HomeMy WebLinkAbout2423 SARATOGA WAY - Building Permits w9 CITY OF COSTA MESA
•
a BUILDING DIVISION
F • �., `1 D
DEVELOPMENT SERVICES DEPARTMENT PE NUMBER
PERMIT E00-01151
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 2423 SARATOGA WY Status: ISSUED
Suite No Applied: 12/05/2000
Vicinity: Issued: 12/05/2000
Parcel Nunmber: 41916508
Applicant: JUREKOVIC, JIM ISSUED BY:
Address: ,
Phone: 714-754-4327
Zip:
Owner: MC NUTT TRUST
Address 2423 SARATOGA WAY
Phone:
COSTA MESA,CA Zip: 92626
Contractor: JUREKOVIC BLDG. CO.
Address: 120 BROOKLINE LANE '
Phone: 714-540-5417
COSTA MESA, CA Zip: 92626
License: 548410
SCOPE OF PERMIT
MISC. ELECTRICAL WORK FOR ROOM 120 SQ. FOOT BEDROOM EXTENSION. REF: B00-01874. 3
RECEPTACLES.
FEE SUMMARY
Quantity Quantity
•ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0
Temp service test $0.00 Busway/100 ft $0.00 0
Res.a/c package $0.00 Standing Section $0.00 0
New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 •
New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0
Pool/Spa $0.00 . 0 up to 10 kva/kw $0.00 0
Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 0
Recept Outlets - $3.30 3 up to 100 kva/kw $0.00 0
Switches $0.00 0 over 100 kva/kw $0.00 0
Non Res Appl $0.00 . 0. Low Voltage Equipment $0.00 0
Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0
Service to 200a $0.00 0 Misc. Conduit $0.00 0
Service to 1000a $0.00 0 Misc.Conductor $0.00 0
Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0
Motors to 1 hp $0.00 0 Circus(mech ride or lights) $0.00 0
Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0
Motors to 50hp $0.00 0 Fireworks Stand $0.00 0
Motors to 100hp $0.00 0 Other Electrical Fee $0.00
Motors over 100hp $0.00 0
Communication drops $0.00 0 Investigation Fee $0.00
Sub panel to 200a $0.00 0 Plan Check Fee $0.00
Pole Light Pkg $0.00 0 Reinspection Fee $0.00
Sign Circuits $0.00 0
Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $26.80
Intermed Pole $0.00 0
COMMENTS/SPECIAL CONDITIONS
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
fora period of 180 days.
•
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required 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 n i-1
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($150)or less.)
I certify that in the performance of the work for whi is permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Califon la,and agree th. s uld become subject to the workers compensation provisions of Section 3700 of t e Labor Code,I shall forthwith
comply with these pr• i• s. 411.1,./. / _
(l
( 'Applicant Sijgnature: n 1.. A A A � - Date:
"WARNING FAILURE TO SECURE 0' ERS'COMPECOVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIE AND CIVIL FINES UP TOONE HUNDRED
OU
THSAND DOLLARE(5100,000),I A••ITION TO THE, , •OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions oft hapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Lic.k Class k
= A� -/5/OD
Contrecbr's Signature: Date:
CONSTRUCTION LENDING ENCY:
❑ 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:
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.).
❑ 1 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:
❑ 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, 1 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 ❑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 tiling 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 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aPermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? j�Yes 0 No
(Section 65850.2 of the Califomia 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? ❑Yes 0 No
(II 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 Califomia Health and Safety Code Section 42303 been made? 0 Yes 0 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 AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection pu •• es.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
_Signe
too
Owners)) /0/`_ pS1aa /�
And/Or i•rized Applicant Date
CODE I PAM INTITIALS CODE* INSPECTION TYPE gag 1011EE5
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final _ 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical 9-itt-e2. /
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
WEIDENKELLER, MARY JANE
From: CHALMERS, SYLVIA
Sent: Tuesday, August 20, 2002 2:43 PM
To: WEIDENKELLER, MARY JANE
Subject: FW: Finalization rescinded
MJ: Please attach a copy of this email to the permits.
