HomeMy WebLinkAbout1095 SAN PABLO CIR - Building Permits CITY OF COSTA MESA
o1 —
BUILDING DGYISION
F I" � 1 DEVELOPMENT SE=RVICES DEPARTMENT PERMIT NUMBER
PERMIT
-"Moisine
1A06-01106
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.tilLDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 1095 SAN PABLO CI Status: ISSUED
Suite: Applied: 07/03/2006
Vicinity: ROOF Issued: 07/03/2006
Primary Occ: R-3 Dwellings/Cong Res<10 Type of Construction: V-N
Parcel Number: 41206110 Zoning: Si
Applicant: POWDERLY, PAUL
Address: 8111 COMMONWEALTH
Phone: 800-400-7692 ISSUED BY:
BUENA PARK,CA Zip: 90621
Owner: KELLER, THELMA VIRGINIA
Address TR
COSTA MESA,CA Phone:
1095 SAN PABLO CIR Zip: 92626-1614
Contractor: ROYAL ROOFING CO
Address: 8111 COMMONWEALTH -Phone: 800-400-7692
BUENA PARK,CA,
Zip: 90621 License: 678705
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: • License:
SCOPE OF PERMIT
TEAR OFF EXISTING ROOF. INSTALL 1/2"COX PLYWOOD,30#FELT,AND 30 YEAR COMPOSITION SHINGLES. 1,800 S.F.
FEE SUMMARY
Plan Check: $0.00 • - • Calc Valuation: $2,900.00
Permit: $83.25 Claim Valuation: $2,900.00
SMIP Res: $0.50
SMIP Corn: $0.00 -
Other: $0.00 .
Inspection: $0.00
Total: $83.75
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)754-6626
2446-46(sdmm)
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.)
.WFcdrtify th Y the pert nuance the wotfocwhich this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compens tion laws o alifomia,a agree the if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
Comply wit a rovisions. (� �2
Scant-Signature:, - (ADate:
..
�W�..�A��N��NGi.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE I LAND SHALL SUBJECT AN EMP OC YER TO CRIMI PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
T110USAND DOILARE(5100.000),IN ADDITION TO THE COST OF COMPENSATION.DAMAG AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRA TORS\DECLARATION:
I hereby affirm that I .m lice• • . ••: . •, -I;T�yf'FS-y er 9(commencing with Section 7000)of Division 3.of.the Busi s an ssions Code,and my license is in full
force,andeffect.Lica .aw01/ I' 10 - Class it
C "Can tactors Signature:- Ay� ' 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).
Lenders 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,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 Code for this reason:
Signature: Date:
Owner ID verified by drivers license. 0 Yes 0 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:
❑ 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? ❑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 Li a plication akermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 0 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 California Health and Safely Code Section 42303 been made? 0 Yes 0 No
_.._ ion officer).
8 (If yes",attach certificate of compliance from the appropriate air pollution control oce
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
correc .• :e 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
a•'ye-describe. •roperty f.- •.•.ction purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
S'naturrO1 egal Owner(s) V
•— ,da cnity prized Applicant—- ' to
CODE I )NSPECTIONTYPE 3 • ;AST URITIAL@ - CODE I INSPECTION TYPE PATE )SLS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final y � 208 Final Plumbing ' •
200 Final Re-Roof I zS rop 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
•
01I ' CITY OF COSTA MESA
4 Ste BUILDING DIVISION
F ,,' h DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
PE?MIT
001-00163
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 1095 SAN PABLO CI Status: ISSUED
Suite: Applied: 02/05/2001
Vicinity: Issued: 02/05/2001
Parcel Number 41206110 Zoning: R1 R1 •
Applicant: POWDERLY, PAUL ISSUED BY:
Address: U
Phone: 714-449-7750
Zip:
•
Owner: KELLER, RICHARD T TR '
Address . 1095 SAN PABLO CIR
Phone: $1. \St
(�
COSTA MESA,CA Zip: 92626
Contractor: ROYAL ROOFING CO. 9p, +
Address: 135 W. SANTA FE AVE.
Phone: (714)449-7750
FULLERTON, CA
Zip: I 92832 License: 678705
Arch : - Eng:
Address: Address: •
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT •
TEAR OFF EXISITNG HOT MOP ROOF. COVER WITH NEW HOT MOP ROOF. CLASS A. .
FEE SUMMARY
Plan Check: $0.00 _ Calc Valuation: $3,500:00
Permit: $97.25 Claim Valuation: $3,500.00
SMIP Res: , $0.50
SMIP Corn: ' $0.00 7
• Other: $0.00
Inspection: .$0.00 •. . ... .
i
Total: $97.75
•
/`
PLANNING &ZONING j
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
NOTES:
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 - - C1
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 worke '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.)
❑ I certify •. e•:-ormance o e rk for whi this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compen.ation laws of alifornia, nd a eel that if should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply -rhes= • .vipiqn +�
Applicant Slgneture: xY Date: `^S •' 0
WARNING:FAILURE TO SECURE WO S'COMPENSATION COVERAG WFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOA I ARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION,D GES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR 000E,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm th am i :- ed under prov' ions o Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force end effect.L: a Class#
Contractor's Sign. u :• �-��fl Date:
•�'" , 7
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 c.,
I hereby affirm that under penalty bf.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 requiresa 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.).
❑ 1,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 Code for this reason:
Signature: Date:
Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: •
O 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,Califomia Administrative Code).
O 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 Califomia 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 end 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 a plication akermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? f�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 California Health and Safety Code Section 42303 been made? 0 Yes ❑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 AUTHORIZATlON.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
ab• --•- ribed property for in urposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signa f Legal Ow T' Z O 0 Hate
A'd/Or Authorized Applicant Date
CODE I INSPECTION TYPE DATE' INTITIALS CODE Y INSPECTION TYPE DATE JNTRIALS
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
204 Final Demolition 250 Final Building/Occupancy
I
A00REZSOFSULOwO: 1095 SAN PABLO CI UHT: ...141 CITY OF COSTA MESA - BUILDING PERMIT
°acwsNNElPlaa`TI' KELLER RICHARD T TR FLOOD : AH-38 PERM NO: B 083449
ADDRESS: 10 SAN
yCSANFFAbbLLO CIR
A AESA,CA 92626 PERMIT NO; B 083449 PLAN CHECK NO; 02484-97 S GOVT; N SUPP: N
557-9887
• APPL.MAILING ADDRESS: CONSTRUCTION TYPE: PERMIT TYPE: STR PURPOSE: ADD
ARCNRECT OR ENGINEER: UC.NO.: JOB DESCRIPTION : 384SF SOLID ROOF PATIO COVER SQ FT: 384
wcx.OR ENG.'S ADDRESS: UMT: CLAIM VALUE: 5, 000 . 00 CALL-VALUE: 6 , 190 . 08 GROUP OCC: R-3 /
CONTRACTOIrSNMiEBLUE RIBBON BUILDERS INC ( 714 ) 581-3636
gONTRACTORg YYIRIO 1135 W. KATELLA AVENUE COMMENTS: SOLID PATIO COVER
ADDRESS: ORANGE CA uc.No.: 232598 *********x-****x-******�E***N(-****>E -�E********N-�E *+Ear*x-�r�r�E�r�E***it****-x�Er.--tt**>E-N-�c->tar* -�E** -
92667 uMr: Z ONING R EQUIR EMENTS
LICENSED CONTRACTORS DECLARATION:I hereby affirm under penalty d•- ...,licensed under provisions d Chapter 9 SETBACKS
(commenting with Sed'on 7000 d Division 3 d the Business and Prof.. . .. and m - is in lull force and effect.
cRYuc.NO:006 05 uc.cuss: B sac....: 232538 EXP: 06/97 MAIN BUILDING ACCESSORY BUILDING
• FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
�) Dale: GA't I/ �«aaaa LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
OWNERBUILDERDECLARATION: fsnder penalty of cary tctodon>opraoomaaa7015Bussrss end Proesions Any yaownty which requpl from apemlittwnatruct.after, PARKING REQ: PROV: PARCEL : 41206110 ZNE: R1 REF NO:
demdch,c reaieny structure'pivossw
tarce.LLm requires theapptiaaiaenw
rd fa suchpermitl°S Sgneddthaor heshe PLANNING NOTES> • REPLACE EXISTING ALUMINUM PATIO COVER WITH A WOODEN PATIO
is licensed pursuant to the provisions d the Contradors License law(Chapter 9(commenting with Section 7000)d Dwaion 3 d the > COVER LOCATED 11FT. FROM F T, FROM R P 1 L 2 4 F T, FR S P/L.
