HomeMy WebLinkAbout1077 SANTA CRUZ CIR - Building Permits PROJECT MESS: 1077 SANTA CRUZ CI UNIT: CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 053995
OWNS AME: PERLBINDER, GERALDINE
ADDRESS: 1077 SANTA CRUZ CIRPERMIT NO: B 053995 PLAN CHECK NO: N GOVT: N SUPP: N
COSTA MESA, CA 92626
CONSTRUCTION TYPE: V—N PERMIT TYPE: STR PURPOSE: OTH
557-5019
ARCH/ENGINEER: REG.NO.: JOB DESCRIPTION : REROOF 2500SF RESID 6 GARAGE W/SHAKES i SQ FT: 6, 000
ADDRESS: UNIT:
CLAIM VALUE: 6, 000. 00 CALC—VALUE: 6, 000 . 00 GROUP OCC: R-3 /
PERMITTEE: PETRONELLA ROOFING ( 714 ) 548-1645
ADDRESS: 2626 NEWPORT COMMENTS• X pq(''���—
COSTA MESA CA 92627 ********************�E*?,ESE �E*sE**�F**sE�Fx�ESB*�L�F�E�k*****�t****�6***** 4!/#k * E�R
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z ON ING R EQUIR EMEN TS R
7000)of Division 3 of the Business and Professions Code.and my license is in toll force and effect. $ E T B AC K S , 6EQUIRED
CITY LIC.:4 32605 STATE UC.: 460707 cuss: 39
•
Date: 7 — /43 - Y / Signaturet ....1' MAIN BUILDING ACCESSORY BUILDING
WORKERS'COMPENSATION DECLARATION: Ihereby ave 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(.' 00.Lab.C). LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
POLICY NO.: 1079987-91 EXP.DATE: 07/01 /92
COMPANY: STATE FUNDPARKING REO• PROV: PARCEL: 42721103 ZNE: REF NO:
❑ Certified copy is hereby furnished. CX Cendi copy is filed with the city Building Division. / PLANNING NOTES>
Dale: 7 ` i7 ' ( / Applicant. -^•� —'� *******************************************************************************
EXEMPTION FROM WORKERS'COMPENSATION OECLAR: r Is section need not be completed if the permit is for one hundred(5100)or less). D E V-E' L OPMENT SER VICES R E Q U I R E M E N- T S
I certify that in the performance of the work for which 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:
•Date: Signature: BUILDING APPROVED BY : DATE:
ode,NOTICE:If,afterstmaking this declaration,wiyoushould become i subjectemithe Workers' rempensation provisions of the Labor
Code,you mull 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: -
whichthis permit isissued(Section 3097.Civ.C). ****************************************** * * ***************** **
LENDER: *******************************************************************************
ADDRESS: LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:Y
OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
(Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct.alter,improve,demolish,or PERMIT 81 . 00 • 60
repair any structure.prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed SMIP/NON—RE$
pursuant la the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business PLAN
and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 byr
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). 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----> 81 . 60 0.00 . 0. 00 81 . 60 81 . 60 • 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. II,however the building or REVENUE DIVISION TOTALS--> COLLECTED• 81 . 60 OVER/SHORT• 00
orimprovement is ofsoldsale).)hin one year al completion,the owner will have the burden of proving he/she did not build or improve BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
far the purpose of
I.as owner of the property.am exclusively contracting with licensed contractors to construct the project(Section 7044,Business 81 . 00 . 60
❑ 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 such projects with a contractor(s)license pursuant to the Contractors'State License Law). I am aware **************************if********************If*******'************************
that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL. F E E BREAKDOWN
❑ I am exempt under Section: B.E.P.C.
for this reason: TYPE QTY D E S C R I P T I I O N UNIT COST TOTAL COST
Date: Owner: SFR 6000 REROOF BY VALUE RESIDENTIAL NOZONE 1 . 00 6,000. 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 OF FEES
25534 and that I or any future building occupant mill/will not(circle one)need to comply with said state codes and the requirements for a
permit fanconstruction or modification from the Air Quality Management District.Residential construction applications are exempt from 7
these provisrors.
