HomeMy WebLinkAbout3484 SAN RAFAEL CIR - Building Permits, ��.n �Y
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CITY OF COSTA MESA
BUILDING DIVISION
DEVELOPMENT SERVICES DEPARTMENT
PERMIT
.lob Address: 3484 SAN RAFAEL CI
Suite:
Vicinity: HOUSE ONLY!
ParcelNunmber: 41205119
Applicant: GALITSKI, GUY
Address: 19792 POTOMAC
HUNTINGTON BEACH CA
Owner: MELTON, CHARLES E
Address 3484 SAN RAFAEL CIR
� COSTA MESA, CA
Contrecror G G ROOFING
Address: 79792 POTOMAC
Arch :
Address:
HUNTINGTON BEACH CA
Zip: 92646
Phone:
BUILDING PERMIT
Zoning: R1 R1
Phone: 714-965-2387
Zip: 92646
Phone:
Zip: 92626
Phone: 714-965-2387
License: 364151
Eng:
Address:
PERMIT NUMBER
� 699-00506 ✓
77 FAIR DRIVE, COSTA MESA, CA 92626
ISSUED BY:
Status: ISSUED
Applied: 04/14/1999
Issued: 04/14/1999
Phone:
Zip License: Zip: License:
SCOPE OF PERMIT
•REROOF - T/O, INSTALL 1 LAYER 15# FELT, INSTALL 7/16" OSB BOARD & NEW 30 YR GAF COMPOSITION SHINGLE
ROOF.
Plan Check:
Permit:
SMIP Res:
SMIP Com:
- Other:
Inspection:
Total:
$0.00
$74.75
$0.50
$0.00
$0.00
$0.00
$75.25
SETBACKS
MAIN STRUCTURE Front 0- 0
ACCESSORY Front 0- 0
PARKING Existina: o
NOTES:
Rear 0- 0
Rear 0- 0
Reouired: 0
FEE SUMMARY
PLANNING 8 ZONING
Left 0- 0
Left 0- 0
Pr000sed: 0
Calc Valuation:
Claim Valuation:
Right 0- 0
Right 0- 0
s2,2oo.00
s2,zoo.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia 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 Inapeetions end tinal approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
WORKERS'COMPENSAnON DECLAIiArON:
I hereby ettirtn untler penelry of perjury one of the tollowing tleclarations: ' � � �
❑ I �eve and will maintain a certifcate of consent to self-Insure for workers' compensation, es provided for by sectlon 3700 of the Lebor Code, for ihe peAortnance of ihe
wark for which ihis pertnit is issued.
❑� I have and will maintain workers' compensatlon insurance, as required 6y section 3700 of ihe Labor Code, for the peAortnance of the work tor which ihis pertnit is issued.
� My workers' compensetion Insurance cartier enC policy number are:
Cerrier. ��� ��--� FJI�� Pollcy Number. � Z(-� 3�� ��� .
(fhfs sec0on need not be camp/etetl i! the peimlf /s valuetl at one hundred dollars ($100) or less.)
❑ I certiry thai in �he paAormance of the work for whic� this pertnit is issued, I shall not employ any pereon in any menner so es to becoma subject to the workers'
compensetion laws of Califomia, and agree ihet N I 6 e sublec� lo Ihe workers' compensation provisions of Section 3700 of the Lebor Code, I shall fonhwlth
comply with �hese provi 1ons. `l
Applicent Signature: - Dete: �— 1 1—�
WARNINO: FFILURE TO SE WOHKERS' PENSATIIXJ COVERAGE IS UNLAWFUL AND SHALL SU6IEGT AN EMPLOYEP TO CRIMINAL PENAlTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($1 . ), IN AOD TO THE WST OF fAMPENSATION, DAMAGES AS PROVIOED FOR W SECfION 3]Ofi OF THE LABOR CODE, IMEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby attirm thet I am
torce entl etted. Lic. p_
Contrectors Signature:�
CONSTRU�
under
AGENCV:
of Chaptar 9(commencing with Sedion 7000) at Divisian 3 oi the f
Class M
Date: _
Code, antl my Ilcense is in full
❑ I hereby attirtn Ihat there is a conswclion lending egency for the perfortnance ot t�e work for which this permit Is issued. (Sec. 3097, Civil Code).
LenOels Name: Lentlers Atldress:
Signature:
Date:
OWNER-BUILDER DECLARATIONS:
I hereby ettirm t�at under penalry of perjury that I am E%EMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sac. 7031.5, Business and Professions
Code: Any ciry or wunty which requires a permit to wnstruct, alter, improve, demolish, or repair any structure, prior to its issuflnce, also requires lhe epplicent for such permit
to flle e signed statement that he or she Is Ilcensetl pursuant to the proNsions of the Contwctors License Lew (Chepter 9(commencing with Section 7000) of Divislon 3 oi Ihe
Business and Protessions Code) or that he or s�e is exempt Iherefrom and Ihe basis for the allegetl esemption. Any violation o1 Sedion 7031.5 by eny epplicant for e permit
suD�ects the applicant to a civll penelry of not more then five hundretl tlollars ($500)J:
❑ I, es owner oi the proparty, or my employees with weges as their sole compensation, WILL DO THE WORK, end the structure Is not intended or oHeretl tor 5ale (Sec.
7044, Busineu end Professions Cotle: The Contrectors License Law does not apply to en owner of property wha builtls or improves ihereon, antl who tloes such work
himsett or herseN or through his or her own employees, provided that such impravements ere not Intended or ottered for sale. If, however, the building or improvement is
sold within one year oi completion, the owner-builder will have the burtlen of proving that he or she dld not builtl or Improve for purpose ot sale.).
❑ I, as owner oi the property, am EXCLUSIVELY CONTRACTNG WITH LICENSED CONTRACTORS to construct the proJect (Sec. 7044, Business antl Professions
Code: Tha contrectors License Lew does not apply ta en owner of Oroperty who huilds or improves ihereon, and who contracts for such project with a contrector(s)
licensa pursuant ro tha Contredore License LewsJ.
❑ lam exemptundersec.
Signature:
Ownar ID venfied by dnver's license. ❑ Yes ❑ No
Business and Professions Code for this reason:
Veritiwtion oi Ownership by (rype of Oaument, i.e. - properry tax blll or deetl):
DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIPICA710N:
Driver's License No.
Date:
Expires:
❑ I hereby certity that no excavation tive (5) or more teet in depth into which a person is requiretl to tlescen4 wlll be made in connection wiih work eufhorizetl by this
permit, entl that no builtling structure, scaflolding, falsework, or tlemolition or dismantling thereot, will be more then Ihirly-six (36) feet hiqh. (Chep. 32, Grp 2, Art 2, Sac.