Business and Prdenons Confer t •hat he or she exempt therefrom and the basis for e
the alleged empton.Any vd amb, Section II�
7031.5byenY apptinni fora Penn subjects the applicant pantytoe civil panty d not fine more thenhundred&ken IMOD- *********************************************i(-***********************-*******.***
❑ I.as Owner of the ProPertY or ntY emPlones eih wages as thee sole compensation.will do the work.and the structure is not intended D E V E L O .P MEN T SERVICES R EQUIREM EN 4T S
or offered for sale(Section 7044,Usines and Professions Code:The Conlnadors License Law does not apply to an Owner of property
who buids or improves thereon.and who does suh work hawed or Inset or through his or her own empoyees,provided that such3-6, �•/ ��
improvementsare not amended o U 2,4
offered ler sale. .however.thebdtlieg or inprw«e«d•add within We Teta dcomplaon,xn ZONING APPROVED BY l DATE: t
owner-builder wg have the burden of proving he or she did not build or improve for the purpose of sale).
o I.sovine;ofiheprmpedy,amexclusively contracting with licensed contractors toconstruct epmlet(Secton7044,Businesand BUILDING APPROVED BY : DATE: el
Prdeasians Code:The Cora dors License Law does at apply to an owner of property who builds or improve(hereon end who 1
centring for such prgeds with a contractor(s)licensed pursuant to the Contractors License Law). I . 1 1 pr
1APPLICATION ISSUED BY: DATE: C
o item exempt under Swim: B.B P.C..bm /'CIIM ten
********************************************** *:,******************* *)(********
Date: Owner: - -- LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:Y
I do hereby cernly that I am aware d end understand the requirements of California Health and Solely Code Sedans 25505.25533.and
25534.and that)o any hautebildkng ompent wi0/wil not we)teed to oomph.with said Yate cedes and theregorements or BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
a permit for onseuction or modification from the Ai Bu t anegenm District Residenlil mmtrudion applications ant none from these PERMIT 124 . 75
provisions. . 62
Dale: ApplicantPLAN 81 . 09 SMIP/NON RES
WORKER'S COMPENSATION DECLARATION:I hereby alum under pending perjury one of the following dd«atons: ISSUE FEE
o Ilune and wiimaintain acertificate dconsent to sett-insure for workers'companion,epwidedlabySection 3700dthe Labor BUILDING-DIV-> PERMIT ISSUE PLAN-CHECK TOTAL PAID DUE
R� code,falhe adam«raedthe work for which this permit is issued,
TOTALS----> 125 . 37 0 . 00 81 . 09 206 . 46 206 . 46 . 00
pe
cat I haveand will maintain workers'compensation insurance.es required by Sedan 3700 d the Labor Code.for he performance d the
work for which this permit is•sad.My workers' nand PobcY numb«era:
CB11;,_ mR"Y9�PY" EXPIRES REVENUE DIVISION TOTALS > COLLECTED: 206 . 46 OVER/SH RT: 00
Policy Number: v96-57U0v5753 01 /01 /98 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT ADING PLAN-CHECK
(my section need not he completed Ithe permit;afor one hundred 00)oless) 124 . 75 . 6 81 . 09 .
❑ IpeoN thatint performance the work for which this permit ,I ,thell g I ptry any med.'. eelo ********************************************************* *********************
become aIbied��to wodsaion•ws d Cefrmit Pres Ne N I eubjsct any ma rt
conan
l q ion d the Labor Code.I •h oompy with those INDIVIDUAL F E E B R E A K D & W N
7'1 ,. �LQ 4( Appo..m. TYPE QTY DESCRIPTION UNIT COST TOTAL COST
Warning:Failure to secure workers'conpewtlon coverage Is unlawful,and shell subject en employer to criminal penalties and
civil Ones W to one hundred thousand dollen($100.000).Its addition to the cost of compensation,damages a provided for In
Secdon3706ofu»LaborCode,Intwtandattorney'sfees SFR 384 RES-PATIO COVER-POST & SOLID ROOF 16 . 12 6, 190 . 08
CONSTRUCTION LENDING AGENCY:I hereby affirm under Penal of perjury that theta•a oormrudipn lending agency for the END OF FEES
performance of the work for which the permit is issued(Section 3097.Ci.C).
LENDER'S NAME:
LENDER'S ADDRESS:
I certify the)I have reed this application and stele that the above information is correct.I agree to camply with ell day end county ordinances
and state laws fabling to building caYrnnn and hereby authorize representatives d this city to enter upon the above-mentioned property
1°""'"6°"'' '. TERRI .OILLIN
86-24-1997/84:21 P11/8286.46
` -138138224
_ Dale
T g 0813449
PERMIT
y .
(5151-46.W P) White-Building&Safety,Green-Fle:Canary-Appicam;Pink-Revenue;Goldenrod-Assessor
-
CONSTRUCTION AND PLANNING - POOL & SPA
APPROVALS Permit# Date Inspector 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 56. Rough Plumbing& Pressure Test i
6. Electrical UF ER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings / 3/4'rp- 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 61. APPROVAL TO DEG* -
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final .
13. Roof Drains 64. Plumbing System - Fina('
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final .
16. Rough Electric Wiring67. Fencing & Access Approval-
-
pproval- '
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
.
(18. Rough Electrical-T Bar Ceiling 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 ❑Gas ❑Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing �/- 73. Undergrnd.Storage Tank 0 Gas C Oil
25. Roof Sheathing 7-711_7 yi� 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat I !/'✓ 75. Dry Chemical
27. Frame and Flashing 7-/77 11 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 Notes: I
34. Final Heating & Air Conditioning
35. Final Gas Pipe-Test
36. Hood or Canopy I-
37. Final Factory Fireplace
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final
41. Solar Domestic-Final
42. Backflow Preventer
ti
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation ' Q'
46. Handicap Regulations w Q
47'. FINAL STRUCTURE & BUILDING l' /t/.R? 6 -# E
L e
48. FINAL PLANNING :APP
..St
49. Electric Release to Edison "-_-: )
`J r,1.0
50. Gas Release to Southern California Gas Cor 1
51. CERTIFICATE OF OCCUPANCY 1
No. Date
r
PROJECT ADDRESS: 1095 SAN PABLO CI UNIT: CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 06785/
DWNEWSNAME: KELLER, RICHARD T TR
ADDRESS: 1095 SAN PABLO CIR PERMIT NO: B 067857 PLAN CHECK NO: N GOVT: N SUPP ; N
:i01. — COSTA MESA, CA 92626
,I• CONSTRUCTION TYPE: V—N PERMIT TYPE: STR PURPOSE; OTH
557-9887
,.,] ARCH/ENGINEER: REG.NO.: JOB DESCRIPTION : T/O & REROOF W/BUILT—UP
ADDRESS: UNIT: S Q FT: 2, 979
CLAIM VALUE: 2, 979 .00 CALC—VALUE; 2, 979 . 00 GROUP OCC: R-3 /N—i
PERMITTEE: COVER RIGHT ROOFING ( 714 ) 832 -0113
ADDRESS: 14262 ALLMAN PL COMMENTS : SMOKE DETECTORS REQUIRED PER 91 UBC, REROOF 1600SF RESIDENCE
S.A. CA 92705 ############################ ################## ############*########*#444-i
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section ZONING REQUIREMENTS SMOKE DETECTOR
7000)of Division 3 al the Business and Prolessions Code.and my license is in full force and effect.
9 CITY LIC.: 0''60 68 STATE LIC.: 6158r`2 class: C-39 EXP : 12/94 S E T H A C K S �c�y RED Date: (cap/4'f Signature:- MAIN BUILDING ACCESSORY BUIREQU.tREv--
WORKERS'COMPENSATION DECLARATION: thereby affirm that lhave a• tate of consent to self-insure or a certificate or Workers' FRNT: FT IN REAR: FT IN FRNT; FT IN REAR; FT IN
Compensation Insurance.or a certified copy thereof(Section 3800.Lai LEFT: FT IN RGHT; FT IN LEFT; FT IN RGHT; FT IN
Minn.: 1263561-93 EXP.DATE: u 8/01 /94
COMPANY: STATE FUND PARKING REQ• PROV; PARCEL : 41206110 ZNE: REF NO:
❑ Certified copy is hereby furnished. Q Certified copy is filed with the city Building Division. PLANNING NOTES>
// 1f"-V.---1,--Z--4--- >
Date:Cy i3L3/ 4t^ Applicant: / ############################################################################ii##
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need ri • impleted it the permitis for one hundred(siooi or less). DEVELOPMENT SERVICES R E Q U I R E M EN T S
I certify that in the performance of the work for which this permit is issued.I- t employ any person in any manner so as to become
subject to the Workers'Compensation Laws of California. ZONING APPROVED BY •
DATE:
Date: Signature:
NOTICE:II,after making this declaration.you should become subject to the Workers'Compensation provisions of the Labor BUILDING APPROVED BY : DATE:
Code.you must forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED BY .