Thanks,
Mrs. Chalmers
Original Message
From: MORGAN, BURT
Sent: Tuesday,August 20, 2002 2:40 PM
To: CHALMERS, SYLVIA
Subject: Finalization rescinded .
Sylvia: FYI Inspector Hook rescinded the 8/14/02 finalization of permit B00-01874 at 2423 Saratoga Way.
Apparently, a pending correction had been overlooked. I am letting you know this since you pulled the permit
from Mary Jane's desk earlier for me. My review of the permit and the amended computer entries by Hook on
8/19/02 are not reflected on the hard copy. I placed the permit back on Mary Jane's desk. Thank you!
BurtHorgan/
1
PRDiECT ADDRESS: 2423 SARATOGA WY UNIT: O CITY OF COSTA MESA — BUILDING PERMIT , • PERM NO: P 049060,
, OWNER'S NAME: EMMA FULLER
. , ADDRESS: SAME AS ABOVE , PERMIT NO: P 049060 a ALAN CHECK NO: N GOVT : N SUPP : N.
•
CONSTRUCTION TYPE: PERMIT TYPE:- PLU PURPOSE: 0TH
714 /549-0116 .
•
ARCH/ENGINEER: REG.NO.: JOB DESCRIPTION , ; WATER HEATER REPLACEMENT • •
SQ FT: •
ADDRESS:- UNIT: • -
CLAIM VALUE: CALC—VALUE: GROUP OCC : / •
PERMITTEE: ADEE PLUMBING & HEATING ( 213 )759-9101 '
ADDRESS: 5457 CRENSHAW BLVD ' COMMENTS: NO STRUCTURAL WORK BEING DONE ' .
• LOS ANGELES CA 90043 ********##*x *********,****** ********x- *N4** E*#>E###*#***** Fir#* *****************
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z 0 N I N G REQUIREMEN TS'
7000)of Division 3 of the Business and Professions Code.and m license is in I force and e1feU. � SETBACKS
cithm: 0303 1iLr+T m.:24019 ,- ,cuss: :-36 -
Date: J`6- f Signature: 0.J` e� MAIN BUILDING ACCESSORY BUILDING
WORKERS'COMPENSATION DECLARATION: thereby aft that 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 1nsu. ce,ora.cer0lied copy thereof(Secion 3Bu,Lab.C1_ LEFT: FT IN RGHT: FT IN LEFT: FT ' IN RGHT: • FT . IN
IPOLICYNO.: wL' ib1U3i119010 • ,ATE: 05/01/91 . .
• 'OMPANY: LIB MUTUAL PARKING REQ: PROV: PARCEL : 42615149 ZNE: : REF NO:
Certified copy is hereby furnished.a�^)Certifiedu. .Mng Oivisi PLANNING NOTES>Date: q- ,g yC Applicant: C( ' \ 1144---S *************##**#**#*******#*3e** **P#****3 **#**iE ******dE*************#**#iE#****
EXEMPTION FROM WORKERS'COMPENSATION OECLARATIO : ' section need not be completed if the permit is for one hundred(5100)or less), DEVELOPMEN T SERVICES R E Q U I R E M E N T ,S ,
I certify that in the performance of the work for which thi er tis 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 •• ,1 DATE:'
Date: Signature: • BUILDING APPROVED BY '
NOTICE:If,after making this declaration,you should become subject to the Workers'Compensation provisions of the Labor `, DATE
Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. r p
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED BY: '�_ • DATE: 7 Er 1hd
which this permit is issued(Section 3097, CI. ***********************************#*#**#****WW> v ..,,,r*****************3x-* ' r.F#
LENDER: *************************************************** *******************1e*******
ADDRESS: • LEGALIZATION ;N F E E SUMMARY STRUCTURAL SEGMENT :N '
•
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/RES GRADING
(Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,atter,improve,demolish,or PERMIT 2 • 00
. repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed 2 5% . SMIP/NON—RES
pursuant to 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.My 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(3500). ISSUE FEE '3 . 00
• 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----'> 2 . 00 3 . 00 0 . 00 5 . 00 5 . 00 , • . 00
does not apply to an owner of a property who builds ar 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 REVENUE DIVISION TOTAL S--> COLLECTED• •
