HomeMy WebLinkAbout2062 SEA COVE LN - Building Permits ar
�� � CITY OF COSTA MESA
�°r9 ^`l BUILDING DIVISION PER IT NUMBER
• DEVELOPMENT SERVICES DEPARTMENT
PERMIT
B99-01353
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 2062 SEA COVE LN Status: ISSUED
Suite: Applied: 08/24/1999
Vicinity: Issued: 08/24/1999
Parcel Nunmber: 42201331 Zoning:
Applicant: DAVID KLAKOVICH ISSUED BY:
Address:
1K. '- Phone: 209.742-5779--1_ -,
/ /. -,;. •Zip: \-,
/ _ \ \
Owner: SEABLUFF CANYON'HOA ', `/' --.„,? Vc:N
Address 2062-SEA-COVE LN t / -_ . _ - __ I. (- .-1 7 'H -,77:,N
/ '/ ' v A \ r ,- :Phone ' 949-631,-0086i ,- �� N,.A
/, COSTA MESA,CA �� Zip: 92627 �& 1 / jy�
/r // N ,'l 2-' ------:.--,>-:->:;<',... / /AVN;,j\
r, .�� (\y/ / Adv�`
Contractor:A PONDEROSA-ROOFING ;' .y. /`
.Address: 7045 HITES COVE �\`�\
i'/ -'iii%% '/ V,,.A
r CA i Phone;- 209-742-5779 1�� ti
1 i7/ MARIPOSA - V-i.\,' -'+ �A
Zip:: 95338/ License: 615531 •_ - \‘10.`, ,i'
Arch ., r _ -- I Eng: �; ; •
..-Address: ,.i� - e /- — Address: , ,� - V'
F '. Phone:"
I1- 3 " / \\\;‘--,:,4",\:‘� � ; �
i' -�`;� ls',. . t
� Zip: I. License: _ r License:
- . _ -- - SCOPE OF PERMIT-- -- - y
T/OFF AND REROOF 6500SF 4UNIT CONDO W/CLASS'S"WOOD SHAKES.ADDRESS INCLUDES 2064,2066'AND 2068 - \
SEA COVE. . - ,.
FEE SUMMARY
\,, Plan Check • ` . i' " e '` 6� t
`, $0.00 . ' � � '- f 1 , ��` _� Calc Valuation ! $z2`000.'oo,
N ' : Permit x$349.25 __ r - -Claim Valuation $2200000
,, SMIP Res:,,', . $2.20 ;1,- ' ,','! 1'
'`SMTP Com. ,:., $0.00X111111
v`- Other- ,1^$0.00 -
Inspection:' 'x\-$0.00 _.
A * . ` ;
,T/�;Total. $351.45 � ��
PLANNING &ZONING ,f:. - ,, .
SETBACKS- -- '�" . . _`, / /
MAIN STRUCTURE'Front/ 0-0 Rear 0-0 - , s -Left • '0--0 - Right• - 0-0- ,
� - ' - .; "i
ACCESSORY Front- 0-0 - Rear 0-0 Left 0-0 . Right. 0-0,',,-
PARKING Existing: 0- ,. Required: 0 Proposed: 0
NOTES: 1
•
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. t '
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
•
DECLARATIONS L-% `J U •
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: cS.7,/7/_ Policy Number:
(This section need not be'completed it the permit is valued at one hundred dollars($100)or less.)
❑ I certify that In the performance of th., work for which this permit is issued, I shell not employ any person in any manner so as to become subject to the workers'
compensation laws of Califomia,a.. agree that if I should become subect to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these provisions
Applicant Signature: Date:
WARNING:FAILURE TO SECUR- ORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOU ARE($100,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Sect 000)of Division 3 of the Business anderofessio-(,1s Code,and my license is in full
force and effect.LIc.# Sc cam/ Class It
Contractor's Signature: ✓ Date: 4F---Z4 —c(30
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,Gry 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 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 Califomia 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 0 No
(Section 25534 of the Califomia 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.
..--..----- presently required, Safetyfully p - '-------
4 If an RMPP is resent) has Section 25534 of the California Health and Code been complied with? ❑Yes ❑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? 0 Yes U 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
(If yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia 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 ❑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.