DATE: 30
which this permit is issued(Section 3097.Civ.Cl. ##################### x�J.=?i
•
LENDER: ############iF#############################################################ae####
ADDRESS: LEGALIZATION: N F E E SUMMARY STRUCTURAL SEGMENT:Y
OWNER BUILDER DECLARATION: (hereby affirm that lam exempt from the Contractors'State License Law for the following reason BLDG PMT
PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
PERMIT G4MT
(Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish,or . 50
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 Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business SMIP/NON—RES
and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by PLAN
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($5001. ISSUE FEE
I. as owner of the property or my employees with wages as their sole compensation, will do the work, and the BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
❑ structure is not intended or offered for sale(Section 7044.Business and Professional Code: The Contractors'State License Law TOTALS----> 54 , 50 0 . 00 0 . 00 54 , 50 54 . 50 . 00
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 se). BLDGPMTPLUMBING ELECTRICMECHANIC FIRESMIP/TOT
one year of completion,the owner will have the burden of proving he/she did not build or improve REVENUE
V O —N TOTALS _ COLLECTED ;
DIC 4 OVER/SHORT:
forthepurpose ofa
GRADING PLAN—CHECK
I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business 54 . 00 . 50
❑ and Professions Code: The Contractors'State License Law does not apply to an owner of property who builds or improves thereon
and who contracts for suchprOjects with acontractor(s)license pursuant to the Contractors'State License Law).I am aware ##################il•###############i(•-le########i('#######################iF###'##ie####
that proof of their Worker's Compensation insurance should be provided to me. IND I V IDUAL F E E BREAKDOWN
❑ I am exempt under Section: B.8 P.C.
for this reason: TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST
Date: Owner: SFR 2979 REROOF BY VALUE RESIDENTIAL NOZONE
I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505.25533,and END OF FEES 1 . 00 2, 979 . 00
25534 and that I or any future building occupant wilUwill not(circle one)need to comply with said state codes and the requirements for a
permit for construction or modification from the Air Quality Management District.Residential construction applications are exempt from
these provisions.
Date: Applicant:
I hereby certify that I have read this application and state that the above information is correct.I agree to comply with all city and county
ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned
properly for•nspection purposes. 0I 00163191-00163192 TOT 54.50
Dewey 1)/1/ Signature: / DATE: 05/30/94 TIME: 09:55
iDriver's License or Social Security a:
Pink—Revenue:Goldenrod—Assessor
-
CONSTRUCTION AND PLANNING POOL ,PA
AP iROVALS Permit# Date Inspector 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 56. Rough Plumbing & Pressure Test
6. Electrical UF ER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap. 0 Undrgrnd.
10. Structural Floor System 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 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 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 0 Oil
23. Gas Pipe-Rough & Test 72: Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing -SyAir 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 PREY. 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 Notes:
34. Final 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 Domestic-Final
42, Backflow Preventer
43. Backflow Irrigation
-1V
44. Landscape Irrigation Stem
45. Sound Attenuation 3 1
46. Handicap Regulations .:-�S
r
47. FINAL STRUCTURB I DING 1/y/fY /�
48. FINAL PLANNING (?•'i .... l
49. Electric Release to EWypn a.
�� �� ee
50. Gas Release to Southgrr yornia Gas Co
51. CERTIFICATE OF (ZUPANCY
No. Date
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. - --
CITY OF COSTA MESA CONSTRUCTION PERMIT P MIT NO. TRACT NO. LOT NO. UNITNO. -
Project Address 1095 San Pablo Circle,Costa Mesa 7,v23.3 6638 9 1 _ 3090 4/15/36 F Y._
Applicant's'k4iiling Address,. 1095 San Pablo Cir. ,C.M. TYPE OF CONSTRUCTION LI NEW LI ADD U ALTERATION I�I REPAIR -' *•
❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P.# A-1 2, o !y • I zone al
•
Owner's Name A. L. &•Virginia Cieck Phone 557-9887 DESCRIPTION OF WORK/USE OF BLDG. Alllmi rittT)'1 pp�� O C',�1y r l L
Address 1095 San Pablo Circle; Costa Mesa • Residence p�/-lr' X L4� S Main Building: Accessory Building: •
Arch/Eng _License No. TYPE OF PERMIT ❑ GRADING ❑ FOUNDATION .gL STRUCTURAL E Front 47 " • - - 0
Address ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL A Rear tq1 - N
Contractor's Name
01 Phone '❑ OTHER �D -n
PROJECT DESCRIPTION SQ. FT. 7�b OCCUPANCY ^,- C Right s N
Address(mailing) ' 1/- coag- Q - {}
CONSTRUCTION TYPE �� VALUATION $ 2• l'" S Left �'`X%KOK�q G
City License No. ZONE GRADING CU.YDS. ACRES R
LICENSED CONTRACTOR DECLARATION r Ping. Ref.# Parking Req./Provided E
I-hereby affirm that I am licensed under provisions of Charter 9 (commencing ' Remarks: ^_ Plannin Notes: �{],. �1 �`_O 0
with section 7000) of•Division 3 of the Business and Professions Code, and �Y�•7�1�I st/.��.-c•-�o- L4�/CL/�e- Tn Coven- 9 in0 r�'/s,„.( '--Q-Ts"'^ ze.) M
my license is in full force and effect. • Voles-M1�� l `1 , 71—m i--•) I LILS—, _ � (� _ S
License Class • —License No. �V 4U'�
Date - SignaturePLUMBING FEES
A
WORKERS'COMPENSATION DECLARATION •
Bar Sink Showers '
' hereby affirm that I have a certificate of consent to self-insure or a certificate ELECTRICAL FEES •
Workers' Compensation •Insurance, or a certified copy-thereof (Section - Backflow Prove nter Service Sink
J00, Lab. C.) Automatic Washer Transformer 0 15-50 KW
Policy No. Company Backflow Irrigation Sewer Ca ' ❑ 50+ KW
P Construction Pole Sub.
8 Certified copy Is hereby furnished. '
Certified copy is filed withththethe city Building Division. Bathtubs Sewer Connection Cooking Unit Meter ❑up to 100 amps
Date 1 Applicant ••
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Clarifiers Solar Collectors -. . . Dishwasher- - -Meter ❑over 100 amps
(This section need not be completed if the permit is for one hundred($100) or
less). Dishwasher , Solar Piping DryersF,A,U.Fan ❑Gas ❑Electric Sub Panel
1 certify that in the performance of the work for which this permit is issued, I - -
shall not employ any person in any manner so as to become subject to the • Drinking Fountains Solar Tank
worke Compens3tion Laws of cad .r•. <`. • Motors 00-1 HP ❑1'/::8
.Dat •uar-Y/�Signaturr -; ----. • 9) t_ Floor Drains Swimming Pool w/Spa
.NO ICE: If,after making this decl ration,you shod become su•ject to the Inc.Solar 09115 HP 016-15+
Workers' Compensation provisions of the Labor ode, you must forthwith Floor Sinks •
Urinal
comply with such provisions or this permit shall be deemed revoked. Fixtures Microwave I
CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet Device Boxes
I hereby affirm that there is a construction lending agency for the performance • Pole Light
of the work for which this permit is issued (Section 3097 Clv. C.) Interceptors Water Heater • Outlets Range
Lender's Name
Lender's Address Kitchen Sink Water Service •
OWNER BUILDER DECLARATION • SWIIChe$ Sign
I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash Garbage Disposal
following reason (Section 7031.5 Business and Professional Code: Any city or • - 9 P Standing Sections
county which requires a permit to construct,alter,improve,demolish or repair P—Trap LaundryTrays -
any structure, prior to its.issuance, also requires the applicant for such permit y - Generator❑0-5 KW❑5-15 KW Trash Compactor
to file a signed statement that he/she is licensed pursuant to the provisions of Roof Drains '
the Contractor's License Law(Chapter 9(commencing with Section 7000) of - •
',vision 3 of the Business and Professions Code) or that he/she is exempt - -
'efrom and the basis for the alleged exemption. Any violation of Section •
-
1.5 .by any applicant for a permit subjects the applicant to a civil .