341, Ttle 8, Celifomia Adminisiretive Code).
❑ As owner-builder, I will not employ enyone to tlo work which would require a permit trom ihe Divislon ot Industrial Setery, as noted flbove, unleu such person has a
permit to tlo such work from the divisian.
Signeture: Date:
Dlvision of Indusinal Sefery Permit Number:
CERTIFlCA7E OF COMPLIANCE AND AUTHORIZATION OF ENTRV: I certify under penalry of perjury that I hava reed this aOPlication and state that the informetion given is
conect. I agree to comply with all state laws entl city ordinances relating to builtling construction, antl authorize representatives of the Ciry of Casta Mese to enter upon Ihe
ebove-describeA property for inspection purposes. I agree not to occupy or allow occupancy oi eny building euthorizetl by Ihis pertnit until tinal inspection.
COUE t. INSPELTIONTYPE
1616 Fi:ed System Final Fire Prevention
1266
200
201
202
203
Pool Spa Finel
Final Re-Roof
Final Block/Retaining Wall
Final Fectory Fire Place
Final Sign
204 Final Demolition
2M8 a6
pdg irmru�
� �
�
v_ �Y- °�q .,
Date
COUEt INSPECTIONTYPE
206 Final Mechenical
20B Finel Plum6ing
210 Finel Electrical
212 Final Fire Prevention
220 Final Planning Aoproval
222 Finel Site
250 Final Building/Occupancy
PAIE IlffIDeLS
�p�ss�a���a�: 3484 SAN RAFI�EL CI ur.,:
am4rcsr,wE�F�vr+: KAUFMAN, JACQUELYN
�oo�ss:TRUST IN C/O
KATHEEN HOSSLER
3484 SAN RAFAEL
APPL. MNIlNO AOOHE53:
ARCNRECT ORENCdlEEP: UC.Iq.:
ARCX.OX F1M.'S �OORE55: UNT:
CqiiRACTOF'SNAME: SERVICE ROOFING ( 714 ) 525-4232
CWIfl�CTOASYAlI1N0 440 E WALNUT ST '
,�p� FULLERTON CA ��.�.: 131545
42632 uNT:
IJ EU COHfRCCTOHS OECLAflATION: I MreEy ellnn �Mm penely d perjury Mel I em licerae� uMx povieions ol Chepx B
( mm ep wil Seclion ]000) o/ Divivon � W Iha Buaineu end Pmfeaeione Cada. eM mY �nae o in lull brce eM eHetl.
mupr+o. 26080 uacuss:C-39 uc.No.: 3159 E, XP; 00/00
Dete: I f C ��„�,o,: �'v--
0 ER BUIIDEN OEClAX4TI0N: I hereby affi'm unJer parety d parlNrV �� � em e�emq f tM Con�redon Licenee law for Ne
wip iaeaon (�ion )W 1.5 Bus'rroas eM Pmfmabne Code: Arry cry a oounry whid� reQuine e permit to omtWct. alter. impan.
�mWeh, w myei eny s�mcluro, pnor lo ns ieauenoe, elso requiree the epplirsnt In euch paimil b fila a eiprieE etelemenl thm he a ehe
IicenaeC W��� lo iM provieiona d ihe Contraqan License lew �CMpter 9(commmciq wi�h Sed'on n1W) d Diveion 3 of �he
dumnma eM Prdeaaiona Code� a ihet he a she b exemq thael�wn eM �M bavis lor ihe elbped examqion. My voblion al5ed'an
)03t.5 by eny eppliuni lor e parmn euEpae tM applcem �o e civil penelry M na mas IhenlNe huMretl Edlen �5500�). .
�� 1, m ownm d the prapany n my smpbyeee wlh wapee u ihe'v wle mmpe�uetian, will do iM woM, vM �ha Nruclure b nM inteikeC
or MmeE br aela (Seclbn l0ad. BmreveM PMaseionaGode: The Contraqws Lioenae Lew Eon'rol apptyloen oxner d prope'ry
wM budde « inpwea iMreon, eM who Ewe euM work h'uneeM a heneR ar thrap� h6 a her own employw, pwNsd Ihet euch
imD�manu ara mi imeMed a dlereE lor aele. N, howeveq the buiNinp a imqovement ie eok wiihin ona yw d mmpletion, ihe
ownu-buiqar will heve IM buNan ol povirp M or eha did (wl Wiltl a improve lor �M puryoee d eele).
❑ I. ea ohner d �M propeM. � exch�siwty conlredip xilh licaneed convaclore b mnsVutl iM prqea (Setlion )014. Bueirefe aM
Proleeeiona COEe: The Coniredon Lranee Lew Coee rwt epply to en owner d p'apMy who EuikM w impovse tMeson arM who
convene M wch prqeee ci�h e comreUor(e) I'renaed pureuent to iha Conveawe Licenas lew).
❑ I em uemq uMer Seclian: 8. b P.C.. In Nn �eeaon:
o�e: ow�a,:
I do hereby conily ihel I em ewere d eM uMenwM ihe �epuiiemenh d Cellomu Heellh eM Sefery CoEe Sadiam a55o5, 25533, ud
255J4, enC Ilat I or eny iWuro buildinp aaupenl will / will na (crcb ma) neeE to mmply w!h eeid etma cadee vM IM mquiremenb lor
e permn la mnavuctpn or modifiWionlrom iMAr�u Gtyl.%nepemeM Disina. Ravdemiel miMrud'on apptiulionsen exemp fmm Ilius
pION9q119.
Dele: AOPlcam:
WONKEP'S COYFEN3ITON DECLARATION: I hereby elfi�m uMx penetty M parjury pp d Iha idbwiiq Eetiveliom:
❑ I heve anE will meiMein e cenHctle d mneem ta veH�ineuro br wakais' companeelion, m 0��� �or by Seaim 3)OU d tM laEor
cads.la iM pMormenu d Ns xak lor wNch ihi� permu i. IwueE.
-n I hm eM Mil meimen wakart wnpxuetion im�re�, u rpui�ed by Seeion ])00 d tlro lebar Cotle. br iM pe�armeMs d �M
X' woM lor which ihle permN u ieaued. My w«Mn' mmpenaetion ineurence um r erM poliry num Wr ve:
c�.,: CALIF. COMP. EXPIRES
Pdiry Numbar: Q 1� 1 �� 9%
�m�e �„�„e�oraa�omnbradrmaw�aa�wo�.n��e�,dddi�lsrrolwro��
❑ Ay Net in Ihe pMwmence d IM work br xfioh thia paimn ie iwwd. I ahell M empby erry pemon in ury menmr eo m to
/ c me wbl� io tM workera' companemion lewa d Cdilamie. en prae thel d I eh III►►► Eeco P wbjep to iM xwbis'
o pey�ef n pruvi m W Seclion W00 0l Ihe Lebor COEe, I ehell lo xilh com0 �' h �� q�pmWa' ie.
