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Home My WebLink About164 VIRGINIA PL - Building Permits CITY OF COSTA MESA . BUILDING DIVISION Ca. F DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER PERMIT B03-00248 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 164 VIRGINIA PL Status: ISSUED Suite: B Applied: 02/12/2003 Vicinity: #B KITCHEN, BEDROOM,BATHROOMS, LAUNDRY Issued: 05/01/2003 Parcel Number: 42606220 Zoning: Applicant: WERNER, JAMES M ISSUED BY: Address: 164 VIRGINIA PL Phone: 949-548-1784 COSTA MESA,CA Zip: 92627 Owner: WERNER, JAMES M , Address 164 VIRGINIA PL Phone: COSTA MESA,CA Zip: 92627 Contractor: Address: ' Phone: Zip: , Licenser. Arch : - Eng: ROBERT COULSON • , . • Address: Address: 7801 ORANGETHORPE AV Phone: #5 Phone: 714-522-2836 BUENA PARK,CA., Zip: License: 90621 \ License: 1730 SCOPE OF PERMIT- CONSTRUCT 276 SF SINGLE STORY ADDITION TO AN EXISTING SFD,UNIT"B."WORK TO INCLUDE EXPANSION OF THE EXISTING - KITCHEN, RELOCATION OF THE LAUNDRY ROOM,ADDITION OF A BEDROOM;AND ADDITION OF A NEW BATHROOM WITH THE REMODEL OF AN EXISTING BATHROOM.A 32SF PORCH/PATIO COVER WILL BE ADDED ABOVE AN EXITING DOOR OFF THE EXISTING MASTER BEDROOM. MM-03-06 FOR REDUCED DRIVEWAY WIDTH-FOR 2 PARALLEL PARKING SPACES. 1-SPACE ADDED TO THE PROPERTY FOR BEDROOM ADDITION. - LOT-8,475 SOFT. BLDG.-26%(2,175 SO.FT.) PAVING-20%(1,712 SO.FT.) OPEN SPACE-54%(4,588 SO.FT.) FEE SUMMARY - Plan Check: $307.16Calc Valuation: $32,018.24 Permit: $472.55. Claim Valuation: $0.00 SMIP Res: $3.20 • SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $782.91 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. 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/Do) DECLARATIONS (> WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: .a ❑ 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 pertorinancl,pf 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: (Thisaction need not be completed if the permit is valued at one hundred dollars($100)or less.) 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 Califomia,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these p .visions. — Applicant Signature: Date: S — 0 WARNING: •SE D' WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,1100). 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 Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class# Contractor's Signature: 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).): 0.' 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 exemptder sec Business and Professions Code for this reason: Signature: , - ' > 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,California 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 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 Dees 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 Masa 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 appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency'? D 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 Safety Code Section 42303 been made? 0 Yes ❑No B (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-de ribed property for inspectio urposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. r Signature Of Legal Owner(s) Date And/Or Authorized Applicant Date CODE P INSPECTION TYPE PATE INTRIAL$ CODE• INSPECTION TYPE PAIS Mad 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 • 3artiV • x`,57 'S \ CITY OF COSTA MESA 4* BUILDING DIVISION 1, Fw.n.s "),• DEVELOPMENT SERVICES DEPARTMENT 1ERMIT NUMBER 4 PERMIT E03-01045 , (714)754-5273 • Fax(714)754-4856 • Www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 164 VIRGINIA PL Status: ISSUED Suite No B Applied: 11/06/2003 Vicinity: Issued: 11/06/2003 Parcel Nunmber: 42606220 Applicant: STEVE HAGLUND ISSUED BY: _ Address: 502 S SANTA FE ' Phone: 714-550-9997 . SANTA ANA,CA Zip: 92705 Owner: WERNER, JAMES M_ \c Address / 164 VIRGINIA,PL Phone: COSTA MESA,CA Zip: 92627 , Contractor: R S HAGLUND CONSTRUCTION Address: 2265 S.RITCHEY ' "Phone: (714)241-1741 • SANTA ANA,CA Zip: 92705 - License: 412567 - • .• SCOPE OF PERMIT CONSTRUCT 276 SF SINGLE STORY ADDITION TO AN EXISTING SFD, UNIT"B."WORK TO INCLUDE EXPANSION OF THE EXISTING KITCHEN, RELOCATION OF THE LAUNDRY ROOM,ADDITION OF A " BEDROOM,AND ADDITION OF A NEW BATHROOM WITH THE REMODEL OF AN EXISTING BATHROOM.A 32 SF PORCH/PATIO COVER WILL BE ADDED ABOVE AN EXITING DOOR OFF THE EXISTING MASTER ' • BEDROOM.REF.: B03-00246 • ELECTRICAL TO INCLUDE:7 LIGHT FIXTURES, 16 OUTLETS,7 SWITCHES,AND 2 SERVICES TO 200 AMPS. 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 • $7.70 7 up to 50 kva/kw ,$0.00 0 , ' Recept Outlets $17.60 - 16 up to 100 kva/kw $0.00. 