1�salty of not more than five hundred dollars ($500). '
LJ I, as owner of the property or my employees with wages as their sole Reinspection Fee $15 Issue Fee- $ 3 '
compensation, will do the work,and the structure is not intended or offered - Reinspection Fee I $15 Issue Fee ' $ 3
for sale (Section 7044, Business and Professional Code: The Contractor's - MECHANICAL FEES '
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 . DEVELOPMENT SERVIC EOUIREMENTS: '
employees, provided that such improvements are not intended or offered for Boiler Hood or Type I ❑
•
sale. If, however, the building or Improvement is sold within one year of com- Canopy Type II 0 Zoning Approved By Dat
pletlon, the owner will have the burden of proving he/she did not build or im- Duct-Under Ground
prove for the purpose of sale). Building Approved By - Dat
❑ I,,as'owner of the property, am exclusively contracting with licensed con- , Duct-Structural Refrigeration System l Application Issued By - Date
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 Duct-Ventilating - ❑0000,000 BTU-'❑100,000 BTU �g� 'SUMMARY OF FEES
•
builds or improves thereon,and who contracts for such projects with a con- • -
tractor(s) license pursuant-to the Contractor's License Law). I am aware that Exhaust System 0 Multiple 0 System Repair/Alteration 1'� BUILDING PERMIT • $ -71F-� oo2 SMTP • $ _ o .70
proof of their Worker's Compensation insurance should.be provided to, me. =- - PLAN CHECK $ •� •OJ PERMIT
❑ 1 am exempt under Section B.& P.C.for this reason Firepl/Fact.Blt. ICBG# . Fire Dampers • ISSUANCERMIT $
• PLUMBING $ '
Date,7 4!-15= 01 Owner " -� --. r. Heating System& Ducting ' Registers ENERGY.P.C. $ •
❑0-100,000 BTU ❑100,000 BT PLAN CHECK -25% $ •
i hereby certify-that 1 hive read this applicaa•n and state that-the above . � GRADING $
information is correct. I agree to comply with all city and county ordinances - _ ELECTRICAL ' $ •
and state laws relating to building construction, and hereby authorize repro- PLAN CHECK 50% $ MICROFILM $
Inspection
of this city to enter upon the above-mentioned Proyerty 'for •
Inspection pyr;szei O j ,at_^�� i MECHANICAL $ `�TOTAL FEE $ /OZ��
•
Signature Q'2�r2�G Date 4
Drivers' License or SS# - Reinspection Fee $15 Issue Fee 1 $ 3 PLAN CHECK 25% $
S
CMF 0865-46,rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor
V
CONSTRUCTION AND PLANNING POOI 'PA
Date Inspector Date . Inspector
APPROVALS Permit# APPROVALS Permit#
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. SAPipe-Undrgrnd. - 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms •
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical UF ER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd. •' •
8. Foundation 59. Gas Pipe, ❑ Undrgrnd.,Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, O Undrgrnd. . . . .
10. Structural Floor System 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 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 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 El Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas ❑Oil
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 Notes:
34. Final 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-Domestic-Final
42. Backflow Preventer
.43. Backflow Irrigation
44. Landscape Irrigation System,
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING 1//,/(/b/ / /�
(nv
4$. Special Requirements Completed
49. Electric Release to Edison •
50. Gas Release to Southern California Gas Co •
51. CERTIFICATE OF OCCUPANCY
No. • Date •
1
IVNOIIIO'" T"" - '^ s
A13JVS 111TH.' - , 06
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3 . O 3u
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'9N!8'idf11d -1113:1:11.331i dOd
03Htf1038 Slid SiliN J3d 31VHVd3S 11— 11tii
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ity of Costa–Ye Building Dept D /hi,'
et) LL—.....__.._.OAT I.15IC-( OTT U'
THESE PLANS MUTT BE OH JOB AT ALL TIMES 1
MAKE NO CHANGES WITHOUT PRIOR APPROVAC
OF CERT.
THE ISSUANCE OR C;;:::TINS OF A PERMIT OR APPROVAL 5!
OF PLANS 1ND EPEm'L.AIO:. S SHILL NCT BE CONSTRUED E o
.' .'I'
TO BE I FC' FOR. OR :\N APPROVAL OF, ANY VIOLATION I
OF ANY CF TNI. i ROVIE:DNS C: THIS CODE. NO PERMIT PRE. / N /
SLIMING 13 ME ACUM;;iTY TO VIOLATE OR CANCEL THE
PROVISIONS CF TH!: C.3DE SHALL BE VALID, EXCEPT IN SO 1
TAR AS 111E VORK OR USE'WHICH IT AUTHORIZES IS LAWFUL. P
THE IKOANLE CF A F_R.VIT BASED UPC'1 PLAN.;AND
itZ0
SPECIFICATIONS SrjALL. hOT PREVENT THE BUIL.DI'fl OCICIAU *
!ROM THEREAFTER REQUIRING THE C,C.ZRCCT!7:1 C: E:LRO:4
IN SAID PLANS AND SPECIFICATIONS OR FROM PREVENTING
BUILDING OPERATIONS BEING CARRIED 0:1 THEREUNDER ViHgt
IN VIOLATION OE THIS CODE OR OF ANY OTHER QBOINATICP
OE THE CELL ,
�__' w`� _ i!
•
• Ci o tin(MM B.ullg Dept.
4
0 " I el' _ _ __ _.._DATE'--�?L 4 I
0 'f THESE PLANS MUST BE ON JOB AT LL TIMES
j I MAKE NO CHANGES WITHOUT PRIOR APPROVAL'
OF DEPT.
3oi .0 N 1 I
THE ISSUANCE OR GR •:TING Ct A PERMIT 01 2?30VAL
OF PLANS AND SPECIr;C.P^':S cHALL NCT BE CONSTRUED
TO EE A PERMIT FOR, OR TTN i PPROVAL C7. ANY VIOLATION 1
OF ANY OF THE PROV.S:OXS GI' THIS COLE. NO FERMIT PRE-
(--.'
TO GIVE AUTHORITY TO VIOLATE OR CI.NCEL THE
! 1 T PROVISIONS OF THIS CODE SHALL BE MG:, EXCEPT IN SO
1 FAR AS THE WORK OR USE WHICH IT AUTHORIZES IS LAWEUL,
(1 0 THE ISSUANCE OF A FER:MIT BAJO UPON PLANS,AND
1 C SPECIFICATIONS SHALL NOT PREVENT THE E'JILDING Of.-ICIAL
FROM THEREAFTER REQUIRING THE CORRECTION CT EAHO,S
a in IN SAID PLANS AND SPECIFICATIONS CR FROM PREVCNTC!"
O r BUILDING OPERATIONS BEING CARRIED 0:1 THEREUNOEd WHO
TI __ IN VIOLATION OF THIS CODE OR OF ANY. OTHER Og:/ XF
0 W Of THE pa,
1
41, -k STRUCTURAL APPROVAL ONLY
—'T I SEPARATE PERMITS ARE REQUIRED
�j � i - ?' rioi FOR ELECTRICAL. PLUMBING,
N c ou erZ -:-.-1-.5______ HEATING. VENTILATING AND
I:rFRIGERATION WORN
nI —
H>ei ._ ..I ACCO MANY
N _..I;..' . :TESTS
n
RE TU DE
90 ' If', 'T'IR'C^'•j . ,i:!:USTRIAL
. C. L.. ,.L. AL) FOR ADDITIONAL
I � REO7iRs7ER'f5.
CITY OF CO^TA MESA REQUEST FOR OCCUPANCY
TRACT NO, de ef , . DATE ape
-
LOT NO. y /
ADDRESS /10 f6 cL7A at) pie." c
The developer of the above entitled tract desires to sell the above set forth
lot prior to the time that the tract has been completed and its streets
accepted by the City of Costa Mesa.
The undersigned, by executing this agreement, acknowledges that (he-she-they)
(was or were) advised that this tract has
not been given final inspection nor has it been accepted by the City of Costa
Mesa as having complied with the conditions of approval which were imposed by
the city at the time the final tract map was approved.
The city assumes no liability for the enforcement of the conditions necessary
for approval other than those conditions protected by surety bond.
The undersigned agrees to indemnify and hold the city harmless from any claim
resulting in damage or personal injury to the undersigned by reason of the
aforementioned uncompleted condition.
BY 0-11.--X_ 4/.., 79611-
"7/ rUrchaser
BY /
4 114*elo-rait`i ari ed
representative
BY
Lender
PROJECT ADDRESS: 1095 SAN PABLO CI UNIT: CITY OF COSTA MESA - BUILDING PERMIT PERM NO; B 066996
OWNER'S NAME: KELLER RICHARD T TR
AOORFss: 1095 SANWPABLO CIR PERMIT NO: B 066996 PLAN CHECK NO: 01525-94 S GOVT: N SUPP : N
,.._"" COSTA MESA, CA 92626
CONSTRUCTION TYPEet- : 5-N PERMIT TYPE: STR PURPOSE: ALT
ARCH/ENGINEER: REG.NO.:
ADDRESS: UNIT: JOB DESCRIPTION : INSTALL ONE SKYLIGHT ( ICBO# 2469 ) SQ FT: 725
CLAIM VALUE: 725 . 00 CALC-VALUE: 725 . 00 GROUP OCC : R-3 /
PERMITTEE: G.W. SKYLIGHT CORP. (714 ) 545-9793
ADDRESS: 3617 W. MACARTHUR BL 506 COMMENTS; NO RAFTERS CUT TO INSTALL SKYLIGHT
SANTA ANA CA 92704 +EiEiF-iE********** x*xEEx**************x***************x**Te*xEr**iE*r+F+r******Tr*******+e
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensee under provisions of Chapter 9(commencing with Section Z ONING REQUIREMENTS
7000)of Division 3 of the Business and Professions Code.and any license is in lull force and effect.