5 . 00 OVER/SHORT •• 00
improvement is sold within one year of completion,the owner will have the burden of proving he/she did not build or improve
for the purpose of sale). BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING . PLAN—CHECK
a' i,as owner of the property,am exclusively contracting with licensed,contractors to construct the project(Section 7044,Business 5 ' 0 0 •
❑ 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).l am aware ******#***#****#*************#*********************#****#************#*******#**
that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL F E E BREAKDOWN '
❑ l'am exempt under Section: B.&P.C. '
for this reason: . TYPE• QTY DESCRIPTIO N UNIT COST TOTAL COST
Date: • Owner _ PLU 1 WATER HEATER •AND/OR VENT 2 . 00 .,, 2 . 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 will/will not(circle one)need to comply with said state codes and the requirements for a
permit for construction or modification from the Air Duality Management District.Residential construction applications are exempt from ,
these provisions. I+• '
Date: Applicant: ' -..t ' \• �'
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 -.r 7 `n `•i• '.'
ordinances and state laws relating to building construction an. - . ..dze representatives of this to enter upon the above-mentioned !_,-:s '] �0 J0
property fo Dection pur uses. +
fiApDate: + �� Signature: CSR. (vj�__ _ _ , . ______,24; .
•
Driver's License or Social Security it:
=nary—Applicant;Pink—Revenue:Goldenrod—Assessor -• ,
CONSTRUCTION AND PLANNING :-v = POt . SPA
Date InspectorDate •Inspector
APPROVALS Permit# APPROVALS Permit # _ •
1. Temporary Electrical Service or Pole ', ' 52.•Pool & Equipment-Location
2. Soil Pipe-Undrgrnd. - • 53. Steel Reinforcement r •
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. P
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 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 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 01241/c/0 G Eo,
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
48. FINAL PLANNING
49. Electric Release to Edison -
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
•
•
CITY OF COSTA MESA
•
66 BUILDING DIVISION
> • „F- , DEVELOPMENT SERVICES DEPARTMENT PERM!'NUMBER
• =1
PERMIT
X300-01874
am®se
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.fta. �LDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 2423 SARATOGA WY U Status: ISSUED
Suite: Applied: 11/17/2000
Vicinity: Issued: 12/05/2000
Parcel Number: 41916508 Zoning:
Applicant: JUREKOVIC, JIM ISSUED BY:
Address:
Phone: 540-4517
Zip:
Owner: MC NUTT TRUST
Address 2423 SARATOGA WAY
Phone: 714-754-4327
COSTA MESA,CA Zip: 92626
Contractor: JUREKOVIC BLDG. CO.
Address: 120 BROOKLINE LANE
Phone: 714-540-5417
COSTA MESA,CA
Zip: 92626 License: 548410
Arch : Eng:
Address: Address:
Phone: Phone:
• Zip: License: License:
SCOPE OF PERMIT
CONSTRUCT 120 SQ.FT. ROOM ADDITION TO EXTEND AN EXISTING BEDROOM IN A SINGLE FAMILY RESIDENCE. NO
NEW PLUMBING PROPOSED.
FEE SUMMARY
.. Plan Check: $126.91 Calc Valuation: $10,260.00
Permit: $195.25 Claim Valuation: so.00
SMIP Res: $1.03
SMIP Com: $0.00 •
• Other: $0.00
Inspection: $0.00
•
Total: $323.19 •
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
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 j ) • ;^•r
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 p licy number are:
Carrier: er X �o Policy Number:
J\Th/rs section need not be completed if the permit is ve ed et one huntl d dollars($100)or less.)