•
Dale: 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 co my
ordinances and stale laws relating to building co ruction and hereby authorize representatives of this city to enter upon the above-men coed
property for inspection purposes. _ -'
9 L�1-q sign — ' �. DATE: 07642-0107TI;E: 2':�
Date. .
Driver's License or Social Security A:
t 641A6 While-Building:Green-Code Enforcement:Canary-Applicant:Pink-Revenue:Goldenrod-Assessor
CONSTRUCTION AND'PLANNING - POOL & SPA
€PPROVALS Permit# Date Inspector APPROVALS Permit + - Date Inspector
d
" . Temporary Electrical Service or Pole . 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. r .j- 53. Steel Reinforcement
i '3. Electrical Conduit.Uiility-Undrgrndi '' 54. Forms
4"YElectrical Conduif,Undrgrnd.. 55. Electrical Bonding .
5. Steel Reinforcement' - 56. Rough Plumbing & Pressure Test • ,
r- ' ^ -'r
6.t Elgctrical UFER Grid. c 57. APPROVAL TO COVER-GUNITE
7.fFootings - _ 58. Electrical Conduit-Undrgrnd. •
i
;`, •.Foundation - _ 59. Gas Pipe, 0 Undrgrnd., Test
9„Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, 0 Undrgrnd. J-
1q.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 Electricat-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT '
20.-.RoughFactory Fireplace ,; . l�` ` '. ,APPRbVALSJ:c-_Permit# , -
21.'Ducts,in.Stryctute., ' -• `c70. 0ndei4jround Hydro
22:Ducts, Ventilating ,. 4. 't * .71. Product-Piping 0 Gas 0 Oil
23r Gas PipexRough &Test i ' - 72. Underglodnd Flush- .
f'," • l ) A .._ •
-
24.n opf Framing. A ' ;73.i.Undergrnd.Storage Tank 0 Gasy 0 Oil 'i
25. Roof Shiathing ;'tr ••T µ T74,.Overhead'Hydro'
,
26`T-Bar Ceiling (Structural) &Nlonocoat 7-4,7
. - .t:z _ 75. Dry Chemical u.•
27-Frame and Flashingz -. _ 76. 151-y Standpipe ,�• `°
28.. Lathing t Siding ' ,y i. z > .. .. 1• - 77.- FIXED SYSTEM FINAL
29. Insulation :, " - , 78.•FIRE PREV. FINAL
30. Drywall Nailing a i HEALTH:DEPT. REQUIREMENT
131. Plaster Brown Coat' 79':FINAL INSPECTION -
`32. -Electrical Power M¢,ter-Final ' - L. ,80.I.FOOD CER(=� R !"�E ISSUED
33.'Final Electric_ fr # '.Notes:
34..Final Hgatinq& P.i4on
Cditioning; • .r
-35.'Final Gas Pipe-Test. - t+ - . -
36'Hood or Cano `" 1. ' .r.▪ 'i n`• '
37.:Final Factory Fireplace - - -
.. r i - s. .. ,,
-
- I . r. t
• ,•
`38. Final Plumbing ._ �� < -- -
39. Water Service-Final. ..' -": -
?40. Gas Service-Final ' y -
�41. Solar Domestic-Final;, - _ 4 y
- 42.`BackfloW Preventer' I. t
S.
-
43. Backflow Irrigation+ . - .
- -1, :. . .
.
44. Landscape Irrigation System, :.,t. , - - - :,; - • - 71
,45.-Sound Attenuation f " = 1 ' '
-1`.46.2Handicap Regulatidnsr,„ - _ _ t •; `- c
•
'47.-.FINAL STRUCTURE,&BUILDING • 5 �G,I; '� - : '
• „ rl ,
48r FINAL PLANNING-2 ' `O ' I0� I I • rI
i
--49;Electric Release to.Edison : I - _ _
47
�50.sGas.Release to Southern Californja Gas Co } •; • �, ` '; i
'51.,CERTIFICATE OF OCCUPANCY ' • ' •, , '
No. Date
CITY OF COSTA MESA REQUEST FOR OCCUPANCY
TRACT NO, 6638 DATE 1/29/71
LOT NO. 28
ADDRESS 1077 Santa Cruz Circle
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)
Casher D.Birdwe1Zwas-er-;;ere) Gail D. Birdwell 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.
