���/' I�bp P T
MAIL ADIDIiIE55 �y99S'�.�.,,.I"�LCVNmA
ADDRESS f MF �J �`
TEL. TRAC��I. LOTv BLOCK
��T� cofT,� MEra No.ss _� �
CONSiflUCTION NEW ADD ALTER P
�ENDER NONG
BRANCH
OWNEF
ADDRESS
VALUE
ARCHITECT TEL. SE S
Ofl ENGINEER N
FIRE
ADDRESS ZONE TVPE GflOUP
e APPROVED
CONTRACTOR Ok'NL.Q. G/C�� BV DATE �
ADORESS s E S /I�VG
TEL. ZONfj-� NO.OF VSE OF NEW��
CITY NO. "K P�� BUILDING `
STATE CITV �'ARDS APPFOVED VAROS APPROVED
LIC. NO. LIC. NO. MAIN BVILDING ACCESSORV BUILDING
512E ys�iC/3P•i8'�X NO.OFBLDGS. (FROMC/LSTREET) 2
OF l0T Z / � NOW ON LOT RONT FT. V FT.
USE OF
EXI5fING BLDG. S C FT. �FT
Separa[e permits are required for L. SIDE FT. FT.
electric, plumbing and heating work. p�.
REAP FT. �/ FT.
USE OF BUILDING AND WORK TO BE PEflFORMED DISTANCE BET. BET. MAIN &
MAIN BLDGS. ACCES^a. BLOGS.
p VAR. #� DATE
IJLOCk G•N�F C.U.P.q� APPROVED
APPROVED � z
I hereby ecknawletlge Shat I heve reatl this application antl state
that the above Info�meNon is eorreei and egreo to comply with
all laws reBulating builtline �e^nruction, anC I shall not employ
eny perwn In violetlon of Ne workman's compansation laws of
the State ot Celifornie.
I hereby certify thet I am properly Iiconsad as a conbactor under SQ. FT.
the State of Celitornie Business antl Professions Cotle, Dlvision 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR
Chaptar 9, antl t�at such licenses ere in full forca and effeci, or 1 THE PURPOSE OF ESTABUSHING A PERMR FEE ONLV:
am exempt trom the provislons ot the State of Caltfornia Busineu VALUATION PERMIT FEE E ��d
untl Professions Cotla, Diviclon 3, Chepier 9.
, �) PLAN CHECK E
Signamra of /� n / /� v�/
Permittee u'1Y'���� S � .� TAX § �
Authorizatl ABent TOTAL PAID S O