HomeMy WebLinkAbout309 WALNUT ST - Building Permits t
t
4`0'"tf4 PCITY OF COSTA MESA
BUILDING DIVISION
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E PIZYZ
• � t DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
PERMIT E01-01026
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(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 309 WALNUT ST Status: ISSUED
Suite No Applied: 12/07/2001
Vicinity: Issued: 12/07/2001
Parcel Nunmber: 42629202
Applicant: DAMON VANOOSTENDORP ISSUED BY: S/-
Address: -
' Phone: 949-646-5062 •
Zip:
- - N
Owner: .' PENDERGAST, PAUL • - - ,
• Address • 309 WALNUT ST
Phone: .
COSTA MESA,CA Zip: 92627 ' 4,
A. -
�'0� •
•
Contractor: JETTY ELECTRIC
Address: P.O. BOX 3033 •
•
.
.Phone: (949)646-5062
NEWPORT BEACH, CA Zip: 92659 '
License: 677322
SCOPE OF'PERMIT _ '
SERVICE UPGRADE TO 200AMP. - _ / - -
FEE SUMMARY .
buantity -- - 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 $0.00 0 .., - up to.-100 kva/kw $0.00 0
r Switches $0.00 0 . over 100 kva/kw . $0.00 0
Non Res Appl $0.00, 1-- : 0.. Low Voltage Equipment - $0.00 0
Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 '
• Service to 200a $30.50 - 1 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 $54.00
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
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 i
2446-46(6&00)
}
DECLARATIONS w
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'` c mpe/v0s5ation Insurance car rr and po.I6number are: ✓ (�^/
Carrier: J FLOC / i✓✓ / Policy Number: 7 5- •
((his sectIODJTe//ed not be completed if the permit is valued at one hundred dollars($1 Jar less.)
❑ I certify that in the performance of the work f hich this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Califo and ogre at if shhoulJ-beome subject to the wo ers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provisio C )
Applicant Signature: Date: 2 - 7-Q
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 1 am licensed under provisions of Chap! (commencing with Section 7000)of Division 3 of the Business and Processions code,and my license is in full
force and effect.Lic.# r^/ 77 _ / - Class it C rf C)
Contractor's Signature: r-- Date: 72 ' -0(
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 operty;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,Businesss and.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. ❑Yes ❑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:
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? ❑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 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.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully 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 apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ 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 ❑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 California 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 purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signator gal Owntr(s)1, Da
An Or Authorized Applicant Date
CODE# INSPECTION TYPE DATE INTITIALS CODE# INSPECTIONTYPE PATE INIm9LS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing / •
200 Final Re-Roof 210 Final Electrical 471.7
201 Final Block/Retaining Wall 212 Final Fire Prevention lit Q:1r
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
c w -I I .
. -
CITY OF COSTA MESA .
BUILDING DIVISION
FN_ .T. 1 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.0
J. FOR INSPECTIONS CALL: (714)754-5626
PERMIT NUMBER B08-00177
PERMIT TYPE B_ROOF2 STATUS: ISSUED
APN: 42629203DATE ISSUED: 06/09/2008
--- ISSUED BY: CAC
JOB ADDRESS: 311 WALNUTDST CM _ Suite/Unit:
Vicinity: . .
Squares: 0 Valuation: .' , •$5,800.00
SCOPE OF WORK: HOUSE-ONLY.TEAR'OFF_ROCK ROOF INSTALL 2 PLY 15 LB FELT AND 3O YEAR COMP. SHINGLES ON A 3:12
SLOPE.•
OWNER: KRAUS,LARRY TR ''. _ Address: 2553 GREENBRIAR LN . Unit:
PHONE: 714-641-9042 City/State/Zip: COSTA-MESA,CA -
APPLICANT: BARNETT,CHRIS _ .. Address: 126 E 18TH ST • . Unit: :UNIT
C103
PHONE: 714-724-1938 City/State/Zip: COSTA MESA,CA
CONTRACTOR: BARNETT ROOFING - - • License No. 661981
Address: 126 E 18TH STUnit: UNIT C103 PHONE: 714-724-1938
City/State/Zip: COSTA MESA,CA '- 92627' ..... . - CELL: - -
ARCHITECT: License No. _ ' PHONE:
ENGINEER: • License-No.. . . r rr PHONE
FEE SUMMARY
Reroof Plan Check: • =;$O.00r� ---. - _ • . - •
Reroof Permit Fee: $125.25 i - - .
Reinspection Fee:
TOTAL FEES $125.25 - '
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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
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.
CODES. INSPEC11ON TYPE DATE INTn1ALS CODES INSPECTION TYPE !ATE INTI11ALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final • 208 Final Plumbing
200 Final Re-Roof F/Pr - 6//3!o a ` Electrical210 Final V 210 Final ElP evention
201 Final Block/Retaining Wall
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign - 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
r ..�
WORKERS" OMPENSATION DECLARATION: Owner ID verified by driv Ise. 0 Yes 0 No
I hereby affirm under penalty of perjury one of the I,......wing declarations: Driver's License No. - Expires:
DI have and will maintain a certificate of consent to self-Insure,/or workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed):
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
s ion 3700 of the Labor Code,for the performance ofthe work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: -
permit is issued. My workers' compensation Insurance carrier and policy 0 I hereby certify that no excavation five(5)or more feet in depth into which a
For-,� person is required to descend,will be made in connection with work authorized
r V 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
qn need not be completed A the permit is valued at one hundred dollars($100)or less.) 2,Art 2Sec.341,Title 8,California Administrative Code).