Byoi • Lee,aL a BY / i
'Gail L. Birdwell �4
1122
f P�uJrchaserhe Birdwell
BY
Developer and/or authorized
representative
BY
Lender
BUILDING SAFETY DEPT
FEB 1 1971
OWNER HELTZER ENTERPRISES - C. M. DATE 9-26_69
JOB ADDRESS 1072 Santa Cruz Circle BUILDING PERMIT NO. 30883
GENERAL CONTRACTOR gams DESCRIPTION of WORK Reci dense W/Att.aohed Gagage
AP No. LOT 28 TRACT ..i8 FIRE ZONE VALUE $2q.563.00
INSPECTIONS Si nature Date GROUP I & J TYPE V ZONE R-1
SOIL Als4 ;_7a SUBCONTRACTOR PERMITS ISSUED
GAS Date Number Signature
WATER mS(f_f3-- j / P,lumbin
ROUGH PL 1S-4.MBING � 2-V ' L�/pyL��(� �l� I,4'��
PROP. SWR. LINE [v-HOUSE CON. r /. 7-7e 15 �/�/�. 407,- g . ' 1b.
SPRINKLING SYSTEM L/ I/
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING /h 57 G )o
TEMPORARY SERVICE OR POLE
UNDERGROUND ❑ POWER 0
ROUGH WIRING r G-i9_7e / Heating and'Yen t
TRENCHES [fi FORMS 47 STEEL REINF. I f -6-"0 tC//O A.f6/4 ��/-7 7.,,-v-••--
FLOOR
SYSTEM ,p 41-r V-10 ej uMi^{'4!tt/JlfueTlkP %. +441' 7/%97 —
BOND BEAM n STEEL REINFORCE [, G /
SHEATHING f/y0/
FRAME AND FLASHING e�,�'/ 1/4 r,fi
LATHING - IN ® OUT 4 K" 7//7/ c
PLASTER, BROWN COAT ‘14 4. ..W $feOr/i c
c
STRUCTURAL, FINAL A.C., FINAL Y' '�j 4�'/1t//n ALA,i EI ! I
HEATING, VENT., Go-/Z 79 i/4�iD
PLUMBING, FINAL AND GAS TEST �..f`-'v
ELECTRIC, FINAL /? 4-7o.70
BUILDING, FINAL .bJ r-xf-
7
30883 ',ov 12-69PafB00 420* ***1 52.25
.# cnsn
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA,CALIFORNIA 92626
APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Completely
REC f Y D ERE Dp DATE ISSUED
BUILDING 1077 Santa Cruz Circle ! V-62
ADDRESS 7 SEP 2 6 1969
PER1 ^
OWNER Meltzer Enterprises-Costa Mesa q.P.No. ---------• _, i 1
t�7 i
MDILBUILDING /O /�j/y''�C;`
ADDRESSz
740 No. La Brea Ave . ADDRESS l
0Wi. Q CITY L.A. Calif. TO 9237-2171 TRACT 6638 LOT28 BLOC
I-z
Z Q CONSTRUCTION
Nt7 ADD AL EPAIR (MOVING DEMO(ISH
OI_ LENDER United California Bank
J w BRANCH Main Office
m J ADDRESS 6th and Spring, L.A. OWNER `vALUEy� r�/
J Q OR ENGINE T Frank Gonzales NOL• 532-687 USE
_ SCS/,7W 3°�
co
I / /)rzc`�
w 2 ADDRESS 1336 E . Chapman, Orange, Calif. ZONE TYPE ✓ GROUP C/°
Ci.I-9
LU z George J.Heltzer & Assocs. APPROVED
J O CONTRACTOR g BY DATE
m z Same as above
J cc ADDRESS
W W TEL. ZONE NO.OF USE OF NEW Single Fan.
ZI- CITY NO. Rl PLANS 2 BUILDING Res. watt.Cftr.
w 0 STATE CITY YARDS APPROVED YARDS APPROVED
to CC LIC. NO. 201098 LIC.NO. 1707 MAIN BUILDING ACCESSORY BUILDING
_0 SIZE -;NO.OF BLDGS. (FROM C/ EET)
OF LOT NOW ON LOT FRONT OFT. FT.