CITY LIC.: 0054365 TATE LIC.: SETBACKS
-'-
E/D—at�e. — Sign. MAIN BUILDING ACCESSORY BUILDING
.RS'COMPENSATION DECLARATION: I here have a certificate of consent to self-insure or a certificate of Workers' FRNT: FT IN REAR: FT IN FRNT : FT IN REAR: FT IN
Compensation Insurance.or a certified copy thereof(Section 'an.Lab.C). LEFT; FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
PDucYNO.: 488398-94 EXP.DATE: 04 /28/95
COMPANY: STATE FUNDPARKING REQ• PROV: PARCEL: 41206110 ZNE: REF NO:
ER
❑ Certified copy is hereby furnis ed. yy Certified copy is filed with the city Building Division. PLANNING NOTES>
2-8 ��" (S: >
Date- 1- ^� A�p�_r���� � ` -'� *******************it************************************************iE**********
EXEMPTION FROM WORKERS'COMPENSATION OECIAARTWN:++rus section need not be completed if the permit is for one hundred($100)or less). DEVELOPMENT SERVICES _R E Q U I R E M E N S
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. ZONING APPROVED BY - :
DATE:
Dare: Signature:
NOTICE:It.after making this declaration.you should become subject to Ihe Workers'Compensation provisions of the Labor BUILDING APPROVED BY : DATE:
Code.you muss forthwith comply with such provisions or Ills permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for Q
which this permit is issued(Section 3097.Civ.C). APPLICATION ISSUED H Y: 0 i DATE: _-_ 4k
*******************.***** **** * * * ** • *****' **************** *
LENDER: *************************************** .****4***********************14**********
ADDRESS: LEGALIZATION:N F E E S MMARY STRUCTURAL SEGMENT:Y
OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RE GRADING
(Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish,or PERMIT 2 1 . 0 0
repair any structure.prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed . 50
pursuant to the provisions of the Contractors State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business SMIP/NON-RES
and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by PLAN 13 . 65
any applicant for a permit subjects the applicant to a civil penalty of not mare than five hundred dollars($500). ISSUE FEE
I. as owner of the properly or my employees with wages as their sole compensation. will do the work, and the BUILDING-DIV-> PERMIT ISSUE PLAN-CHECK TOTAL PAID DUE
❑ structure is not intended or offered for sale(Section 7044.Business and Professional Code: The Contractors'State License Law TOTALS----> 21 . 50 0 . 00 13 . 65 3 5 . 15 35 . 15 . 00
does not apply to an owner of a progeny 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.II,however the building or
improvement is sold within one year of completion.the owner win have the burden of proving he/she did not build or improve REVENUE DIVISION TOTALS--> COLLECTED: 35 . 15 OVER/SHORT: 00
for the purpose of safe). BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN-CHECK
I.as owner of the property.am exclusively contracting with licensed contractors to construct the project(Section 7044.Business 21 . 00 . 50 13 . 65
❑ and Professions Code: The Contractors'State License Law does not apply to an owner of properly who builds or improves thereon
and who contracts for such projects with acontractOr(5)license Pursuant to the Contractors'State License Law),I am aware . .*.".**.**{(..I[.*.N.**.*.*.{(.*.****.*.*.*.***.***.*.*..)(.*.**.*..M*..)♦*.*.*.*.*.*..N.*.*.*.****..".**.*.*.*.�.******,*,*,*, **„N.,**„x,**
that proof of their Worker's Compensation insurance should be provided to me.
❑ am exempt under Section: B.J.P.C. I N D I V I D U A L F E E B R E A K D O W N
for this reason: TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST
Date' Owner: SFR 725 ALTER BY VALUE RESIDENTIAL NOZONE 1 . 00 725 . 00
I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505,25533,and END O F FEES
25534 and that I or any future building occupant MINN not(circle one)need to comply with said state codes and the requirements for a
permit for construction or modification Iron the Au Quality Management District.Residential construction applications are exempt from
these provisions.
Date: Applicant:
I hereby certify that I have read this application and state that the above information is correct.I agree to comply with all city and county
ordinances and state laws relating to building construction and hereby authorize representative o ' city to enter upon the above-mentioned '
property for inspectionyppurposes
Date: -G? -9 -s-�5-...- - . `.-., ‘, A•\6 \ 01 0 �5F 26-0TINE:I20159728 TOT 35.15
16:11
Driver's License or Social Security w: \\
(MOI -ie- teidino:Green-Code .. . . ay-Applicant:Pink-Revenue:Goldenrod-Assessor
POOL & SPA -
CONSTRUCTION AND PLANNING i T
,4''RSV/AI_S Permit DUO Inspector APPROVALS Permit .? Date Inspectu
I__-1__- -...___ ^ . _ I
, 1. Temporary Electrical Serve.; cit Po;e I 52. Pooi & Equipment Luc.lt.on 1
{ I
2. Srnl Pipe:Undrarnd - I ' 53. Ste.;l Rcinforcemirt I
1.
------'-----
` --- -- ' `- -„ t
;. F'. t c. C'-"...t•L.ii,. . ,1 I 55, E,r.:. -fi-- -
L1ca' Bind n
1
'- C r^ a "_ - __ r0 R. ai I Pl..r,b mq , ' ,r,,. st i _.._- _.__-____ - -'I
I. F t C.F ,. ,,,i _ j 57 /1P?PGy/11 -ICS Cf)VcR GU': `r - -
1 (=nnt nus. - I- 58, Electrical Conduit-In iltqrnd. ,I
N F.. „I;t,n„, - - - - - - --- S0. G....P p::. C, L^dr,1, d . T t --- - - - - ----
I I ! 2 1,\
B3 R•ciii•.osh I .r...e . i -1' P I ,
1U. S' ,:ct. _r t-/ to Gl . APPROVAL i C) JI CIC
I
12. S.wr.' F.,,p i I G3. klr,rt_r & Vcnt.Fm ;
H - -- } , { f -- -- - - --h-- -
i3. Ru-,4 iamn'' r,-_-- _ - '-_', _ - __ .__--__ _-� oi. E'um�ieng $yste,n : ' eJ __ - 1
iiii-F,ii .1
:. r ___ __ SG S'I;.,r S;stcmr,,l., _ _ __ ___-_._ __
,C. In...,.`, 'u.Ctr�c __ _ __ _ 67. Fcnc,n7 & ACr.ran Aan.-t�____ _ .__ ___T
-__-___---_�__-_- -_,___ ___ _-__-- �- •1 -____;
/. Hc_gn U..r,ng S^,ri 58. APPROVED FOR PLASI EKING
1P,. Hp, p, Electricar''T Bar Re , -iaEJ. POO VSPA SYS'TE::SFINAL 1
12 ° ..r. Ir-.at'^] & n'. C.:- . • _ _ `` I FIRE DEPT. HEOUIRE,l"E2JT --`j
2i • I ' .k'F3rL IL•I S ?crn,:t ii.
_,__- _ _t_--- .-
:1 -.t,. - S,rl..;tr r - i :'0. U Idcrg-^ _nd Htr::,,
_ I 71. Product Plp.rG 1 . G., _-O:' I I
7.3. G P P- la•', e: T r I - /?. UI d,:.gra 1 F! ,, - -
-- __ -_ _ _ - _ _- _ _1___- ._
2y P I. ' In -,
1 ti"✓L]a❑ Ny„lu
2b, i L. - (- rEt -tzt.. . . _ :'Dieter ' /b. Pry l:nrnnr 4l 1
- Y' 9w6� _
2/. r n. T , f-r,•_,. ,,. .-ix [%
q 6 I 7l J Y c "d n�
?E. '.J • q � �- -_--_-- -- - I I 7/ FIXED S TE'.. ' ":Aii - ---- 1 - - -- I
I 1 I 7E. F1,It PRLV. FINN,
-- - --- -- -- - ------, - '-- --- ;--- --- - -- --- - - -- - - - - - . _ .. - _. r
• T- -:. I',(:AL'l l'1 r)_aT R:C1 idle..,c- T
iJ-1. ;1 t r _ _ . nc,. I 1 70. F'RAL INSr''.r:l
1? "i'.-h,r9 P 2 ei '.•r:_r . I 1 ' '7.1 :;4100 CE R rir-lc'.� .,
la
1.
oc.
