HomeMy WebLinkAbout268 WALNUT ST - Building Permits •
4 �,;: CITY OF COSTA MESA
w � �,� BUILDING DIVISION PERMIT NUMBER
t;t ,"``"' ' DEVELOPMENT SERVICES DEPARTMENT
riCli
��;
* PERMIT
' c.mm E99-00434
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
• ELECTRICAL PERMIT
Job Address: 268 WALNUT ST Status: ISSUED
Suite No Applied: 05/19/1999
Vicinity: SIDE YARD BEHIND CARPORT Issued: 05/19/1999
Parcel Nunmber: 42628320 ^
ISSUED BY: ne)
Applicant: WILLIAMS, CAROL
Address: 268 WALNUT ST
Phone: (949)645-4410
COSTA MESA,CA Zip: 92627
Owner WILLIAMS, CAROL
Address 268 WALNUT ST
Phone: (949)645-4110
COSTA MESA,CA Zip: 92627
Contractor: Eat 9 I Pit D
Address: L a401
Phone: Da fJ1 ��
Zip: 4��
License:
SCOPE OF PERMIT
INSTALUREPAIR EXISTING ELECTRICAL FOR EXISTING PORTABLE ABOVE GROUND JACUZZI.
FEE SUMMARY
Quantity Quantity
ISSUE FEE $22.00 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 $1.00 1 - up to 100 kva/kw $0.00 0
Switches $0.00 0 over 100 kva/kw $0.00 0
Non Res Appi $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 $22.00 2 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 $45.00
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
DECLARATIONS I I I\
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($100)or less.)
❑ 1 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 provisions.
Applicant Signature: Date:
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 DOLLARS(5100.000),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 and effect.Lic.N Class N
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 1 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 es 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 throughliis'orher,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 completltn,-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 roe Lia r Y
p p ce se Law LUSIVELYpCONTR_.._ WITH LICENSED CONTRACTORS to construct the project(Sec. 7044, Business and Professions
Code:The contractors License Law does not appfy,to amowner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.). "x
❑ I am exe' �(()''der sew .� u ..m�1fBusiness and Professions Code for this reason:
signature: /(//711.9'( — �/91/Y1 c
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).
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 al 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—"Y"es 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? 0 Yes aNo
(Section 65850.2 of the California Government Code requires that the requested information be fumished 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? ❑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. gree to comply with all ste laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
ab0ovcribed prop ori e n r osesU agree not to occupy or allow occupancy of any building authorized by this permit until t_naljnspection.
C9 LUI/
Signature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
fi4DEA INSPECTION TYPE gm EMU CQDEY INSPECTION TYPE PAPE DITITIAL$
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
2446-46
.1.4 -t1J. .; CITY OF COSTA MESA -
ti. qsEllilir,�,� BUILDING DIVISION
t;r " '" DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
� arc*�; PERMIT
,
m I99-00285
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 268 WALNUT ST Status: ISSUED
Suite No Applied: 05/18/1999
Issued: 05/18/1999
Vicinity: EXTERIOR OF HOUSE 'y
Parcel Nunmber: 42628320 ISSUED BY: rl-`
Applicant: WILLIAMS, CAROL
Address: 268 WALNUT ST
Phone:
COSTA MESA,CA Zip: 92627
Owner: WILLIAMS, CAROL
Address 268 WALNUT ST
Phone:
COSTA MESA,CA Zip: 92627
Contractor: 0\44 N g_4(2,..,
Address:
Phone:
Zip:
License:
Arch/Eng:
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
REPAIR EXISTING UNDERGROUND GAS LINE AT EXTERIOR OF HOUSE AT WATER HEATER/KITCHEN
AREA.
FEE SUMMARY
AMT QTY AMT QTY AMT QTY
ISSUE FEE $22.00 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 $0.00 0 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 $0.00 0
Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0
Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0
Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $0.00 0
Drain, Roof $0.00 0 Shower $0.00 0 Water Heater/vent $0.00 0
Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0
Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 0
Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0
Gas(1-4 outlets) $5.50 1 Sink,kitchen $0.00 0 Water Softener $0.00 0
Gas(Over 4 outlets) $0.00 0 Sink,service/mop $0.00. 0 OTHER $0.00
Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00
Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00
Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0
Interceptors(Sand Auto) $0.00 0
TOTAL CALCULATED FEES: $27.50
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
DECLARATIONS
V1ORKERS'COMPENSATION DECLARATION: 4
1 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($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 provisions.
Applicant Signature: Date:
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060F 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 and effect.Lic.a Class 4
Contractors 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).
Lenders Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that 1 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 pursuAe t to the Contractors License Laws.).
❑ I am ezer r sec. L Business and Professions Code for this reason: q
Signature: (/J l �Q Date: — L 1(�/
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(38)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).
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 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 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? 0 Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be fumished 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 ❑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
El (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 COMPUANCE 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-rigs Ped props for Ins ec' p rupees.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
CODE 4 INSPECTION TYPE 1291E )NTRIALQ CODE4 7NSPECTIONTYPE PATE ameba
1616 Fixed System Final Fire Prevention 206 Final Mechanical AA''
1266 Pool Spa Final 208 Final Plumbing 5-I11p-9 9 13W
200 Final Re-Roof 210 Final Electrical •
201 Final BIock/Retalning Well 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
0...---7"RFs, , CITY OF COSTA MESA
F4a. � t BUILDING DIVISION
DEVELOPMENT SERVICES DEPARTMENT
u• PERMIT P RMIT NUMBER
E99-00021
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 268 WALNUT ST Status: ISSUED
Suite No Applied: 01/13/1999
Vicinity: Issued: 01/13/1999
Parcel Nunmber: 42628320
Applicant: WILLIAMS, CAROL
Address: 268 WALNUT ST
Phone:
COSTA MESA,CA Zip: 92627
•
Owner WILLIAMS, CAROL
Address 268 WALNUT ST
Phone:
COSTA MESA,CA Zip: 92627
Contractor:
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
ELECTRICAL UPGRADE.