9 �
_•) AVdcam:
Inp: Felluro b• uro woAx�'rompnuaVon eovxp� � unNwNl, entl alull �ub/�cf en s oyw ro etlMru/ pm�IHu m0
ll llrra �p ro on� ��ntlrM tMuund ao1Nr� (StOq000A In �tldltlon ro Ilr� cwt ol ro n, darrrpq �s provMstl br In
Sktlon 0106 0l fM L�DoiCotla, InHnst, entl �ttomsy9 /ws.
CONSTNUCTION LENDINO 1OENCY: I hemby eifirm undx penelry d par'ryry �het tharo ie e mnnrutlion IeMinp epency br the
peAOrmeMe d Ihe xoA for whl h th9 Vermi n uwed (5opion �9]. CN. Cl.
LENDER'S NAME: .
LENUEN'S AOUflE43:
I ceniy Ihm I heve eeaE Iho epplicaum uM mma thet the ebove iMametion ia cmM. I piee Io oompty wilh ell tlly xM muMy adirieriwe
end atme lews reWinO �o buildinp conmmdim eM hereby emhorae repreaentelivm d ihia dry io enter upon ihe ebv+e-men�oned piaperry
brinspedion purpoaey. '
ROBERT FUGADE
� P t Neme )
Dma: � /
!F sta� „a ,e�ea�,avi���vco ao .
Il/
(5i51�46.WP) While-Buikvpd ery:OrearFle:Cenery-Appirant:Fnk-Revenue:Goldenm�/aaewr
CITY OF COSTA MESA —.BUILDING PERMIT
'PERM NO: B 076783
PERMIT NO: B 076783 PLAN CAECK NO: N GOVT: N SUPP: N
CONSTRUCTION TYPE: ��—N PERMIT TYPE: STR PURPOSE; OTH
JOH DESCRIPTION : T/OFF ROCK ROOF 5 REROOF W/ROCK ROOF SQ FT: 2,1V0
CLAIM VALUE: 2,100.00 CALC—VALUE: 2,100.00 GROUP OCC: R-3 /
COMMENTS: X
*�****+�*****��*****x***�*�**�*****��t�c�*******+��t*�t���***+�x*x*�r*�t�**********�r****
Z O N I N G R E Q U I R E M E N T S
5 E T B A C K S
------------ MAIN HUILDING ---------- --------- ACCESSORY PUILDING ---------
FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
LEFT: FT IN RGHT: FT IN LEFT; FT IN RGHT; FT IN
PARRING REQ: PROV: PARCEL: 00091205 ZNE: REF NO:
PLANNING NOTES>
> 1� '
�ElE 1ElE if 3E if if !F if !E 1E 1E 1E iE iE 1E iE iF iE iE iE �IE �E iE IE �E iE iE 1F �f jElE iE 1f iE IE iE 1E iElE'IE iE iE 1E 1E if 1F 1E iE iElE 1E iE 1f iFlE iF if iE If iE 9ElE 9E fE 1E �E �EAE'lElE 1F jE iF *!E iE 1k
D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N�T.S
ZONING APPROVED BY DATE:
BUILDING APPROVED BY : DATE:. �
APPLICATION ISSUED BY: DATE: Jj V
iE9E9('1E'1E�IEiEjEaEiEiEiE')EiEiE'�E1f�ElE1flfik 3EiE1E3ElEiE3Eik1FiF iE1E
LEGALIZATION:N F E E S M A R Y STRUCTURAI;,SEGMENT:Y
;i r• . « .
� m i,
HLDG PMT PLUMBING ELECTRI�C s-MECHANIC FIRE SMIP/RES GRADING
PERMIT 54,00 " � ,- .50
(.: • ' ' � ,' / SMIP/NON—RES
PLAN .. � '
ISSUE FEE �� A, " i
HUILDING—DIV—> PERMIT ISSUE PLAN-CHECK, = TOTAL PAID DUE
TOTALS----> 54.50 0.00 'r%; 0:00�� 54,50 54.50 .00
REVENUE DIVISION TOTALS--> COLLECTED',: � 54.50 OVER/SHORT: .00
BLDG PMT PLUMBING ELECTRIC MECHANIC;' FIRE SMIP/TOT GRADING PLAN—CHECK
54.00 '- - .50
ii �
!f 1E iE iE 1E iE fE iE iE ff !E fE 1E 1E �E iE fE �E iE 3E fE iF 1E iElf fElf fE fE iE iE �)E 1f IE �f �E 1E IE ib if jk IElF 3f iE iflE 1f iF 1E i(� ik if iE 1f if !E 1E if 1f iE 1E 1E iE iElF jE if !E iF 1f !E!f jE iE * 1f 1E dE
I N D I V I D U A L� 'FrE E,�(B R E A K D O W N
TYPE QTY D E S C R I P T I O`N � UNIT COST TOTAL COST
i`
SFR 2100 REROOF BY VALUE RESIDENTIAL �NOZONE 1.00 2,100.00
END OF. FEES ^
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��� CONSTRUCTION AND PLANNING �
APPROVALS Permit #�
1. Temporary Electrical Serviceor.Pole
2. Soil Pipe-Undrgrnd. ' •
, 3: Electrical Conduit Utility-Undrgrnd.