USE OF
EXISTING BLDG. R SIDE 6 FT. FT.
I- SIZE OF NO.OF
Z NEW BLDG. ROOMS STORI ES L.SIDE 5FT. FT.
UEXTERIOR WALL ROOF n
_ COVERING COVERING REAR Q ( FT. 6 FT.
J USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. SET.MAIN&
1
Q. MAIN BLDGS. ACCESS.BLDGS.
< Residence with attached garage VAR.# DATE
C.U.P.# APPROVED
-
zPlan No. 404-1/47 APPROVED WLD 04.0 DATE lOh / Li
0
0 I 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 �f 390 Vi6
H any person in violation of the workman's compensation laws of C�
V) the State of California. (/L,./�� / m
? I hereby certify that I am properly licensed as a contractor under V / �SO. FT. tefr � �
the State of California Business and Professions Code, Division 3, THE AMOUNT S WN UNDER VALUATION IS FOR • s9r
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: O
am exempt from the provisions of the State of California Business
Sc
and Professions Code,ONisi° PERMITFEE $�Signature of � ) -Permittee PLAN CHECK $itzli —'f�Ps}ePl? ��^
Authorized Agent &. la
TOTAL" •#`77-T- Art
1.
li COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 .
APPLICATION FOR BUILDING PERMIT
, For Applicant to Fill in Completely
RECEIVED BY DATE RECEIVED DATE ISSUED
BUILDING /0 (1 /
ADDRESS IO / / �� C—LJ if iL i! !
PERMIT NO.
OWNER A.P. NO.
MAIL BUILDING
ADDRESS
ADDRESS
W W TEL. TRACT 66 395 I LOT ag BLOCK
6-0 CITY NO.
ZQ CONSTRUCTION NEW ADD ALTER I REPAIR I MOVING f)FMOI ISH
O N LENDER
am
J D BRANCH
J to OWNER
CO J ADDRESS VALUE
-CO
ARCHITECT TEL. USE $
Q OR ENGINEER NO.
V N FIRE
WQ ZONE TYPE GROUP
2 ADDRESS
aw .
W 2 APPROVED
J O CONTRACTOR BY DATE
CCI Z
J cc ADDRESS
w W ZONE NO.OF USE OF NEW
3= CITY NOL PLANS BUILDING
Z_
WO STATE CITY YARDS APPROVED YARDS APPROVED
to CC LIC. NO. LIC.NO. MAIN BUILDING ACCESSORY BUILDING
D O (FROM C/L STREET)
SIZE NO.OF BLDGS. �,
OF LOT NOW ON LOT FRONT 5--V-FT. FT.
USE OF
EXISTING BLDG. R SIRE ` FT. FT,
I— SIZE OF NO.OF
ZZ NEW BLDG. ROOMS STORIES L.SIDE FT. FT.
U EXTERIOR WALL ROOF r., /
_ COVERING COVERING REAR 4l FT. O FT.
J USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
a
a MAIN BLDGS. ACCESS.BLOCS.
Q VAR.# DATE
O C.U.P.# ,/ APPROVED
CO �O _BAYPROVED �// sn E rY/�j /7d
O
C-1
I hereby acknowledge that I have reed 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
N the State of California. W
ZI hereby certify that I am properly licensed as a contractor under SQ. FT. a
r.
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:
am exempt from the provisions of the State of California Business IC
VALUATION
end Professions Code, Division 3,Chapter 9. Nco
PERMIT FEE $
3
Signature of m
Permittee $ PLAN CHECK $ E
Authorized Agent a
` TOTAL FEE $
OWNER BIRDWELL) Casher D. DATE 3-16-71
JOB ADDRESS 1077 Santa Cruz Circle BUILDING PERMIT NO. 32819
*4 GENERAL CONTRACTOR William Dietz DESCRIPTION of WORK Patio Cover
AP No.412-061-29 LOT TRACT FIRE ZONE VALUES 856.00
INSPECTIONS Signature Dote GROUP S TYPE V ZONE R-1
SOIL PERMITS ISSUED
GAS SUBCONTRACTOR
Date Number Signature
WATER Plumbing
ROUGH PLUMBING
,
PROP. SWR. LINE ❑ HOUSE CON. Q
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING
TEMPORARY SERVICE OR POLE
UNDERGROUND ❑ POWER El
ROUGH WIRING Heating and Vent.