Sign re Of Legal Owner(s) at��,,,,
t—t"J.-..:J
Or Authorized Applicant Date
CODE it INSPECTION TYPE PATE INTITIAL$ CON. INSPECTIONTYPE EAAg INTDIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 9 Y 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
2446-46
eA C1TY OF COSTA MESA REQUEST .FOE OCCUPANCY
TRACT NO. SM 121 DATE
LOT NO. 53
R
Eo oD
ADDRESS 2062 Sea Cove DEpt•
KMOING
0311 1 ' Pm
The developer of the above entitled tract dgAires tosell ,tlltil &%&et forth
-Z/ igi91101111121
lot prior to the time that the tract has beep 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. The undersigned acknowledges that this
agreement is made solely for the :;eneft of the city and does not inure to
the benefit' of the undersigned or any of them.
•
. BY
.. . - Pu c aser�•
•
BYE
Developer /or authorized
• represent rive
GREAT WESTERN
BY SAVINGS & LOAN ASSOCIATION
8g§lidaSHIRE BOULEVARD •
""x'•• I BEVERLY HILLS, CALIF. 90211
• 64.-J
t/ a ��
. 000
(ma pggSIDENt
CITYOF COSTA MESA REQUEST FOR OCCUPANCY
TRACT NO. J` 1 I 'a\ DATE
LOT NO. 53
ADDRESS soUa p2l Cut
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
14:2,_ept_i 11>ef-eaAA-12
Purch&Ser
BY
Developer and/or authorized
representative
BY
Lender
CITY OF COSTA MESA.'
BUILDING SAFETY DEPARTMENT .
POST IN CONSPICUOUS PLACE •
ON THE JOB -
t
.. - DATE ISSU D
MAR. �® /.9 V,
.• A,P, NO. PERMIT NO.
• 45335
, BUILDING ADDRESS
2062 Sea Cove
' TRACT LOT BLOCK
' '10018 53
NEW ADD ALTER REPAIR MOVING DEMOLISH
•
E .
OWNER -
The Gregory Company
'i j, , -USE -
. . ..Rea: w/att. Garage .
f.i • FIRE ZONE TYPE GROUP - _
ao PDR-MD - V T & d
t ;,.S'3' PhSETBACKS '- ;
' ' . Front Yd '5' '. Side Yd- R L_0_ Rear 8' 4 •
Side Yd. R L ' Rear - .
BUILDING 'INSPECTION RECORD
TO KEEP BUILDING.PERMITS VALID, WORK 'MUST BE COM-• .
- - MENCED WITHIN 60 DAYS WITH ROUTINE INSPECTIONS.AT -
LEAST EACH 120 DAYS THEREAFTER UNTIL COMPLETED. '
.. ;,• . ` ',STRUCTURAL_,/ M•. DATE •'
r " Trenches It Forms r[3 WS:011 ' •
Floor SVs[em ,�fi'�•• � .
Steel Reinf r,1 �EZEIMI : •
• Sheathing
FY" .i rame and Flashing �,Era
illireln -.
Insulation' W,��)altr)� /L-- - 1 , -
• _ath.ing r Nam Z' d-70 ,
Dry Wall Nailing
OM. / -to
Plaster;Brown Coat _ 1.10Wa '
• ' Sound Attenuation '
•
Handicap Regulation mango i
•
FINAL .j
k,_ - - PLUMBING •
r-
I Soil :V),K(� '-i- S' 5
• Underground Water 7- dts, i_, - /41...V.
Rough Plumbing 7�, ,C"2-24..-:. 7n'
Prop.Sewer Line and House Conn K/ � //"Q"7/
` ''� .• Street Sewer Conn. �/'; ////-7'�
r
•
Water Service G -�� '310-70'
i
Sprinkling System �,�� /� �7
•
Gas Test /t/("�•� t°///s 7i }
- FINAL �- S-JQ
HEATING, AIR-COND.AND REFRIGERATION
• Refr. Lines,Pressure Test ,
.
Ducts, Underground - �/c� /3'L"74'
Ducts,in Structure O//e` fi/942-/e--,1 e
Ducts. Ventilating - ' ✓cf� /.--4,ye
•
is Rough Heating and Air-Cond. , 7-4-Zia
• FINAL 0/0 3-8-79
ELECTRICAL :/-
Temporary Service or Pole —� — .