4. Electrica� Conduit-Undrgrnd. �
5. Steel fte�nforcement� �
6. Electric3l UFER Grnd.
7.. FootingS
8. Foundation -' '
, �9. Water PiPe-Undrgrnd. . '
70. Structuraf Floor System - .
11. Property Sewer Line & House Connection
12. Sewer Cap " •
13. Roof Drains `
14. Rough Plumbing ` -
15. Rough Electricai-Conduit „
76. RoughElectricWiring =
�
17. Rough Wiring Sign �
18.. Rou9h Elecirical-T Bar Ceilinq
19. Rough Heating & Air Cond�tioni�g
20. Rough Factory Fireplace
27. Ducts, in Structure �
22. Ducts, Ventilati�g
23. Gas Pipe•Rough & Test , �
24. Roof Framing �
25. Roof�Sheathing '
26. T�Bar Ce�ling �Structuraq & Monocoat
27. Frame and Flashing - .
28. Lathing & Siding - " . '- -
29. Insulation
30. Drywall Nailing
31. Plaster 6row� Coat �
32. Electricyl Power Meter-Final
33. Final Electnc � � ,
� 34. Finaf Heating& Air Conditioning
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 pomestic-Final �
42. Backf�ow Preventer
43. Backflow Irrigacion
44. LandscaPe IrriOation'System � . �
45. Sound Attenuation
46. Handicap Regulations
47. FINAL 57RUCTURE & BUILDING •
48. FINALPLANNING "
49. Electric Release to Edison
50. Gas Release to Southern California Gas Q
51. CERTIFICATE OF OCCUPANCY
Date
POG SPA' � � I �=
Date Inspector AppROVALS Per 't# 1 Oate Inspector
u
mt
_�
52. Pool & Equipment Location.f-
53. Steel Reinforcement ' -
54. Forms ' ` �
55. Electrical Bonding
56. Rough Plumbing & Pressure Tesc
57. APPROVALTOCOVER-GUNtTE
58.� Electrical Conduit-Undrgrnd.
. 59. Gas Pipe, O Undrgrnd., Test
60. Backwash Lines, P-Trap, �7 Undrgrnd.
61. APPROVALTObECK �
62. Backwash & Receptor-Final -
63. Heater & Vent-Final � , -
64. Piumbin9 SYstem - Finai-' ' ,�•
65. Electrica6Fina1 � �
66. Soiar Svstem�Final , .
67. Fencin� & Access Approval �
68. APPROVED FOR�PLASTERING
69. POOL/SPASYST�EM1ASFINAL
, FIRE�DEPT. REQUIREMEN7 ..�
: x : APPROVACS �-� Permit # '-
� �
, _ 70..Underground Hydro
�-- 77. Product Piping O Gas G�' Oil
72. Underground F�lush "
- 73. Under9rnd. Starage Tank � Gas ❑ Oil
� 74. Overhead HYdro '
- 75. Dry Chemical - -
` 76. Ory StandpiPe , ,:
..e:
r 77. FIXED SYSTEM FINAL .
�' 7$. FIRE PREV. FINAL � - '
HEAITH DEPT. REQUIREMENT
` � 79. FINAL INSPECTION
. ' 80.: FOOD CERTIF�ICATE ISSUED �
[ � rvotes3 /.r 9� ' �/a �Qa �.R�a�• •
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ADo���ant to fill in all spaces except those witnin heavr Oo[tler lines antl sign all apvropriate tleclarations.
' CITY OF,COSTA MESA .CONSTRU TI, N P RMIT . PER NO. " TRACT NO. , ' LO�I NO. UNIT N6. � ' ' , ' , , � , � � � � �
ProjectAddress .� G�' S7S � � ' . ��5153 I:�/1:4/B6 �� • .5�00 '�TL
TVPE OFCONSTRUCTION � NEW �AD� ALTERATION REPAIR � � , F
Applicant's Mailing Address ��-� ' � . . .
0 ^^ /� ❑ CONVERSION ❑ DEMOLISH ❑ OTHER q p # � � � Zone •
Owner'sName _�y:'�'�1�.�1� Phoneg s � ' - '1' ' •- -" " - -� - � �
�7 DESCRIPTION OF WOFiK/USE OF BLDG.
Address N J ' � S Main Building: • • Accessory Building: �
Arch/Eng. � License No. � TYPE OF PERMIT GRADwG ..❑�OUNDATION Q STRUCTURAL � T Fronq � ; � I � � - � ' � p
Address ❑ TENANT ❑ ELECTRIGAL LWPLUINBING ❑ MECHANICAL B qear . � � � � N
�C ❑ OTHER . . � � A �
Contractor's Name hone � Right -"� ' � ' � -'� � - ' "-' " ` ' ' � G
/� PROJECT DESCRIPTION 5[3. �FT. OCCUPANCV
Address(ma'1"na1 � �r C� � `CONSTRUCTION'TVPE � VALUATION$ � g Lek � ' � �� ' R
City License No. _' e'g��'� � ' ZONE GRADING CU.vDS. � /iCRES Ping. Ref. # • � �� � Parking Req./Provided E
LICENSED CONTRqCTOR DECLARATION � .
Q
I he�eby iffirm that I am licensetl untler provisions of Cha�te� 9(commencing Remarks� - PldnOing NO[¢5: � ' ' M
with section ]000) oi Oivision 3 of the Business antl Professlons Cotle, antl .r
my license is in full ntl effect. . ' //� . ' ' . ' '
License C 5 � - L� C SC O � I � S
� Date " signature � : ' ' PLUMBING FEES' ` ' • ' ' � -'
�: WORKERS' COMPENSATION DECLARATION � , B3� Sink � ShOw¢�5 . 1 ' ELECTRICAL . FEES ��
� �ereby affi�m�that I M1ave a certificate o( con5ent to zelf-insu�e or a certificate . � �� , � � „ r .
`, Workers' Compensation Insurance, or a certitietl cooY,thereof (Section gackflow Preventer� • ' Service Sink ' - � ' ' • -
\�800, Lab.-C 1 n �q �� �% _ Automatic Washer . Transformer ❑ 15-50 KW
Policy No. �N��'�/..(� Company�`..�� Backflowlrrigation � . 'SewerCa . - ❑ 50+KW ,
�iC¢rtifietl copy is hereby fumishetl. � - P - COniL�UCtiOn.POlESub. �, , , ^
� Cer " i opW is� tiled with�the city��.���yyy��}�tl���' isioJ'111 / Bathtubs �^ $ewer Connection � Cooking Unit. � , _ Meter �up to 100 amps .
Date� �� `n� Applicant�� I��A �-�I.i% fI . . .