I� I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
< I compensation laws of California,and agree that Ifhould become subject to the workers'compensation provisions of Section 3700 of the Labor Cod I shall forthwith
comply with these provision. "
Applicant'Signatu— ra: � "b ^a At Date: /.:D �
WARNING:FAILURE TO SECURE ••' ERS'COM-OP ION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTI AND CIV FINES UP TO ONE HUNDRED
THOUSAND DOLURE(5100,000). 'omON TO 111111T • T OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of apter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Lic.4 _ i Class N
lir
,Contractor's SI_ g�nature=�$itflb %t&', " '� 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).
Lender's 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 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:
❑ 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).
1
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? 0 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 application a ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes U 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 ❑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 AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
nature Of Legal Owner(s) / Datyf M /1
Or - f • And/Or Authorized Applicant / ppp7a67 to
DOMS INSPECTION TYPE all INTRIALS CODES INSPECTION TYPE PATE !MALI
1616 Fixed System Final Fire Prevention 206 Final Mechanical /
1266 Pool Spa Final 208 Final Plumbing r� elf ri • '/
200 Final Re-Roof 210 Final Electrical A '/��/` i.`1•
201 Final Block/Retaining Wall 212 Final Fire Prevention '�g.�i/�:cT���1Fria��
IVVf ri 34�1 1 i P""E II
202 Final Factory Fire Place 220 Final Planning Approval r ;sI t1-:.JnJ'iR�
Ai
203 Final Sign 222 Final Site ViA4.
204 Final Demolition 250 Final Building/Occupancy 1 ;' ,
jilt •..
of BUILDING: 2.4. SARATOGA, WY _.._ .UHT:. -.
"__ _. CITY OF COSTA' MESA _-. BUILDING PERMIT
EIFIOIOINN:ZILLER, EMMA M .. _ - _ ,. _ PERM NO: B 073475 ,
ADDRESS: 2423 SARATOGA WAY
COSTA MESA,CA 92626 PERMIT NO: B 073475 PLAN CHECK- NO: N GOVT: N SUPP: N
APPL.MMONO ADDRESS: CONSTRUCTION TYPE: VN PERMIT TYPE: STR . _ . _ , _PURPOSE: OTH
ARCHITECT OR ENGINEER: LIC.NO.: JOB DESCRIPTION : T/OFF, SHEATH & REROOF W/COMP .SHINGLES SQ FT: . , 2, 999_
ARCH.OR ENG.'S ADDRESS: UNIT:
CLAIM VALUE: 2, 999 .00 CALC—VALUE: 2, 999 .00 GROUP OCC: R-3 . /
coNTRACTDWSNAME: STOUT ROOFING INC ( 310 ) 923-6775
ca.rRACTowsuMUNc P 0.
BOX 4309 _ :OR:MT:NTS. SMOKE DETECTORS ARE REQUIRED PER 91 UBC
ADDRESS: .DOWNEY CA uc.No.: 402536 * ih *145,1,14*i4i454*i4i4i4949Ei4***141E*RrereEx-sE eEeExxRE * -ersE* iESE+H REAE* eEereESE sEiE *xsEeE-FP****ERE**x***90241 UNIE ;;10// : 5,.
ZONING REQUIREM , NTS
LICENSED CONTRACTORS DECLARATION:I hereby affirm under penal :rjuty that I am licensed under prove' a of Chapter 9 $ ETBACK $
(commencing with Section 7000)of Divison 3 of the Business and Profess' .e,annd my license b in full face ed.