•
;i r. ...,
Underground 'VOW'' /F'�2740 •
Power Meter I .
Rough Wiring - 6/1%" ,[/7r- OYt
FINAL #5-a) "---.6-_7,9
Do not occupy this project until final inspection has
' _ been made and occupancy has bee approved
• Building Final 5--f7)(1
Special Requirements
' Occupancy '
NOTICE
24-hr. notification required when the job is ready for inspection. You
• must furnish PERMIT NUMBER and the JOB ADDRESS FOR EACH
RESPECTIVE INSPECTION. CALL 556-5273. •
-
` • APPROVED PLANS SHALLBE ON JOB AT ALL TIMES
CMF.5?dh
OWNER THE GREGORY CO. DATE 3-3-78
JOB ADDRESS 2062 Sea Cave BUILDING PERMIT NO. 45335
GENERAL CONTRACTOR Same DESCRIPTION of WORK Res.w/att. Garage
AP No. LOT 53 TRACT 10018 FIRE ZONE VALUE S 42,700.
INSPECTIONS Signature Date TYPE V GROUP L&' tj ZONE PDR—HID
SOIL - PE$MITS ISSUED
GAS SUBCONTRACTOR Dote Number er I
Sianature
WATER
P
ROUGH PLUMBING � t / �]
PROP. SWR. LINE Q HOUSE CON, / or /t , 7i f/.
ta
SPRINKLING SYSTEM - t t .>$# /O as%- q 7023/
M fSCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING
TEMPORARY SERVICE OR POLE
UNDERGROUND fl POWER
ROUGH WIRINGHeat' •,an V . t J j
TRENCHES U FORMS Li STEEL REINF. O (fly1-i 7/ at
• T..07-11-1A/
/ 1 i 3
FLOOR SYSTEM 4/i F' 111,11',018 Aral.
BOND BEAM ri STEEL REINFORCE 7
SHEATHING
FRAME AND FLASHING
LATHING - IN n OUT
PLASTER, BROWN COAT
STRUCTURAL, FINAL • Eland c •
HEATING, VENT., REFRIG. AND A,C., FINAL
PLUMBING, FINAL AND GAS TEST n
ELECTRIC, FINAL
BUILDING, FINAL /fat. 5;G.79
�' 45335 38. 99 j/05/78 I'I'0e89 Ti.
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200. COSTA MESA,CALIFORNIA 92626
V
APPLICATION FOR STRUCTURAL PERMIT
For Applicant to Fill in Completely — Use Ink Only
RECEIVED BY DATE RECEIVED DATE ISSUED
BUILDING a' �t /�
_ADDRE5S�U�pzs� (�.O✓� �yy,J� inns
OWNER tho gregf1Y'�[ (`(1T1T1Any A.P. NO. /o, ter[ o / PE inns
• MAIL BUILDING /y
ADDRESS 3187-g Airway ave ADDRESS2Q62 gem air',
C o • C
CITY costa mesa NO`' 51-385C TRACT' 1001E1 LOT• 53 BLOCK
CONSTRUCTION NEW ADD ALTER I REPAIR •(MOVING OFMOI ISH
C •
BRANCH
OWN the gregory company
ADDRESS •
OOR ENGNE R harrison/1orenziM. 751-38gt15 -
w/att garag4 4296000
FIRE
ADDRESS 3187-g airway ave ZONE TYPE V GROUP I&J
APPROVED
CONTRACTOR gregory construction co BY DATE
ADDRESS 3187-g airway ave •
TEL. O E O.OF USE OF is,:,&12...r..
CITY costa mesa NO. 751-384 t� NS L....., BUILDINDk C_t,.
it�y+ 8
STATE o (gyp8CITYYARDS APPROVED YARDS APPROV D
Qi LIC.NO. 2591 LIC. NO. 00817L MAIN BUILDING ACCESSORY BUILDING
671 SIZE 429'x992' NO.OF BLOCS. 0 (FROM C/ EET)
A. OF LOT NOW ON LOT FRONT FT. FT.
a USE OF ,t�y.��j,�. •
EXISTING BLDG.