EXEMPTION FROM WORKERS' CO PENSATION DECLARATION Clarifiers � , i, . • Solar Collecmrs - Dishwasher �. . Meter ❑Ov¢� 100 amp5
(This section neetl not be cOmpletetl if the pe�mit I5 for one huntlretl ($300) o� � , . - - _
iess). � , � ' Dishwasher- � ^ _ _ , Solar Piping . - Dryers ❑Gas ❑Eleccric Sub Panel - ,
I certify that in the performance of the wo�k fo� which.this perm�t is issuetl, I - . . - , - ' '
snall not employ any person in any manner so as to become subject to the Drinking Fountains � Solar Tank "�. Fan Mamrs �0-1 HP �1 %;6
Workers' Compensation Laws o! California. ' � ' . _ � , . _ '
, �ate, ' Si9nature Floor Drains ' �• i Swimming Pool w/Spa F.A,U. '' i� Inc.Solai �9-15 HP 016-15+
. . NOTICE:If,after makinq this tleclaration, you shoultl become subject to Ihe.._ - -
Worker5' Compensation provisions Of the Labo� Cotle, you mu5t forthwith FIOo� SinkS . � - U/indl � ' �
compty with Such provisions oY this permit Shall be tleemetl �evoketl. � Fixtures � Microwave •
CONSTRUCTION LENDING� AGENCV G05 SBrviC2 ' � Ouil¢t5 • '� WdtE� ClOset � D¢vIC¢ BOxES �
I hereby affirm that there is a consVuction lentling agency for the pertormance ' ' Pole Light' ' �
of tne work for which this pe�mit is issuetl (SectiOn 309]� �Civ. C.) . . � ' . , - - � ,
Lentler�s Name � � Inierceptors ater Heate . Outlets Range � -
Lentler;s.Atltlress_ � � _i Kiichen.Sink . . _ WateuService -- -_ - -Switches- � � � � � - Si9n : ' � - " -
OWNER BUILDER.OECLARATION ' . ' •
I hereby aftirm that I am exempt from the ConVactor•s License� Law�Por the ' Lavatories � ' Auto-Waih � Garbage Disposal � Standing Sections �
following'reasdn (Section ]031.5 Business antl Professional Cotle:�9ny city,or
county which requires a permit to construct, alter, improve,'demolish or repair � p_7�yp . � Laundry Trays Generamr �0.5 KW 05-15 KW , Trash Com actor ' �
any st�ucture, p�ior,to its issuance; also �equireSlhe applicant tor SUGh permit P '�
[o fiie a signetl slatement that he/she ii licensetl pursuant to the pinvisionsof Roof Drains � ' •
1he Contractor's License Law (Chapter 9(commencin9 with Sectio r7000) ot ' ' ' ' � � �
� '�,,;yision-3 of the Business�antl-Pvofe55ions Gotle) or-that he/She is exempb-- -- - - - - , --� � • - - , � -- � � - _ - - -'
�wrefrom-antl�the ba5i5�for the allegedexemption. Any violation ot Section � � � � � , I , � � � .
:,,531'.5'by any applicant tor a permit subjects the applicant to�a civil � � ' 1 " ' '
' ���naltyrof not more than�five huntlretl tlollars (5500). - � � � , . , ; � ; i . ; . ;
LJ I, as� owner of the' property or my employ¢¢5 with wages as their sole RelnSpectlOn Fee $15 ' Issue F¢¢ ' $ 3
. � tompensation, will tlo �the wo�k, antl ihe structu�e is not Intentletl or offered - ReinSpection F¢e � $15 • luue Fee '= $ 3
for sale (5ection 7,044,'Business'antl Professional Cotle: The Contracmr's � � . ' MECHANICAL� �FEES �
t License lAw tloes not apply to an owner of a property who builtls or impvoves
�� thereon', antl who tloes such work himself/herself or through his or her own - , i � - _ - DEVELOPMENT SERVICES REQUIREMENTS: . '; � ,
i employees, providetl that such improvements are not intenUetl or offeretl for � Boiler _ � HoOd o� � Type I ❑ . . ' ' .
, sale: It,�however,'ihe builtling or improvement is soltl within one year of mm- ". ' -- Canopy Type I I ❑ � Zoning Approved By - Date
-�pletion,�the owner wilPhave the bu�tlenp( proving he/she ditl not builtl or im- . Duct- Under Ground - I . ,guitding Approved By ' Date � �
. prove for the'purpo5e af Sal¢) � � , ; � • � - _ ��rt/
�� 0'I; as owneraf the,prOperty, am exclusively contracting wlth licensetl con- Duct - St�uCtu�31 , REfiig¢�dtiOn SyStCm AppliWtion ISSp9d By � D3te LCJ /YRl�i
�: tra[tOrs to construct the project (Section ]044, Business antl'Professions Cotle: ' ' �- _
� The Contractor's License Law tloes�not aOP�Y��O,an owner of property who Duct - Ventilating , � � ' �0-100,000 BTU ❑100,000 BTU � • ' � , ' �. SUMMARV OF.FEES .' � � .- � �
builtls or improves'tM1e�eon,-antl who mntracts for duch projects with a�con- � ' '; � ,_ . �' .
traclor(s) iicense pursd5nt co tne Cantractor's License Law). I am aware ehat ' ' � - BUICDING PERMIT $r ' SMIP .$� '. � -
. Exhaust System�❑ Multiple ❑ ' System Repair/Alteration - i . � � ' ' �
proof ot thev-Worker's CompensaHon insurance shoultl-be piovitletl to me. . � � P�qN�CHECK �- $ PERMIT,�
' � L7 �I am'exempt untler Sectlon ' ' •B.�& P.�C.`for this'reason � � � Firepl/FacC BIt.JCBO# ' ' � ,Fire Dampers _ j _ ` � J ' BLUMBING � ;� '. � $ � - ISSUANCE $C�
�. I :
Date� � ' pwner " � Heating System & Ducting� � _ Registeis � • � - ' " p�,qN�CHECK 25%� $- ^ ENERGV�P.C. $ �
� i I hereby certify�that ,I nave �read �miz application antl state that the above_. ❑0;700,000 BTU O100,000BT - -,. - - = ' - ' t ,GRADING $ - '
. information is correcL�l a9ree to comply with all city antl county ordinances � ' - ' ' ELECTRICAL � $. - .
' i ana state laws relating'.to builtlinq construction, and hereby authorize reore- _ . � _ _ � ' . � ' " , - ' pLAN;CHECK "�50% $ � � ' MICROFILM _. $ � � '-
' Sentatives bf ( is� <ity to';enter upon, the above-menbonetl' prope�ty to�-- � . � , � ' , _ i � . � , � � , : .