-� - - '-- - -- - - - - -
7u. stem p' Ca ropy
J7. « -11.F;ct or l' Fr:.G:e - _ I / _ ____ _ _ ._ _ ._ __ _ ._ -___ __
38. Firm P.i.mbirg { __--I - -I-`
ts'atrr $':rclre Fi.,:.' I F�' __ __ _ ___ _ _ _-_---_ _ t
S7
»G Ger sr, :e.F.-a1 __ _ _--__ ±_ ____i,_.___I _ . __--_ _ - __________ __ -
' 42. 3•ekrla,; Presntar 1 I
-- 4-- 1 'r ? `q 40-x- "L
`�
43. 0,,Citio:: Irrrr;atio • -1 /J
94. L-1'�Csc.!.-1. ,r' uric Sy^.t m r ���
45. Sound Po C'.13t:on I
45. N�r-oiaP IR _tip-, 1 7
A7. FINA1_ STRUCTURE C: RUILDine
'-� Gl7Q� - ,'�.°----_- - - -- - --_ - -- -- -_- -- .
rr;e FINALPLANNING I I L-
r-d£. E'.ctr,c Fe;cE,a to Edison
- -I ------ - - ----- - - -- - -'
_
L __,JEC. Cd, Rek,..ce to Southern Cahlorn•J Gas Col •• -- --- -- - -- --- -- - _-----�
sit. CERTIFICATE OF OCCUPANCY 1L__ •- - _
No.__�--- Deft I
ommasumm 1095 SAN PABLO CI UNT: CITY OF COSTA MESA - BUILDING PERMIT
a xmtaSNAKEIVKNwm: KELLER RICHARD T TR FLOOD: AH-38 PERM NO: E 083450
ADDRESS: 1095 SANTPABLO CIR
COSTA MESA, CA 92626 PERMIT NO: E 083450 PLAN CHECK NO: N GOVT: N SUPP : N
557-9887
en.MAILING ADDRESS: CONSTRUCTION TYPE: PERMIT TYPE: ELE PURPOSE: ADD
•
ARCHITECT OR EpepsaA: LCND, JOB DESCRIPTION : 384SF SOLID ROOF PATIO COVER SQ FT:
ARCH.OR ENG.'S ADDRESS: WIT:
CLAIM VALUE: CALC-VALUE: GROUP OCC: R-3 /
CONTNACTORSNAIIE BLUE RIBBON BUILDERS INC ( 714 ) 581-3636
CatmACTORS MAI IINa 1135 W. KATELLA AVENUE COMMENTS: SOLID PATIO COVER, RE: #B83449
ORANGE CA 232598 :+e+E****�E*�t*�E*****Ater*******�r�EAE�e***�E-�E*�E**�E**-x+E*>EIE*�r**Sr*at***�E*�t�E-�(*********-ir**Sr�ESE*+tar
A0°"�S` uc D.92667 ' will Z ONING REQUIREMENTS
LICENSED CONTRACTORS DECLARATION:I hereby Wunpenalty der peny s perjury Mel I ren ficeneed under provisionss Chapter 9 SETBACKS
(commencing with Section 7000)d Division 3 of the Business and Prolesalors .... is n Ml lace end Wed.
CETYuc.No.:00650S uc.cuss: B uc. •.: 232_ e P: 06/97 MAIN BUILDING ACCESSORY BUILDING
�'2���7 ft FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
Dae: Fs LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
OWNER BUILDER DECLARATION:I hereby affirm oder penally el perjury ... ., exempt horn the Comrade,License law Ia the-
fdlowigreaon(Sedion7D31.5Bosiem and Profession Cods:Any pya coutydudh requires aperme to construct.eller.improve. PARKING REQ: PROV: PARCEL : 41206110 ZNE: REF NO:
and"eA oMPS any nuctur.P6°'I°a isuante.al"rpdmthaappFard far such pemdto Ne asigneddaeowd that hea she PLANNING NOTES>
licensed pursuant to the provision el the Contractors License Lew(Chapter 9(commencing with Section 7000)of Dweion 3 of the
renes and Professions Codej or that he or she is exempt therefrom and the base for the alleged esenpon.My violation of Section >
7031.5 by any applicant for a petrel subjects the applicant ID•siva penally of not more than five hundred dollars Iwo. *******************************************************************************
❑ I.as owner of the property ormyemployees rich wages esOwe olecompenscion,wuidoMrworkadthestucu,umtintended DEVELOPMENT S -E R V I C E S R E Q U I R E M E N T S
or offered for sale(Section 7044,Business and Professions Code:The Conrao, en d License Law does not apply toowner property
Morons bolds or os thereon.andsuch who does work lamed or hea el or through his her own employees,plaided that such
improvements area intended or offered for sale.If.however.the building opmvinneva sold within cos year smnpletion.the ZONING APPROVED BY DATE:
uikl
owner-0er will have the burden d proving he or she did not quid or improve for the purpose d sale).
o Las Owner dthe propery.emetxct CCedraClbg*ith licens6dmnbecwaamamatheKWd(Sedlon7044.Buinne•nd BUILDING APPROVED BY : DATE:
Professions Code:The Conrdrs License Lae doss not apply b n owner of property who builds or improves thereon and who ` (Cr)Dam apa(a such projects under
ma,aer(e)Icerme pursuant tomanomrada'Laaue law). APPLICATION ISSUED BY: DATE: SI �i (
❑ tem enema uMer Scion: B.AP.P.,la this,seer: ************************************************* ***************it ** ******
Dae: owner: LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:N
I do hereby cnly that I em aware el ad understand the,adranme of Catania Heath ard Seamy Code Sedbm 25505.25533.and
25534,and uvul or arymae building eodcnwil/wisnot(was Ole)need to cam*with Sal on odes andlheaaniremwela BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
a permit for construction or modhcetionfrom the Airlflagarnere Disut.Resideraiel condi-edam appicatia,are exempt hM
am an
pro sloe. PERMIT 2 . 00
Date: Applicant' PLAN 50% SMIP/NON RES
WORKER'S COMPENSATION DECLARATION:I hereby Stam oder penalty of perjury one d the following declarations: ISSUE FEE 2200
.
a
o Ihave dwilmaintanacertifcatedmnenitose4a
'in ,laworkers'compensation,apn, radedlpbSedion3700of the Labor BUILD ING-DIV-> PERMIT ISSUE PLAN-CHECK TOTAL PAID DUE
Coda, M»wakfowlichlhsp«maiaeaued, TOTALS 2 . 00 22 . 00 0 . 00 24 . 00 24 . 00 . 00
{:I
I have and oil malarial workers'compensation insurance,n reqimed by Sects 3700 of the Labor Code,for the Performance d the
"°dIp"edlNa°ermma�ad.Mw°d„' gis�gA�d° °n°°owyn"mb° a EXPIRES REVENUE DIVISION TOTALS--> COLLECTED: 24 . 00 OVER/SHORT : . 00
Pare` 01 /01 /98 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN-CHECK
Poky Number: vYV-3avVvv.yn ��
a„don nes m be completed d the petrel is one s hundred dollen I3 t09)or loss.) 24 . 00
❑ I nilly ger in the performance d the work b which the prem*b'... .. nal emrploy person In pry menm t n m to
became subject to the workers'compensation e d CMMaria, ' . erg.. , . a I became the workers' **************************'****'*************************** *********************
oonmen atioe prwa(J of Section 3700 d the le of we..I shall lath pry with --- . a . .. ''� INDIVIDUAL F E E BR E A K Dy O 14 N
9 Dais: 412 a a 7 pp�u
W.m/ng:Fsfweto sacumaobm'carpanatin connwe lit tnkWMe'dshat n employer to(linens! ens\MPTYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST
civil lines tar to one hundred thousand dollen(slalo A in addition to the cost of c.n mtus .damages ea pwvdsd for In
Section 3706oythe Labor Code,Interest, d
end Attorneys ELE 2 FIXTURES, LIGHTING 1 ST 20 EA. 1 . 00 2 . 00
CONSTRUCTION LENDING AGENCY:I hereby affirm under penally of perjury that there is a construction lending agency for the END OF FEES
pdormace d the work for with the penny is issued(Section 3091.Cu.C).
LENDEWS NAME:
LENDER'S ADDRESS:
I certify that I have read this application and alae that the above irdormdon b correct.I agree to comply with all dry and county ordinances
end state laws relating to building construction ad hereby authorize,9,sematives d the city to enter upon the abo e-mentioned property
Ia inaPeel ian Par pase .r. RI bDILLIN
l6-24-1997/B4.21 DM/Q4.B8
P (0/2 tile) 7 PERMIT-.RePTB=B1
T Date: ::::
. . OwredAgerdApuimnt/Cm,da
(5151-40,W P) White-Bulling A Safety:Green-Flo:Cenery_Apptcan:Pink-Revenue Goldenrod-Assessor
•
CONSTRUCTION AND PLANNING P00 3PA
APPROVALS Permit # Date Inspector 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 56. Rough Plumbing& Pressure Test
6. Electrical UF ER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, 0 Undrgrnd.,Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, O Undrgrnd.