0 Switches $7.70 7 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 $61.00 2 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 • INOTICE: 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,permitshall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned Ifor 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 I 2446-46(6/00) DECLARATIONS f ( I ) WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: •0 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. -8' 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: Cartier: 5+414E -'TY h el Policy Number: O 127 ES Z (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ 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,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisionns. Applicant Signature: i .�N Date: 11-61-a" WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST 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 Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force end effect.Lic.s 4 L ZS Lr7 Class p S- Contractors Signature: /e A 01141.A...4--.4 Date: Si -ro-o7 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: Lenders 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 ❑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: I 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? ❑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 aPPermit for such construction or modification from the South Coast Air Ouality Management District or from any other air pollution control district or agency? 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 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. Signature Of Legal Owner(s) Date X2 .4 a -A-( And/Or Authorize pplicant pate PAPE I INSPECTION TYPE P9IE LN7IDAL4 ODE f INSPECTION TYPE PAIL MALE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 3-14•7-DV Abe 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 CITY OF COSTA MESA - 4"H) BUILDING DIVISION >:f . DEVELOPMENT SERVICES DEPARTMENT PER IT NUMBER t /4• 011 . PERMIT "taa, ,o s P03-00736 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 164 VIRGINIA PL Status: ISSUED Suite No B Applied: 11/06/2003 • Issued: 11/06/200320 Vicinity: ! ,l// Parcel Nu umber: 42606220 ISSUED BY: Applicant: STEVE HAGLUND - Address: 502 S SANTA FE - Phone: 714-550-9997 SANTA ANA,CA Zip: 92705 Owner: WERNER, JAMES M Address 164 VIRGINIA PL ' •„, Phone: N COSTA MESA,CA Zip: 92627 Contractor: R S HAGLUND CONSTRUCTION " Address: ' 2265 S.RITCHEY - Phone: (714)241-1741 - SANTA ANA,CA " Zip: 92705 License: 412567 - Arch / Eng: . _ . . - - - - - - Address: . Phone: Zip: License: - SCOPE OF PERMIT CONSTRUCT 276 SF SINGLE STORY ADDITION TO AN EXISTING SFD,UNIT"B."WORK TO INCLUDE , ' EXPANSION OF THE EXISTING KITCHEN, RELOCATION OF THE LAUNDRY ROOM,ADDITION OF A BEDROOM,AND ADDITION OF A NEW-BATHROOM WITH THE REMODEL OF AN EXISTING BATHROOM.A ' .32 SF PORCH/PATIO COVER WILL BEARDED ABOVE AN EXITING DOOR OFF THE EXISTING MASTER BEDROOM. REF.:B03-00246 / PLUMBING TO INCLUDE: 1 BATHTUB,1 DISHWASHER, 1 GAS(1-4 OUTLETS), 1 SHOWER, 1 , KITCHEN SINK,2 WASH BASINS,2 WATER CLOSETS,AND 1 WATER HEATER. -. - FEE SUMMARY AMT QTY AMT gTY . AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 Sump Pump " $0.00 0 Backflow irrigation $0.00 ' 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $9.80 1 • Pressure Regulator $0.00 0 - Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $19.60 2 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 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. 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: Carder: 5faf>: -C“.r.all Policy Number: Ol 2.7S Z.- (This (This sectlon need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ 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,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisio0s. Applicant Signature: ADate:Data: 1 I- b-03 WARNING:FAILURE TO SECURE WORKERS'CCLPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEE$. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect.Lic.N 41 zs/o'-1 Class ft 8- Contractor's Signature: Jr A a•inc, -..-s ( Date: I t- G,-02 CONSTRUCTION LENDING AGENCY: J ❑ 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).): o 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.). O 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,Callfomia 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? ❑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 Callfomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of en 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_aPermit 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 LJ No (Section 65850.2 of the California Govemment 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 ❑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? ❑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 purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) Date -g OXez II —Gi -p3 And/Or Authbrized Applicant Date CODE f. kJSPECTIONTYPF - IH)IDMI& ;ODER INSPECTION TYPE 121,11 INImAL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical ' 3-9- 0V "/ 1268 Pool Spa Final 208 Final Plumbing - /V 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