� insPection. p� �: � - � � �_.��_'C�' ' . . . . ` � . � �' ' � � � � . ' MECHANICAL� $ � �TOTALFEE $ ��J. -
� Signature / pate��Sl(! Yl e� . �y,' . � . . � �
-orivers' License or 55 � i -� ' - Reinspection�Fee $15 � Issua Fee . � � $ 3 ' PLAN CHECK - 25% $� � ' • �
' _ � .. _ � . _ . . � ' __ " ..... _'_ � : .__ . '. :�. .�_.. __ _ _'_'_ _ _' __ _ '
CN1F 0865-46, rev. 30/84 White - Builtling; Canary - Appliwnt; Pink - Accounting; Goltlenrotl - Assessor �
CONSTRUCTION AND PLANNING POOL & SPA. . _
APPROVALS Permit # Date Inspector AppROVALS Permit # Date Inspector
1,. Temporary ElectricBl Service or Pole 52. Pool & Equipment Location , '
2. Soil Pipe-Undrgrnd.' � 53. Steel Reinforcement �
3. Electrical Conduit Utility-Undr�rnd. 54. Forms c.:
4. Electrical Conduit-Uridrgmd. � ' 55. Electrical Bonding `'-"- .,
5. Steel �Reinforcement . 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. � , .57. APPROVAL TO COVER.G-UNITE � '
�. 7. Footings ,-� � 58. Electrical Conduit-Undrgriid. "
8. Foundation � � . ' �
59.-Gas Pipe, O Undrgrnd., �CsF
9. Water Pipe-Undrgrnd. � . � 60. Backwash Lines, P-Trap, �Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK :,
� r
11. Property Sewer Line & House Connection 62. Backwash & ReceptorFinai�
12. Sewer Cap � 63. Heater & Vent-Final ��� �
13. Roof Drains-. � � , � 64. Plumbing System - Final
14.' Rough Plum6ing , ' 65. Electrical-Final
15. Rough Electrical-Conduit � 66. Solar System-Final -
16. Rough Electric Wiring .- "'- " 67. Fencing & Access Approval '
17:'Rough Wiring Sign - � 68. APPROVED FOR PLASTERING
78. Rough Electrical-T Bar Ceilirig . 69. POOL/SPA SYSTEMS FINAL
19: Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace � APPROVALS Permit # '
21: DuCts, in Structure � 70. Underground Hydro �
, 22. Ducts, Ventilating . 71. Product Piping 0 Gas ❑ Oil , �
23. Gas Pipe-Rough & Test � � 72. Underground Flush � '
24: Roof Framing. � 73. Undergrnd. Storage Tank O Gas ❑ Oil
25. floof Sheathing : 74. Overhead Hydro - � .
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical ' .
27. Frame and Flishing � � 76. Dry Sfandpipe
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 MeterFinal ,. 80. FOOD CERTIFICATE ISSUED �
� 33. Final'Electric Notes: �
34. Final Heating & Air Conditioning � � ' � '
� 35. Final Gas Pipe-Test , �
36. Hood or Canopy , '
37. Final Factory Fireplace
38. Final Plumbing . � �7 �� . � .
39. Water Service-Final . �
40. Gas Service-Final . � - . • �
41. Solar pomesticFinal - � • �
42. Backflow Preventer � � ' ,
� 43. Backflow Irrigation � �
44. .Lantlscape Irrigation System �� � - �
• 45: Sound Attenuation� � �
46. Handicap Regulations - � � ' � '
47. FINALSTRUCTURE&BUILDING • .
48. Special Requirements Completed
, 49. Electric Release fo Edison - , �
50. Gas Release�to Southern California Gas Co � �. �
51. CERTIFICATE OF OCCUPANCY �
No. Date .
Applieant to fill in all :paees within heavy borEer lines ana.sign all appropriate declarattons
Ch Y OF.COSTA MESA PERM�T NO. TRACT NO. LOT NO., � B�DG. NO.
CONSTRUCTION PERMIT � —3
Project Address , 3ri a ae 1T. � TVPE OF CONS RUCTION �
Owner ackie 8,ll IR3T1 Phone - ❑ NEW •�D ❑ ALTERATION
AddreA� 3 San Ra£ael Cir. Costa Mesa, �i •'�REPAIR ❑CONVERSION ❑DEMOLISH
Arch7Eng. ' ' ' "' LiCense Nb. ❑ OTHER -
Address - - " ' --' ' � - �ESCRIPTION�OF WORK �NG�AL L
_ " lJiL-. i`.i c�T-r�r.e _
Address
5� 1T1C. Phone �'a'�
., os esa, a:
CONTRACTOR �ECLARATION
rm that I am�llcensetl�untler provi
h sectlon ]000) of. DlNslon 3
Coae, .�a2,�ny license is in
U Li<
Si9pature
OMPENSATION DECLARATIO
No._..,.__ .
�I hereby atfirm that I have a certitiwte ot consent to self-insure or a
�certificate�o( Workers' Compensatlon Insuranca; or a certifietl"copy
' ereof (Se�{�Q!��Q +}� b$� ). _
y No. ""� l'�"�i�"iCompany Uni�ard Ins.
ertHied COpy is h!r¢by turnlsh¢tl.
��'Certltletl copy is filetl with the dty Builtling DiJision.
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
,(This sectlon neetl'• not be� completetl it the permit is for one huntlretl
(E300� or less). --
I cert fy Ihat in the performance o( Ihe work (or whlch this permlt is
i55uetl, I shall not emPloy any person In any manner so as to beGOme �
subject to the Workers ComOensation-Laws of�California. -- -
Date Si9nature
NOTICE: If atter making this tleclaration, you should become�sub�ect
to Me Workers' Compensation provlsions of the Labor Cotle, you must
Tor[hwith compty with such'�provisions or thls permit shall be tleemetl
revoke0. ' ' - • - - - - • � � �
�CONSTRUCTION LENDING AGENCV
I he�eby dffirm that [h¢r¢ i5 a mnstruction Ientling aq¢nty for [h¢ per-
tormance_of, the.work for which,tbls permit is i5suetl.(Section 309]
Civ. C,). `. � -
Lentler:s+Name. � ��-- � }� � �� `��
Lentler'S Atltlress �- � -'�
OWNER BUILDER DECLARATION � "'
I hereby d/firm that 1 am exempt from.the Contracror's License l.aw for
the followino reason f5ec[ion ]031.5 Business antl Profeszions Cotle:
�ness antl �Profe55ion5 Cotle) o� that he is exempt thet¢(rom entl Ih¢
Por the allegetl, ezemption. Any violation of Section 7031.5 Cy
appli�nt to� a pe�mit subjects Ih¢ applit'ant to a civil penalty
0 ot more than tive huntlred tlollars ($500).
❑ I, a5 owner ot lhe property, or my employees with waqes as their
Sol¢ COmpenSation, will tlo the work, antl the Structu�e is not intentletl
or oiteretl for sale. (Section 7044, Business antl Professions Cotle: The
Contractor's License Law tloes not apply to an owner�of�a property
who bWItlS or improve5 thereon, antl who tloes such work himsel! or
throu9h� his�Own employe¢5, provitletl tha[ Suth improvements are not
Intentl¢tl or of(eretl for sale. 1f, however, the builtling o� Improvement
is sold wilhln one year ot completion, the owne� will have Ihe burtlen
o( prOving h¢ tlitl not builtl or improve for the pu�pose of sale).