CITY UC.No. 059377 LIC.cuSS: C 39 sac. 025 6 EX30�• 5MAIN BUILDINGACCESSORY BUILDING/ p /J /� FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
ae: �/ 2tl�`�� Contractor / l � / - - LEFT: FT .. IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
JfOWNER B ILDER DE RATION:I hereby affirm under penally of parlury thet I am exempt/rom the Contractors Licenae :w for the
tepowing reason(Section 703L5 Business end Professions Cale:Any city which requimepenttoardoud.` er improve. PARKING REQ: PROV: PARCEL: 41916508 ZNE: REF NO;
z.°`mloh,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement I : he or she PLANNING NOTES>.-'
; ,-sensed pursuant to the provisions d the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the �-
4 tineas end Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.My violation of Section -
7031.5bYanYapplicant for a permiteubpds the applicant to a civil penally of not more thanfive hundred dollars(S500p. '!4*********56*14***14**********14**D4**********************14**d4**********14*'1E14***ibi4***
❑ Les owner of the prom"or my employees with wages es their sole c°mpeneaton,will do the work.and the structure is not intended D E V E""L O P M E N T SERVICES REQUIREMENT-- S
or offered for sale(Section 7044,Business and Profession Code:The Contradors License Law does not apply loan Owner of property
who builds or*proves thereon,end who does such work himself or horse,or through his or her own employees,provided that such [r^
improvements are not intended or offered for sale.II,however,the building or improvement is sold within one year of completion.the ZONING APPROVED,;BY DATE:
owner-builder will have the burden of proving he or she did not build or improve for the purpose of sale). h �
❑ I,as owner of the property.am exduseey contracting with licensed contractors to c nstrud the project(Section 7044,Business and BUILDING APPROVED BY : DATE: -.
Professions Code:The Contractors 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)licensed pursuant to the Contractors License Law). H
❑ lamexempt under Section: B.A PL..for this reason: APPLICATION ISSUED BY: DATE: DI
*********Sb*****4R4******Sb9b******** * *SP****9P******ilei,*************14 **
Dew °w"°` LEGALIZATION:N FEE SUMMARY STRUCTURAL' SEGMENT:Y
I do hereby candy that I am aware of and understand the requirements of California Health and Safety Code Sessions 25505,25533.and
25534,and that lorany future buildingo«upanlwill/willnot(circlecos)needtocompywihsaiddmecodesadtherequirementsfor . BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
a permit for construction or modification from the Aiou ltyMenenagemenl District.Residential construction applications are exempt from these PERMIT 54 . 00 . 50
provisions.
Date: Applicant:
SMIP/NON—RES
PLAN
WORKER'S COMPENSATION DECLARATION:I hereby affirm under penally of perjury one of the(dowing declarations: ISSUE FEE
❑ Ihave and witmaintain ecentlice!.oconsent toeetimure for evon,as provided for by Section oft
3700 of BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
ode,for henna TOTALS > 54 . 50 0 .00 0 .00 54 . 50 54 . 50 .00
haveI end elf maintain waken'compensation insurance,as required by Section 3700 d the falser Code,for the performance of the
«kf«whitlh this permit is issued.My workers'gyrppeg>ADpq insurance comer and policy number are:
EXPIRES REVENUE DIVISION TOTALS--> COLLECTED: 54 . 50 OVER/SHORT: ,0 .0
Carrier:
504l4119C4.110004687 10/19/95 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN CHECK
Policy Number: 54 . 00 . 50
This section need not be completed a the pampa is for one hundred dollars 100)or leas.) -
❑ I certify dial in the performance of the work for which this permit / I shall not employ any pe manner m as to
become subject to the workers compensation laws d Califon', agree t : H should bjed to t.. workers' *'*'*'*K'*'X'*'*' '*'****'*****'*'N'iE161E1('!f"1h1f1f'if'1('i('ifl('I('if'i41f'141(IE1E1FiEihik141E1E1liF1EM'MN'iE1h1E'M'If'1PiE1E1E1EifiFi4l41fiE1E1(•')E1h1E14
®°°"- n°'ya/sa°j �gOw Applicant
°,' i. °"•'yw" those` INDIVIDUAL F E E BREAKDOWN
1( Gia (/ C/� i
"riming:Failure to secure worker'compensation coverage Is unlawhd,end shall subject en employer to cd.nal penalties all TYPE QTY D E $ C R I P T I O N UNIT COST TOTAL COST
civil fines up to one hundred thousand dollars($100,000),In addition to the coat of compensation,da as provided ler In
Section 3706 of the Labor Code,Interest,andegomey'a fees. SFR 2999 REROOF BY VALUE RESIDENTIAL NOZONE 1 .00 2, 999 . 00
• CONSTRUCRON LENDING AGENCY: I hereby affirm under penally of perjury that there is a and"mdion lending agency for the END OF FEES
performance of the work for which the permit is issued(Section 3097,Cir.C).