R-5112E 7 T. FT.
z
[—I
. Separate permits are required for L.SIDE FT. FT.
• electric,plumbing and heating work.
/ - - _REAR 13 FT. FT.
GM RUSE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
Q� MAIN BLDGS.^ ACCESS.BLOGS.
VAR.# / /0 DATE I7 t _72
Q . C.U.P.# // ^ DATE f] /(Q Q
,.. At had garage JROV�j"', �N DATE 3[D -? 0
a HOLD FOR SPECIAL REOUIREMENT5
W
QI hereby acknowledge that I have read this application and state r.,N
yz that the above information Is correct and agree to comply with . -. -
0-1 a ell laws regulating building construction, and I shall not employ
Z any person in violation of the workman's compensation laws of i
677 the State of California. , -
3 I hereby certify that I am properly licensed as a oractor under I1562 SO. FT. 626 garage w
nt
the State of California Business and Professio itode, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m
Chapter 9, and that such licenses .-• in d, II e and effect,or I THE PURPOSE OF ESTABLISHING P.PERMIT FEE ONLY:
tD
am exam. ro the provision • he —t California Business VALUATION PERMIT FEE $ a
and Pro -Worm••de, Divisio ha. er r. In
Signet e ofIFF
/ / PLAN CHECK $ !d 7.90
e/o 2
PaimlKee /�_ $ /(� TOO
TAX $ '1e !O
7 ` d /aV{e
U
AuthorizAir
t TOTAL PAID $ /�/t
%a firair
7255 3/13/78 .166.00 TL
COSTA MESA BUILDING-SAFETY DEPARTMENT 7255 3/13/78 I66.000KTO
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 7a5 nnfint,653 aF 1 A
APPLICATION FOR STRUCTURAL PERMIT '•
For Applicant to Fill in Completely—Use Ink Only RECEIVED BY DATE RECEIVED■ DATE ISSUED
BUILDING �^ /J /
ADDRESS 2, ps
/ PERMIT NO.
OWNER / i i - A.P.NO.
MAIL / BUILDING �D /. �J
ADDRESS
/ ADDRESS 41
TEL.
CITY NO. TRACT LOT BLOCK
CONSTRUCTION NEW (ADD ALTER REPAIR MOVING DFMOLEH
LENDER
BRANCH pay
. OWNER i &A -• •
A
ADDRESS /,JJrt .
ARCHITECT TEL. USE Pic is /. -1 /
OR ENGINEER NO.
. FIRE
ADDRESS ZONE TYPE GROUP
APPROVED
CONTRACTOR /(fBY DATE
ADDRESS
TEL. ZONE NO.OF USE OF NEW
CITY NO. PLANS. BUILDING
F STATE CITY YARDS APPROVED YARDS APPROVED
LIC.NO. LIC.NO. MAIN BUILDING ACCESSORY BUILDING
LU SIZE NO.OF BLOCS (FROM C/L STREET)
0. OF LOT NOW ON LOT FRONT FT, FT.
Q USE OF
.�. EXISTING BLDG. R SIDE FL FT.
to
I-,
Separate permits are required for L.SIDE FT. FT.
electric,plumbing and heating work.
W REAR FT. - FT.
Foy USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
Q< MAIN SLOGS. ACCESS'BLOCS.
��, / VAR.# DATE
Qs s C.U.P.IP APPROVED
.l/ U APPROVED
wl —11Y DATE
12W
0 I hereby acknowledge that I have read this application and .tate n
04 that the above Information Is correct and agree to comply with m
C. all laws regulating building construction, and I shall not employ •
Z any person in violation of the workman's compensation laws of
the State of California.
3 I hereby certify that I am properly licensed as a contractor under SQ.FT. — a
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR 0
Chapter 9, and that such licenses are in full force end effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
am exempt from the provisions of the State of California Business VALUATION PERMIT FEE 3 /4G�OD n
and Professions Code, Division 3,Chapter 9.
Signature of ,S PLAN CHECK >< 0
Permittee S / TAX $ F
U
TOTAL PAID f //_/
Authorized Agent e e)(11L6 (/Y