❑ 1, as owner bf the property, am exclusively-cont�atting with'
licensetl contractors to construct the project (Section 7044, Business
antl Pro(essions Cotle: The Contractor's License Law does noEappry [o
an owner Of property who builtls or improves ther¢on, antl who com
tracts from such projects with a Contractor(s) Iicesnetl� pur5uant to
the Contracto�'s License Ldw).
❑ 1 am exempt untler Section B. & P. C. for this
reason � ' - " - "
Ozte ' Owner- ' ' - -
I hereby certify that I have�reatl thls applicdtion antl state that [he above
informatlon is mrreCL I agree to mmply with all ciry antl county
ortlinances antl state laws relating to construction, antl hereby authorize
aob #77z9 � j e�
,.
. _, . � � .
i►. . . .. r.. . .
�TVPE OF PERM17
❑ GRADING,,_, /❑ FOUNDATION ❑ STRU,.C.,T�URAL
-O TENANT IKELECTRICAL ❑PLUMBING LMNECHAI
❑ OTHER
•PROJECT DESCRIPTION� �
SQ. FT. ' - ' - . .
OCCUPANCV_CONSTRUCTION TVPE
VALUATION ' ZONE
'GRADING CV. VDS. ACRES
PCUMBING '+ _-PLANCHECK
BATHTUBS SHOWERS
TOILETS �' �� . . .� VRINALS
LAVATORIES DOUBI.ELAVS
KIT. SINKS DISHWASHERS
SERVICESINKS ' ��SUMPS
FLOOR'SINKS. C' � � F1.00R DRAINS
DRINKING EOUNTAINS
INTERCEPTORS CLARIFIERS
SWIMMINGPOOL PTRAP
WATERSERVICE ALTERATION
GASSERVICE OUTLETS..,.*,_n
WATER HEATERS BTU OUTPUT.�,_
SEWER CONNECTIONS .
SOLAR TANK COLLECTORS
SOLAR PIPING SVS.
ISSUE FEE
MECHANICAL GLAN CHECK
NEATING SVSTEM 0-300,000 BTU�
AND DUCTING 300,000 �+ BTU _
REFRIGERATION 0-100,000 BTU�
SVSTEM q L' /� 100,000 + BTU _
��i r
SVSTEM.REPAIR,ALTERATION,
EXHAUSTSVSTEM MULTIPLE
repr¢sentatives of thi5 city to ¢nler upon the aDove mentionetl
property for,iqnspectlorJ, purposes. .
Si9nature �ye •--'�� �^ �-^"�-
CMF 0865-46 White-Builtling; �anary-Appliwnt; Pink-Ac<ounting; Goltlenrotl-Assessor
A.P. �
ZONE
REAR YARD (TO P/L)
PKG. SPACE REQ.
STREET WIDTH
SPECIAL CONDITIONS:
�`oZl ./C'lY } I 6.50 , TL'�
_ATIONS�
REF. � �
)PE�RTVNLINE �
- . y
'PROVIDED '
PARK FEE S '
ELECTRICAL PLAN CHECK
�GENERATOR p-1 KW_1-30 KW _
�TRANSFORMER . . .
. APPLIANCE 10-50 KW_50 + KW _
MOTORS 0-1 HP_1-10 HP�,
�(INC.SOLAR) ` 30-50 HP_SO+HP _
iFIXTURES OUTLETS SWITCHES
GAS TUBE SIGNS .
� POLE LIGHTS
� PANELS MAIN
.i. ;. � SERVICE
.r• p
ISSUE FEE
ACPLICATION APPROVED
' SUB
AMP .' � . .
L7
� _ SUMMARV OF PEES � � '
`'. BUILDING , _
7 _ �, PERMIT $ '$MIP $
PLAN GHECK $ - PERMIT
' -� ISSUANCE $ '
H, OO �PLUMBING $ � �
. GRADING d
PLAN CHEGK $ '
ELECTRICAL $ ^OO . $
' PLAN CHECK $ ' MICROFlLM $
MECHANICAL $�. ' TOTALFEE$
PLAN CHECK� $ ' ' �-E55 AD- _ �
VAN/JCE PC $
` _ �llo� F� i D E� 1
N • �o S i�o,2T,96 F
' `°` CONSTRUCTION AND PL'ANNING POOL & SPA . , ' ~
APPROVALS Permit# ��-�3y � Date Inspector pppROVALS . Permit# ' � � Date Inspector�
1. Temporary Electrical Service or Pole _ 43. Pool & Equipment Location �
2. Soil ipe-Undrgrn ' 44. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrn . 45. Forms �
4. Electrical Conduit-Undrgrn , 46. Electrical Bonding '
. tee ein orce - 47, Rough Plumbin & Pressure Test
6. Electrical UFER Gin 48: APPROVALTO COVER-GUNITE
7. Footings � �' 4g. Electrical Conduit-Undr rn � '�
8: Foundation � . ' � 50. Gas Pipe, ❑ Undr �rn, Test � � � � � � -
9. Water Pipe-Undrgm 51. � Backwash Lines P-Tra ❑ Undr rn' '
10. Structural Floor SYstem 52. APPROVAL TO DECK �'
11. Property�Sewer Line & House Connection 53. Backwash & Rece tor-Final �� � �
12. Street Sewer Connection n. ' 54. �Heater & VenbFinal � ' '
13. Rough Plumbing � . -� -
14. Rough Electric-Cohduit _:56. .Electrical-Final_. � � •
15. Rough�Electric-Wiring - • 57. SolarSystem-Final � � � �
16. Rough Heating & Air Conditioning � encing & Access,Approval �. - ,�
17. Ducts, in Structure �� ' APPROVED FOR PLASTERING � � �'�
� 18. Ducts, Ventilating •� . .. ` . . � . ' . „ ~ .. . 1 ..
19. GasPipe-Rough&Test 60. POOL/SPA�SYSTEMSFINAL „ � . � � � ���
20. Roof Framing � •
.. � . • . •�� . � '. .. , ,� .y' .. -
, .21. Roof Sheathin � • , , .