LENDER'S NAME:
LENDER'S ADDRESS:
I certify that 1 have read this application and state that the above information is coned.I agree to comply with all city and county ordinances
and state laws relating to building construction and hereby authorize representatives of this dry to enter upon the above-mentioned properly
for inspection punpoaes. LENE BURFOR' •
:71 Name j/
Signature d OwAganVApDcarhi •nlred« /Date:7ZO 9 /
01 00187154-00137.157 GCT
DATE: 07/2./95 TIME: 0?a24 54.50
/
(5151-65.WP) White-Building&Safety;Green-File;Canary-Appicant;Pink-Revenue;Goldenrod-Assessor
h_
•
1
CONSTRUCTION AND PLANNING •P00 SPA t
J4PPROVALS Permit# Date Inspector APPROVALS ' Permit# Date Irispector
• .
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location , .
2. Soil Pipe-Undrgrnd. J 53. Steel Reinforcement J
i--3.iElectrical Condtlit Utility-Undrgrnd. 54. Forms - .
z
c ':4`Electrical CondRt-l. drgrnd. - 55: Electrical Bonding , . 1.71-1
-
r .,-.. i
• %5:;�teel Reinforcement 56. Rough Plumbing & PressuFe-Test_ .T. °`
-tr4 lectricalUFE :6-nd. - _ 57. APPROVAL TO COVER-GUNITE •• •
i;.�7 CF,00tings 57 •
58. Electrical Conck :Undrgrnd. • ,
aQf Foundationo% - 59. Gas Pipe, 0 UritPgrnd., Test ,
J� p 'Cr.m ,
Water Pipe-Und..rgtnd.1 - 60. Backwash Lines,<L-Trap,16 Undrgrnd.
10. Structural Floor System , 61. APPROVAL TO`DECK i •'
•11.FProperty Sewer Line-& House',Connection 62, Backwash & Receptor-Final ,'
12. ewer Can i...? ' 63en 1 . Heater & Vent-Final ;