10. Structural Floor System 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 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 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 El Gas OOil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing . 73. Undergrnd.Storage Tank O Gas O Oil
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 PREY. 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 /040 ,i/ Notes:
34. Final 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 Domestic-Final
42. Backf low Preventer
43. Backflow Irrigation
44. Landscape Irrigation System
'
Cr
45. Sound Attenuation111
ff
46. Handicap Regulations y E
47. FINAL STRUCTURE & BUILDING
48. FINAL PLANNING
oto
49. Electric Release to Edison % I'd
4.
50. Gas Release to Southern California Gas Co Sr
c,:orn
51. CERTIFICATE OF OCCUPANCY
No. Date
OWNER HRLTZER ENTERPRISES - C. M. DATE 9-26-69
JOR ADDRESS 1095 San Pablo Circle BUILDING PERMIT NO. 30364
f :RAL CONTRACTOR Same DESCRIPTION of WORK Residence W/Attached Garage
Ar No. _ LOT q TRACT 6.3$ FIRE ZONE VALUE $ 22.034.00
INSPECTIONS Si nature Date GROUP I&J TYPE V ZONE R-1
SOIL /445'3 —30 SUBCONTRACTOR PERMITS ISSUED
GAS Dote ( Number 1 Signature
WATER ed9 M «/-7?C' Plu 'bin.
ROUGH PL BING .y !`llC �O" _rJ�.[�r1 f'r}t , Cj _7 4
Le-
PROP. SWR. LINE HOUSE CON. a -i 6 7!0-70 , U$. - ' • b-s' n ,,T4--8,4
SPRINKLING SYSTEM V/V///
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING MSS. 7U
TEMPORARY SERVICE OR POLE
UNDERGROUND ❑ POWER ❑
ROUGH WIRING
ge _,_/C s Ne.A{a.5ttii(TIn((j/q/y'an��V�enJt.� J y
TRENCHES VD FORMS EC STEEL REINF. 7-,7-ra 11 ^L,��%= / ��[,(i1! i74�/O D.
FLOOR SYSTEM 4f-9.-70 r�� 'S/PLS i� b a-7,, 'Inn
BOND BEAM STEEL REINFORCE [1 1
SHEATHING 5.-"1-(-70 k verii y-Ya
FRAME AND FLASHING� n
�l O
L NG - IN f OUT S,TQ
IJ
F ER, BROWN COAT V KW—Pr.
STRUCTURAL, FINAL ry,� y,Ele ri.a
HEATING, VENT., REFRIG. AND r;�/ . M ,t' .' o rj.Q� mite) p5ao-72 /x'1
PLUMBING, FINAL AND GAS TEST [t /`fid 4.2,1"../2
ELECTRIC, FINAL C� � -A 7(.
BUILDING, FINAL - /rte - ',A-7a
cnsa0Q 394* ***124.50
r '40864 'EN 12-69
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA,CALIFORNIA 92626
For Applicant to Fill in Completely APPLICATION FOR BUILDING PERMIT
REC�E /�Y' D E REC VED OATS ISS
BUILDING 1095 San Pablo Circle ` lei- va b7e StP i. 5 b
ADDRESS
PERMfla
OWNER Heltzer Enterprises-Costa Mesa A.P.NO. 1LAn-4
BUILDING /075 ���
MAIL 740 No. La Brea AVE: . ADDRESS Ct. ,/'t
ADDRESS ZZ
Lu W CITY EL.93� /32171 TRACT 6638 LOT 9 BLOCK
L.A..A. Cal.
Z < CONSTRUCTION United California Bank NEW ADD ALTER REPAIR MOVING nFMOLISH
- co LENDER
O Gz"/
a m Main Office
4/1
J r BRANCH
_I Cfl
Q W ADDRESS 6th and Spring, L.A. OWNER TI
03_I VALVE .�/ d
J-CO ARCHITECT Q OR ENGINES Frank Gonzales TEL. 532-6871; USE 2 . �✓Y'
ZN
< 1336 E . Chapman Ave. FIRE //
war ADDRESS p ZONE TYPE !� GRO45
d w APPROVED
W Z CONTRACTOR George J. Heltzer & Assocs . BY DATE
J p
CO Z same as above
:ICC ADDRESS
W W TEL. ZONE NO.OF USE OF NEW single ram
Z F CITY NO. RI 'PLANS 2 BUILDING Res. w/att.Gar.
w-0 STATE 201098 CITY 1707 YARDS APPROVED YARDS APPROVED
to CC LIC. NO. LIC.NO. MAIN BUILDING ACCESSORY BUILDING
r0 SIZE NO.OF BLDGS. (FROM C/L apt
OF LOT I NOW ON LOT FRONT T. P p, FT.
USE OF ^ '
EXISTING BLDG. R,SIDE IJ FT. FT,
I— SIZE OF NO.OF
ZNEW BLDG. ROOMS STORIES L.SIDE FT. FT.
Z
EXTERIOR WALL ROOF
V
COVERING COVERING REAR -13 FT. - FT.
J USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
C.
C. MAIN BLDGS. ACCESS.BLDGS.
+ DATE
Residence with attached garage0 C.U.P.# APPROVED `,///
I—
Plan 402 APPROVED DATE /V/ h 14
4 9
Z WLD IV
0
UI hereby acknowledge that I have read this application and state
D ,,that the above information is correct and agree to comply with
CC all laws regulating building construction, and I shall not employ
F any person in violation of the workman's compensation laws of rt
CO the State of California. m
zI hereby certify that I am properly licensed as a contractor under /y yo SO.FT. 9✓� A-3o
the State of California Business and Professions Code, Division 3, THE AMOUNT S OWN UNDER VALUATION IS FOR
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: Iki
C
am exempt from the provisions of the State of California Business VALUATION
and Professions Code, Divi on 3,C •ter 9. O d co
PERMIT FEE $ O
Signature of ,
Permittee r • $0202).°2Y PLAN CHECK $ �/�O CO
E
u.
Authorized Agent
` TOTAL FEE $ 4'2 re0
OWNER CTFCK Al, DATE 3_2_79
JOB ADDRESS 1095 San Pablo Circle BUILDING PERMIT NO. 47592
C RAL CONTRACTOR hwnpr—B1 Ar DESCRIPTION of WORK B1 ockwa LL
AI- No. 412-061-10 LOT TRACT . FIRE ZONE VALUES 100.00
INSPECTIONS Signature Data TYPE V GROUP T ZONE p „1
SOIL PERMITS ISSUED
GAS SUBCONTRACTOR Number I I
Signature
WATER Plumbing
ROUGH PLUMBING
PROP. SWR. LINE IJ HOUSE CON. p
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING
TEMPORARY SERVICE OR POLE _
UNDERGROUND ❑ POWER 0
ROUGH WIRIfNG 'L q WIRING 'Heating and Vent,
TRENCHES lJ FORMS fl STEEL REINF. QJ�Irk,
Q
FLOOR SYSTEM /
BONO BEAM ffl STEEL REINFORCE n
SHEATHING
FRAME AND FLASHING
LI 'G - IN n OUT n
PL LR, BROWN COAT
STRUCTURAL, FINAL ElertrIc
HEATING, VENT., REFRIG. AND A.C., FINAL
PLUMBING, FINAL AND GAS TEST n
ELECTRIC, FINAL
BUILDING, FINAL
•
04 r? a s)r1
- COSTA MESA BUILDING-SAFETY DEPARTMENT F'
P.O. BOX 1200 COSTA MESA,CALIFORNIA 92626 ..•.4343 3/02/79 5.50 TL
PPL AT ON FQRjISRUVRFpgPERMIT 5.50CKT0
For Applicant to Fill in Completely — Use Ink Only _E r E 2/ DAYadte�ElBI-NNW,'
i A
BUILDING ADDRESS 0 ' 5 $ • . ;W C ZCLE . !/L. _ .�ti ►
PERMIT NO.
OWNER Is„..` C I ec A.P.NO. _ —�
MAIL �j BUILDING
ADDRESS I OqG SP .I cAaLD CIRCLE ADDRESS r _
TEL. TRAC' • LOT ' BLOCK
CITY COSTA MESE NO. 4
CONSTRUCTION NEW rip REPAIR MOVING f:FMOI LSH
LENDER OWE'
r1R
BRANCH
OWN R / tete_ _
ADDRESS �/ 70, VALUE /CD x�
ARCHITECT TEL. S s a �(J -
OR ENGINEER 0 W N ER NO. - - -
FIRE T
ADDRESS ZONE TYPE„.......-----GROUP J
APPROVfireiCONTRACTOR 0 y3NER BV DATE '3 ,7 i2.
ADDRESS
�— TEL. ZON�( PNO.OFLANS USEIOF NEW
CITY NO.