Policy Number:
0 As owner-builder, I will not employ anyone to do work which would
0 I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above, unless
issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California, and agree that if I should
become subject to the workers' compensation provisions of Section 3700 of
Applicants Signature Date
the Lab. o.'- I .h.Al h.ith com. with these provisions. p�
A. Vif�Q CJ\ Division of Industrial Safety Permit Number:
Applicant's Signature Date+ HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. 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
LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons,or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
A its in full.force
and effect. ' (� G� a registration form for acutely hazardous materials? 0 Yes 0 No
R� 4•I ll I SJasaroi Ly� 1 (Section 25533 of the California Health and Safety Code, with some
--
elk
_ r ^ / f, . Gob exceptions, requires registration with the Costa Mesa Fire Department by
_`/Uv b /`4#.`J� each business which at any one time has on hand a quantity of acutely
Con dor ignature ate 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for Mich this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name: hazardous materials)? 0 Yes 0 No
(Section 25534 of the California Health and Safety Code provides that the
Lender's Address: 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.
Signature Date 4, If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes 0 No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? ❑Yes 0 No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Govemment Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors information be fumished on applications for non-residential building permits).
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 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? 0 Yes 0 No
applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes",the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec. 7044, Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No
thereon,and who does such work himself or herself or through his or her own
8. (If"yes",attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements-are not intended or offered for
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE:.I.certify that under penalty of perjury-the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
-city ordinances regarding Hazardous Materials and Emissions.
❑ 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 Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
0 am exempt under sec. the information given is correct. I-agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: 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.
Stgnat f LzP I Ownerls n Date
Signature • Date • 1—„C1
3051-46 01071 Andn d Applira t v opal to
1 r . I
CITY OF COSTA MESA
BUILDING DIVISION
> %f ,.,,,. ..►I DEVELOPMENT SERVICES DEPARTMENT PER T NUMBER
11.1411 PERMIT
.amr w OS-02274
(714)754-5273 • Fax(714)754-4856 • www.cl.costa-mesa.cawILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 309 WALNUT ST Status: ISSUED
Suite: Applied: 12/13/2005
Vicinity: RESIDENCE AND ATTACHED GARAGE Issued: 12/13/2005
Primary Occ: R-3 Dwellings/Gong Res<10 Type of Construction: V-N
Parcel Number: 42629202 Zoning:
Applicant: ENRIQUEZ, CARLOS 44,
Address: 22365 EL TORO RD
SUITE 297 Phone: 949-770-7663 ISSUED BY: i
LAKE FOREST.CA - Zip: 92630
Owner: CIRAULO, JOSEPH C TR
Address PO BOX 1157
Phone:
NEWPORT BEACH,CA Zip: 92659-0157 ,
Contractor: PLATINUM BEST VALUE ROOFING CO
Address: 22365 EL TORO RD
SUITE 297 Phone: 949-770-7663
LAKE FOREST,CA
Zip: 92630 License: 753512
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
REROOF RESIDENCE AND ATTACHED GARAGE:T/O EXISTING COMP ROOF,REPAIR/REPLACE SHTG AS NEEDED,1 LAYER 30#FELT(SBS BP
"EAGLELITE MALIBU TILES."
5.5 PSF ICBG#ER-4660
4200 ST FT
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $15,000.00
Permit: $251.25 Claim Valuation: $15,000.00
SMIP Res: $0.00
SMIP Corn: $0.00
Other: $0.00
Inspection: ' $0.00
Total: $251.25
PLANNING &ZONING
SETBACKS •
MAIN STRUCTURE Front 0-0 Rear 0-0 , Left 0-0 Right 0-0
ACCESSORY Front 0-0 . Rear 0-0 Left . 0-0 Right 0-0
PARKING
Existing: 0 Required: 0 • Proposed: 0
•
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(WOO)
i t
DECLARATIONS
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.
p-}i1 have end 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'ecompensation Insurance carrier and policy number are:
Cert e�J7� �.u..-d) Palicy.Numberf 1 "233 1 r)--,- 30O'1
(This section need not be completed i/the permit is valued at one hundred dollars($100)or less.)
❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Calif. ,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
_ comply with these pro ' ns _
Applicant Signature: (D Id-- 13 'OJ
WARNING:FAILURE TO SECURE WO'tar ATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DrY I ARE(5100,000),IN ADDIT•, • COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that.l.am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Ls in full
force and effect.Lic:ai ' 5'S 51,. Class-0 C -1,1
-
Contractors Signature: 1 (D81 la -13 - 0y
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,CMI Code).
Lenders Name: Lender's Address:
Signature: - Date:
a.,,,;:;0.
OWNER-BUILDER DECLAff7ONS: 1,z
I hereby affirm under pena4g$t erjury tljet' an EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Cotl4'7.ny city unty which,req'Lires al permit to construct,either,improve,demolish,or repair any structure,prior to its Issuance,also requires the applicant for such permit
titsigned men(thafhe or'She Is licensed pursuant to te provisions of the Contractors tUcense taw(Chapter 9(commencing with Section 7000)of Division 3 of the
Y8' G958 and Pr Bions Code)or that he or she is exempt therefrom end the basis for the alleged exemption.Any violation o1 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 properly,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 properly,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. 0 Yes 0 No 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 Califomia Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health 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 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 permit 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 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? 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 purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Si t 1 Legal Owner(s) Date
�J ���� 1a- ) 3-OS-
nd/Or,jtAet acf'Ouyplicant (Date.
CODE r INSPECTION TTP[ PAIL INTMAU . CODE INSPECTION mg OATS 1ICEMAL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical •
1266 Pool Spa Final a � 208 Final Plumbing
200 Final Re-Roof �I~ If 111 O& r / 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 • •