13. Roof Drains _ . - 64. Plumbing System - Final -.
14. Rough Plumbing' "--- 65. Electrical-Final ' '
2
15. Rough Electric Cofl^duit ,' 66. Solar System-Fynal '
16. Rough Electric2'iripg . `. l 67. Fencing & Acd cApprovat
17. Rough Wiring Sinn ! . 68: APPROVED F'QfjPLASTERING
-18. Rough Electricaj;T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Roush Heating & Air Conditioning -F1"R�EAEP141 EQUI�EMENT al
'- 6.1 is i•' I ' __ .*' '/. Qr• r. v
20. tough FfactoEf F eplace r •rc * _ .-.., ,22:1 C: APPeiTto •;4d4 , Permit#.: >,
21. Ducts, intrtictufE'• •• •• `'S " v - '- 7 "& ? t
1 x C., ^,-+ rr t 0`lJndergi ,uad Mi,'dro x
ti- , •. r .S G.Y, i- 1 t••'a,
22.-Ducts �e`ntitin��. `Ti .*. - C r; i-:i 71. ProducL'Piping t as broil
i- _ r:
23.Gas'PiperPo Tgh & Test T r s_ CC O1' r 72, Undergi5u�d i;ushe_ : c v
24.`RooTFr n ing' `•'r " ` p r '* S :-,cr
V;;: T s 7 . 7-4. Undergrnd.Staczje_-Tank ❑Gas 0Oil
r,
25. Roof••Shcgthing trio. C ., l 74aOverhead HYd' Ti
:-..•-•
,9gs �e ��
e n+ u t * v t.* c. i--,
26.'T-Bar Ceiljng (Strac urall &h1a�tocoat T n ..,p 7jyDry Che nical c.,-= Y. 7.-r1
27.Frame and Flashing- .x K ' i Wx - 76. Dry Sta dpipCw * - J
28. Lathing&'Si§ingL i - Y -1 7?•. FIXED-SYSTaci;.FINF4L-i
29. Insulation' • o:. l •• r , i ir S. FIRE PR EV. F1&AL , > u
30. Drywall Pn1:_.ail ng ".,:::.2...r., ,., ' S p;HEALt* DEPtT.REQUIkEMENT
31. Plaster Bcbw6Coat* 5 , TR+ 7.- ^ I 1 t`p, 79. FINALTPECIRON > ,' _
tv
32.`Electrica't`Power Meien44nal a: ! 1 j cc 8a. FOOD CERTIFICATE 6SSUEDi
. . 33.finai•Electric• .G i ;. ' u: (Totes: - ytr 4: !- n n%f7
34. inaT Hexing`.& 41N22pklitionirtg= n * ! ' `4 - 5 `moi Vrr
1 c,
35.;
OWNER SAN VISTA BUILDING CO. DATE 8-4-67
JOB ADDRESS 2423 Saratoga Way BUILDING PERMIT NO. 27392
GENERAL CONTRACTOR same DESCRIPTION of WORK res. w/att. gar.
AP No. LOT 245 TRACT 5160 FIRE ZONE VALUE $13,240.00
INSPECTIONS Si nature Date GROUP I&J TYPE V ZONE R3
SOIL S kid'"? SUBCONTRACTOR PERMITS ISS ED
GAS r Date Number Signature
W ATER`IL/ Sp J-/'C.•7 � / n lambing n L
ROUGH PLUMBING �y-/'•S / .2Yz5.) .;�ja /` t,y-o7 SO V ) #C.'I_M
PROP. SWR. LINE ❑ HOUSE CON.e- /(. Sir s/-iS"--(..;
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING /k- -u--6"7
TEMPORARY SERVICE OR POLE
UNDERGROUND 0 POWER ❑
ROUGH WIRING ';/%/7�y./j,�r� % y.(J/(,�7 Neatin and Ventf[, �/�' �f��J �}
TRENCHES ❑ FORMS ❑ STEEL REINF. ❑ �e �':x' Litre te. �J'Lj ' 17i"'12 !a7 jrf'tT.91 .
FLOOR SYSTEM ^ a= /f��rlllyyy(( -7;/ ! /
BONO BEAM n STEEL REINFORCE I I _
SHEATHING ? 7e/1,,.j , -i / •: .•
FRAME AND FLASHING ��,/ C JJJ /„ a - j9 67
LATHING — IN Fir-I `1- /p / - 1
PLASTER, BROWN COAT ' jipe- //I "J _
STRUCTURAL, FINAL APS! - / Sr I-
HEATING, VENT., REFRIG. AND A.C., FINAL ,� alio •� �/VVw.G�t" G'' --e ARES S
PLUMBING, FINAL AND GAS TEST sp- `ny�{-' /�4''-{.2
ELECTRIC, FINAL /iJ 7
BUILDING, FINAL Q-
27392 1
PAID
COSTA MESA BUILDING-SAFETY DEPARTMENT- AUG 11-67CNSA O 763* ***to7.5Q
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For Applicant to Fill In Completely APPLICATION FOR PERMIT
S4,(147 R PRINT 4147 BUILDING .