TRENCHES 0 FORMS ❑ STEEL REINF. 0
FLOOR SYSTEM
BOND BEAM n STEEL REINFORCE n
SHEATHING
FRAME AND FLASHING
LATHING - IN n OUT n
PLASTER, BROWN COAT
STRUCTURAL, FINAL Electric
HEATING, VENT., REFRIG. AND A.C., FINAL
PLUMBING, FINAL AND GAS TEST n A
ELECTRIC, FINAL / ry Y ����/
//
BUILDING, FINAL /f
82819 MAR 16-71cnsnOQ 1iO3 LJa*****9,0Q
/, COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
APPLICATION FOR BUILDING PERMIT
For Applicant to Fill in Completely
�j� /� /nn J ,// RECEIV BY f2/TE R CEEIV D D TE IS UEED
BUILDING/O I7 S NTil l EOX Cr / � �
ADDRESS ON ('�
OWNER C4.11/Fie 0.. 3/RawELL A.P.NO. ///C� 4//:10:7 PERM14 et/ I :'1
ADDRESS/077 £4x17A /� BUILDINGDR7
/� (�/cUZ C(�.�/ ADDRESS /D /j o� �A/��/ GSA
d U CITY &JST-4 m�f4 NOTE
2124' TRACT ase LOT 22R BLOCK
ZZ
C CONSTRUCTIONA No AJ� NEW ADD ALTER REPAIR MOVING DFMOI ISH
O N LENDER ��/
0- m
J 7 BRANCH / '�� /�
JN OWNER 11MJ 7). &4,{//j//D I/I
Jm ADDRESS • - / VALUE }�[/',-T�/� M/
< ARCHITECT TEL. US �i[/ U L(J --
OR ENGINEER NO
O N FIRE
Z Q
W< ADDRESS ZONE TYPE g. GROUP
0.LyCu • APPROVED 7
J O CONTRACTOR W ILLI4,. a Er BY DATE 3- 7/
m Zn (j
:I sr ADDRESSP0•BOX Q t /l
W W TELZON NO.OF USE OF W
0= CITY+ r/ (}ef�' a_
G PLANS BUILDI
Z Ioukr7-Atio VALLA ND.7 W' �( �B
w0 STATE �1 CITY "• "• • YARDS APPROVED
to CE LIC. NOB/, ,299 /c24 LIC.NO. MAIN BUILDING ACCESSORY BUILDING _
JO SIZE iNO.OF BLDGS. (FROM J/
OF LOT NOW ON LOT / -• -0 1. FT.
XE OF
EXISTINGBLOCS/Ai
c3-CE
Limit/6L (�/� K - • i/h FT.
I— SIZE OF NO.OF
Z NEW BLDG. ROOMS STORIES FT.
UEXTERIOR WALL ROOF
_ COVERING COVERING REAR c 3 3 FT. FT.
i USE OF BUILDING AND WORK TO BE PERFORMEDDISTANCE BET. BET.MAIN&
a
Q ,t /q/ AMAIN CCESS.BLOCS.
DATE
O Iu Cr4C.C. 48o
TRT! O CoC ✓E/(a APPROVED
N APPROVED/ i- _ DATE , ./y 7/
Z
0
UI hereby acknowledge that I have read this application and state
O that the above information is correct end agree to comply with
CC all lows regulating building construction, and I shall not employ
I— any person in violation of the workman's compensation laws of
CD the State of California. t03
o
Z I hereby certify that I am properly licensed as a contractor under SO. FT. 6
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR 5
Chapter 9, and that such licenses are In full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: le
am exempt from the provisions of the State of California Business VALUATION
and Professions Code,Division 3,Chapter ,t to
'� 00 PERMIT FEE $ : /'—[/ D
Signature of ///°°�//j r D
Permittee $ �(J-L .` PLAN CHECK $ " _ E
v (([[JJ `o
u.
Authorized Agent TOTAL FEE $