22. Frameand Flashin -• - ' •NOTES: �. , ' �• � • � � '
' 23. Insulation - � �- • ' � � - Z �
24. Lathing & Siding � � - ; '
25. Drywall Nailing • ' � • - . - • ' ^ ' '
26. Plaster Brown Coat ' � � � � � � ' - '
� 27. Electrical Power MeterFinal ' ' � � - � � � ' ' " ' "
28. . Final, Electric �- ' • ' � - � � " �
29. F,inab Heating & Air Conditioning � ' - � ' ' • � �� �. � �� �
. 30. Final Gas Pipe-Test � ' � � � ' '" " ' �
31. Final Plumbing � � � � " � � � �
32. Water Service-Final �� • • ' � � • �
'•'33. Gas Service-Final � • ' � � � � �
34. ' Solar pomesticFinal . ' � -' � - ' '
' 35. Landsca e S rinklin S stem � � � � � ' ' '
; 36. Sound Attenuation � - ' �
37. Handicap Regulations - ' � � �- � � � � '
38. FINAL STRUCTURE & BUILDING � �� � � � � ' � " � '
39. Special Requirements Completed � � - ' ' ' - '
- 40. Electric Release to Edison � " � '" - �' � - �
41. Gas Release to Southem California Gas Co. �-• - -� � � � �
42. CERTIFICATEOFOCCUPANCY •
-- No ,'Date -
� ,
•; ; _ . �� ' __ � : . . . - .
��OWNER SCP�U
� JOB ADDRESS
� GENERAL COt�
�p AP No412-05
INSPECTIONS
SOIL
GAS
WATER
ROIIGH PLUMBING
PROP. SWR. LINE
SPRINNLING SYST
MISCELLANEOUS
ROUGH HEATING 0
TEMPORARV SER�
UNOERGROUND �
ROUGH WIRING
FLOOR SYSTEM
BON� BEAM �
SHEATHING
FRAME ANO FL�
LATHING — IN
PLASTER, BRON
STRUCTl1RAl, F
HEATING,VENT
HOUSE CON.
L\
POWER
REFRIG. AN� A.C.. FINAL
DATE 10-25-7k
wao. vw�.rtir � �viv v� nvnn �+��
TRACT FIRE ZONE VALUE
Si nature Date TVPE V]�j GROUF
� �" 3�129
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For App/icant to Fill in Completely
BUILDING � , � �., _. ,., _ _ ' .
P��:� :t�:t:t
r,ci zi ���;;;.00 a7s:> 6Z.12
APPLICATION FOR BUILDING PERMIT
E DATE RECEIVED DATE ISSUI
/�
OWNER �I . K�t J M.c�.�J A.P. NO. L�Ci� � � " c
MA14 BUILDING
Z AODRESS Sq^ �" ADDRESS .
W W TEL. TRACT r/ �j OT BLOCM
a U CITV C�� t0. /�ti rs NO. c/ �6 (.
zZ
Q CpN$TRUCiION W ADD
a m LENDER x X
J � BRANCH
J N OWNER
m� ADDRESS L E
J m ARCHITECT '" TEL S � $ L
a OR ENGINEER N .
V � FIRE �
W Q ADDPESS � ZONE TVP ROUP
aW
WZ CONYRACTOR f'��L� N—L ByPROVED , DATE ��S
J Q
m Z i
J� ADDPESS 4 � 03 L wJ U
W w � TEL. Z� NO.OF/� VSE OF NEW S
Z� CIT V�(L A�u NO. y(- �(� � � P�� C.� BUILDING
w� STATE CITV VARDSAPPROVED VARDSAPPROVED
j O IIC. NO. �_( 'Z� ? g UC. NO. MAIN BUILOING ACCESSORV 9wLo1
SIZE NO.OF BLDGS. (FROM GL STREE-,
OF LPT NOW ON LOT � FflONT FT.
USE OF
EXI5T�NG BLDG. T
f' SIZE �F NO. OF
Z NEW LDG. ROOMS STORIES L.SIDE
U EMEPIOR WALL ROOF A
COVERING 'fJ C COVERING CRdS�Co� �Qoc�. REAR FT.
J USE OF BUILDING AND WORK TO BE PERFOFMED DISTANCE BET.
a � lP MAIN BLDGS.
a
Q VAR. 3W
O C.U.P.�'
y `A ]� � �2 �v�� APPROVED 1�
!//�
z
�
VI heraby acknowletlge thet I have reatl this application antl state
� that the above iniormation is correct antl aB�ee to comply with
� all laws regulatin8 buildin8 �onsttuction, and I shall not employ
F any parson in violation of the workmen's compansation lews ot
y the State of Celifornia. ��
zI herehVi certify that I am proparly licensetl as a contractor untler SR. FT.
the Stete of Calitornia Business antl Professions Code, Oivisicn 3, TH AMOUNT 51
Chaptor 9, and t�at such licanses a�e in full force antl etfect, or I TME PURPOSE OF
am exampt from the provisions of the State ot Californla Business VALUATION
and Professions Code, Division 3, Chapter 9.
SignatNre of r b I�C � e /'
Permlttee _ �� $ �OD
Authofized Agent
FT.
IAX �
O
R VALUATION IS FOR '
0 �+ PERMIT FEE ONLV: ¢
m
EE $ � �
_�K $ 20- 5Io E
2E $ If � u
* " 29544
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 7200 - COSTA MESA, CALIFORNIA 928R8
For Applicanf fo FIII In Complefely
TYPE OR PRINT
ooR�sa° 3484 San Rafael l�.t.tJ.
COSTA MESA, CALIFORNIA
� ARCHITECT
WI uas
ngeles 90036
Frank Gonzale
1336 E. Chapm
srr 19 ' � n�orrr
DESCRlPTION OF WORK
WALL
s
WOOd
FIRH
36-1104 z°Ne
0
0
le
.or iy
( HBREBY ACKNOWL6Oa6 THAT 1 XAV[ RBAD TNIB APPLICATION
AND BTAT6 TXAT TX6 ABOVB �f CORRBCT ANU AOR66 M COM•
PLY WITH ALL CITY ORDIfUXCi� AHD YTATi LAWY q[6YLJ1TIN0
BWLDINO CONBiRYCT10F1.
SIGNATVRB OP
PERMITTfi
AUTHORIZiD AG[ � ��
. ' JAN -7-69�-k��00 774x **� 1 U8.CL
ui _ �
APPLICATION FOR PERMR
BUILDIN(3
Fo� Offlm Ute Only
n[cc�rt No. P[P_M17 yo._
er
YARDB MPROVED
MAIN BUILDINO
VAR. A
�rxc wwo�ert axowi
■UNP088 OP 6BTA1
VALUATION
s ��j �j'/"�'y _
ZONING
u.a
ew�
fALL Bfi LEBS THAN
U.B.G.REQUIRHMENTI
YARDSAPPROVED
ACGEG80RY BUILDINO
DATH
18 ROR TH6
FHe ONLK £
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