//}}''(('' PLANSL�i.G` BUILDING 6/
F• STATE CITY YARDS APPROVED YARDS APPROVED
LIC.NO. LIC.NO. MAIN BUILDING ACCESSORY BUILDING
(4 SIZE NO.OF BLDGS. (FROM C/L STREET)
4 OF LOT VRREGu L.FtiR I NOW ON LOT I _FRONT FT. _ FT.
Q USE OF
EXISTING BLDG. REStOG).)CF R.SIDE FT. FT,
Ul
/ /
F Separate permits are required for L.SIDE F�q {-7 C(r/,Iyrs-s 1,-) p/.
electric,plumbing and heating work.
WREAR FT. FT.
QUSE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
G C o iz�
& TE $_LJCK E l4CS
CE ,MAIN BLDGS. ACCESS.BLOCS.
/' VAR.# DATE
n / ,(Ljr � C.U.P.# APPROVED
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I hereby acknowledge that I have read this application and state in
ed that the above Information is correct and agree to comply with n
4 m
all laws regulating building construction, and I shall not employ i
Z any person In violation of the workman's compensation laws of 2
S the State of California. ,�
3 I hereby certify that I am properly licensed as a contractor under SQ. FT. NI
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR o
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FE5E ONLY:
am exempt from the provi •, - •
- s of the State of California Business PERMIT FEE $ Q x/0 w
VALUATION
and Professions Code • 3,Chapter 9. - n
' / PLAN CHECK $ rn
Signature of �r`,G v LLo
Permittee `� $ / �• TAX $ � )
Authorized Agent ` TOTAL PAID $ 5C JT•t"' U
OWNER HELTZER ENTERPRISES DATE 7-9-70
1/41
\NOR ADDRESS 1095 San Pablo Circle BUILDING PERMIT NO. 32040
* ( :RAL CONTRACTOR Game DESCRIPTION of WORK Add Bedroom to Residence
AP No. - LOT of TRACT 6638 FIRE ZONE . VALUE $ 1.700.00
SINSPECTIONS Signature Date GROUP i TYPE V ZONE R-1
\ SOIL SUBCONTRACTOR PERMITS ISSUED
' GAS Date Number Signature
WATER Plumbing
ROUGH PLUMBING
PROP. SWR. LINE Q HOUSE CON. D
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING
TEMPORARY SERVICE OR POLE
UNDERGROUND fl POWER 0
ROUGH WIRING J tH eating and V/e t._
TRENCHES FORMS STEEL REINF. gj %/�/ / . ' / / /7/ /-57/. X66,0
FLOOR SYSTEM -`-�( r i/�(e 7D ^,//�/ ` /
BOND BEAM n STEEL R NFORCE n
SHEATHING $/6
FRAME AND FLASHING P'6/TD
L VG — IN OUT Zr
SHEATHING ;
- 11/474
PL ER, BROWN COAT Oet M/'
STRUCTURAL, FINAL
q IC
HEATING, VENT., REFRIG. AND A.C., FINAL Al S /—(2"7/ !an(w[L � a... i /4-2o 3/5.6p- v
PLUMBING, FINAL AND GAS TEST n
ELECTRIC, FINAL �J 41.0/7�
RIIII num: PIUAI f'��/_>Jf�
• 22040 PASO
JUL -9-70rq$A00 715* ****Z5.5C
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Completely
RECEIVE BY, DATE RECEIVED DA,E ISSUE D
BUILDING /0 9,� /044 , Ar •�/ ` ' a /
ADDRESS (, ,,pp
OWNER / e zer -r ,, 4t " L.t , aliA.P.MAIL /J AADDRESS 7 f/O /Y0. Lai (,_re J/ reABUIOLDRINGs D ES
w W ,QQ ,p 1 _ TEL. 2/3aU CITY I-,4 . ea11. NO.93 z�Tj~z Zrill CONSTRUCTION fflinO r- ~/1LENDER Lf/� / e l efl)� �!Y/7/�
a m Si/
J D BRANCH !!/-n DFF/v
-I co / / OWNER • = e
aJ ADDRESS S-rim- r / � e VALUE 00
Q
ARCHITECTTEL.J�1`60/? SE I erS . $ OD
N OR ENGINEER / Co ..../ N•
O in FIRE I
W 4 r CC ADDRESS /334 CAOPmn dye, ZONE TYPE .4 GROUP i
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�,[/�/ APPROVED
J D CONTRACTOR G eerie ki/ Alt e/�p 11 S'J'pG BY DATE
CO Z /
J K ADDRESS sign, 'ear
WW TEL. ZONE NO.OF USE OF NEW / /
Z = CITY NO. �/ PLANS 2- BUILDING Reefre,'
CY
W-O STATE y CITY YARDS APPROVED YARDS APPROVED
j O LIC . NO. 2 Ivo • d' LIC.NO. MAIN BUILDING ACCESSORY BUILDING
SIZE I NO.OF BLDGS. (F ROMS](L STREET)
OF LOT NOW ON LOT FRONT OW PTO-Kt. FT.
USE OF
EXISTING BLDG. R,SIZE 21 +FT. FT.
I- SIZE OF NO.OF T
Z NEW BLDG. ROOMS STORIES L.SIDE VD/N FT.ga$I FT.
✓ EXTERIOR WALL ROOF I- /`^'y�
_ COVERING COVERING REAR 110-4-
sp+ FT. \` FT.
J USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
a MAIN BLDGS. ACCESS.BLDGS.
C-
Q ,/ 9 �// / y / /) VAR.# / DATE
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Add
/ I�'�N /SOD�I l ( C.U.P.#I- ,.�t APPROVED /�/
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ri/pn eZ- 4 APPROVE It �/, DATE 4C--0/ /0
Z 7LANlJL6�
0
UI hereby acknowledge that I have read this application and state
✓ that the above information is correct and agree to comply with
CC all laws regulating building construction, and I shall not employ
I- any person in violation of the workman's compensation laws of
CO the State of California. / /LSO. FT. b
z I hereby certify that I am properly licensed as a contractor under O
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
cC
am exempt from the provisions of the State of California Business
and Professions Code,D' ision 3, C te/r/[9. VALUATION yr O O m
��� - / 7—'r"• PERMIT FEE S / ai
N
O ai
Signature of f p
Permittee $ // /DO PLAN CHECKS c+ ) `r Q E
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Authorized Agent TOTAL FEE $ rytFt to u_
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COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA,CALIFORNIA 92626
APPLICATION FOR BUILDING PERMIT
For Applicant(O(Fill I/1 Completely
/' ,� _ RECEIVED BY DATE RECEIVED DATE ISSUED
BUILDING ADDRESS I 0 1 ) O,),....ed (M
PERMIT NO.
OWNER A.P. NO.
MAIL BUILDING
Z ADDRESS ADDRESS
W_ La NEL.
CITY NO. TRACT (063 LOT BLOCK
ZC CONSTRUCTION NEW ADD ALTER REPAIR (MOVING DEMO!ISH
OI-
LENDER
am
J D BRANCH
J co OWNER
m J ADDRESS VALUE
j.<
CO ARCHITECT TEL. USE $
OR ENGINEER NO.
U N FIRE
WQ ZONE TYPE GROUP
m ADDRESS
IL w APPROVED
W Z CONTRACTOR BY DATE
—10
Ca Z
J co ADDRESS
W W TEL. ZONE NO.OF USE OF NEW
O r CITY NO. PLANS BUILDING
ZF
LU-O STATE CITY YARDS APPROVED YARDS APPROVED
to K LIC. NO. LIC.NO. MAIN BUILDING ACCESSORY BUILDING
D 0 (FROM C/L STREET)
SIZE I NO.OF BLDGS. '1 r.‘ J
OF LOT NOW ON LOT FRONT QV FT. IJ (_ FT.
USE OF I
EXISTING BLDG. R SIDE FT. FT.
I— SIZE OF NO. OF
2 NEW BLDG. ROOMS STORI ES L.SIDE _5 FT. FT.
VEXTERIOR WALL ROOF ^ //
_ COVERING COVERING REAR c9a_FT. FT.
—1 USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
O. MAIN BLOCS. ACCESS.BLDGS.
VAR.* DATE
Q V 4 C U.P.# APPROVED
0
IU) /
APPROVED I /9/�
I— BY l 'ATE //
Z
0
(~.1 I hereby acknowledge that I have read this application and state
D that the above information is correct and agree to comply with
CC all laws regulating building construction, and I shall not employ
I— any person In violation of the workmen's compensation laws of
V) the State of California. b
I hereby certify that I am properly licensed as a contractor under SQ. FT. o
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR j
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: ik
iz
am exempt from the provisions of the State of California Business VALUATION
and Professions Code. Division 3, Chapter 9. CO
PERMIT FEE $ N
D
Signature of m
Permittee $ PLAN CHECK $ E
`o
LL
Authorized Agent TOTAL FEE $