BUILDING lit g a n a., ^ L /„lar For Mike Use Only
ADDRE68 0�!' r o` /Lcv' 1'+� U' 1
RECEIPT NO. P 911T NO.
COSTA���"" �M/ES�AA.CrCALIFORNIA j�/y� q//� 0.... 75'90
OWNER Q--��11wy[[V ✓-1 /N{�,,6.4.2-1461.// R[C[I .(T / �y�� pAO Te/ _4
ADDRESS `L-� ( y "L/atibtP/L cl'N.U'Q ADDRESSFIRE yyyr----++++ (,JI//�j�-
(^1 'nJ TFL /` ZONE TYPE J °ROUTES
CITY '.o-it 1 .-Q NO. ���TI _
11�////////����ARCHITECT /J �,.�, ..11..�� APPROVED y7/// �/'0)
OR ENGINEER lf�/LY_ ..L1 NO. Z3—!ZZ' BY /' DATES �� y�
--1i-124,11-11"40
ZONING
ADDRESS 90a-cr�zy . wL.w 'O 0-4.4.1" n
ZONE NO.OF ntir, NEW F-i-,43;
R_3 PLANS a BUILDING /p,JF�
CONTRACTOR �.LL E Z A� -�vf
LEGAL I JI LRA'si b3
ADDRESS n clAALtiR- DESCRIPTION
CITY (� -L�(/^ A.P.NO. 56.,:30 .- 03 — z /S
:/ NOTE: NO[AVE OVERHANG SHALL BE LESS THAN
STATE TEL. BO'TO SIDE B REAR P.L
LIC.NO. NO.
VES
SIZE o� .r/ NO.Or BLOCS. ALLOWED (U.B.C.REQUIREMENT) - . -
OF LOT 9„0 K / a I NOW ON LOT �J
USE OR YARDS APPROVED YARDS APPROVED
EXISTING BLDG. ! MAIN BUILDING ACCESSORY BUILDING
-(FROM C/L STREET)
EETBACK4LHtGPROM FRONT 0 FT. FT.
CENTER OF STREET REAR YARD
SIDE YARD LEFT I RIGHT R.SIDE O Pr. - FT.
DESCRIPTION OF WORK L.SIDE 0 Fr. FT.
NEW ALTERATIQN ADDITION REAR 0 FT. PT.
DISTANCE BET. .BET.MAIN e
REPAIR MOVING DEMOLISH I MAIN SLOGS, ACCESS.BLDOS.
BUILDING NO.OF A/'.,/c!, / VAR.# DATE
SIZE ��II[ i Li ROOMS ! STQRIEs 1 C.U.P.# �I APPROVED r�
COVERINGE
EXTERIOR
1 (7I RCOVERING Vl ®�.PROV[D,../// DATE 7-Z7-1/
USE OF B•ueA w TO BE PfIFr� �nom"--LL�" "'�Wfre a
V �c ,L I.L(. Y 9
// yer
.196 0 sc.rr.J 9fo°' 1
I HEREBY ACKNOWLEDGE THAT/ NAVE READ THIS APPLICATION THE AMOUNT BNO UNDER VALUATION 18 FOR THE j
AND STATE THAT THE ABOVE IS CORRECT'AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT PEE ONLY. JA.
PLY WITH ALL CI NUNCIO AND STATE LAWS REGULATING VALUATION
BUILDING CONS UCTIO PERMIT FEE $ 7,c' PI
-
SIGNATURE OF
PERMITTEE -1-.4.4-�iC./v�- � .T9D PLAN CHECK Sr-29-)2,6-4-‘
G-�
/ $/ 9( ��,�J
AUTHORIZED AG
TOTAL FEE 5 7SO