FEE SUMMARY
Quantity Quantity
ISSUE FEE $22.00 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
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 $27.25 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 $49.25
Intermed Pole $0.00 0
COMMENTS/SPECIAL CONDITIONS
•
•
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
DECLARATIONS
WORKERS'COMPENSATION DECLARATION: r .r 4
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 carder and policy number are:
Camey: Policy Number
(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 provisions.
Applicant Signature: Date:
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES 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,end my license is In lull
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).
Lenders 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
ugcts 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 properly 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 Licen^e.Laws.).
❑ I am exempt' er sec. 1 - 1. Business and Professions Code for this reason:
Signature:A. (/7(Y/1-L Y/ 4.011,44i.A. Date: vim, /—/ .S'� yej
i
Owner ID verified by drivers license. 0 Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-properly 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,lalsework,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
rnafedal? 0 Yes ❑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 then 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 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 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 Quality Management District or from any other air pollution control district or agency? 0 Yes 0 No
(Section 65850.2 of the California Government Codo requires that the requested information be fumished 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 ❑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.
r 6
ggarlp V 'a r L al OGiner(s) D
�7i`L�. /- /3. 49
And/Or Authorized Applicant Date
CODE, IILSPFCTION TYPE PATE ItlIMALS CODE4 IN$PECTIONTYPE DATE It1IIAL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing n.�,�'/z 5-1-2019
200 Final Re-Roof 210 Final Electrical ,! 41° `
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
-OWNER FOSTER. BRENDA 0 DATE 5-9-58
JOB ADDRESS 268 Walnut Street BUILDING PERMIT NO. 6734
G NERAL NTRACTOR Owner-Builder VALUE $ 35.00
LOT TRACT FIRE ZONE DESCRIPTION OF WORK Board Fence
( UP J TYPE V ZONE R4 PLAN NO. 6734
PERMITS ISSUED
INSPECTIONS DATE SUBCONTRACTOR DATE NUMBER
Trenches Forms Steel • 4
Floor System •,r j
/
Steel Reinforce Chimney Re-Rod 4'
Bond Beam -�Y
Jr v
Frame and Flashing /✓ {'
Lathing, In Out /
Plaster, brown coat /y-1. V '0
Underground soil WIG Pipe Test /( /It' in -/
Top Out f I/ t 'y,a _
Furnace It G�
Gas Vents ,. 1 10 11,Rough Plumbing ,WL/.(' I r JJ/
Cesspool Septic Tank /'I .// \/JINN
Prop. Swr, Line House Con. St. Swr. �' ✓p 4L f
•
Sprinkling System G/(U J,/-
r'n Final ;
I 14 ting Fixtures, Final / i)) _
Final Gas Test /v
-Construction Pole
Underground Power
Rough Wiring
Fixtures, Final
:",OCCUPANCY
Form 210-5M-1-57
6714
COSTA MESA BUILDING DEPARTMENT •
* I P. O. Box 3I7 rEE RECEi"E,® I 6734
COSTA MESA CALIFORNIA
v� FOR APPLICANT O FILL IN
C.L. OF STREET------ (} lJ -�
I FINANCE DEP' . I BUILDING AfQQRESSS ��4 «l 2 Cc r� ��f�/
_ ______,Rim_ LINE _ �ITY OF I OSTA 6 :SAI Owner Fy /I-t dc/ rG y� ! 'e&
I— T 12 FT. 6IIT. VO
FOR 60 FT. S
T. STREET 50 FT. STREET
I i Mail Address� {�� � �� �
10 F
City < "�c-� [ :7"A'2-"e-S-1
Ph. No. • ..---7..---7/
' I I Contractor Ph. No.
Address
50 /IIF PRON
/IF PROP. F, ,crate
City Lic. No. � Lic. No• .
150 FT la
Size of Lot J rt.*?I � 1 i9--/33-. O S.
r,a�+7tY No.
ix
/I /
w Lai ` N Setbacks: C/L Street Rear 0S LGN
I cc a i cc u. Side Yard - Righ Left ". --
---- - 0
to a. t> Type of Fence • �� ..21—
U.
7�
U. ALLEY QR ROP, LINE aI d
o t I
h--: 414'0.41.-t i,j) -"1 I hereby acknowledge that I have read this application and state
ci rc LL Z %j ut la-HE:E {f I that the above is correct and agree to comply with all City Ord-
I atp Zr K . Linances and State L.•••:.-&?:r:n•. • building constr_oistn..
t— J j C I Signature ' _
I ® 'Z 10 I of Permittee �GJ!��i . _
I '', `� y FT
p I I Agent
37 6 IN. 'am >-• ° w \F' . I
FT. •Q r V m • g I 4oLa
I FOR OFFICE USE ONLY
I z . N I FT1 I
Y.
J m Per I I I wJ /
r - I 60 FT ST. Iec ved by Date ece' ed Date Issued
� FT. ST.
C
i u ' 1
PROP LINE t` 1 VALUATION �o
— 1- - - y , // Permit Fee $ /
O /,
YV/ , 12 a7
►- /�Jr"— I $ •S � Plan Check $ �! ° I)-12.
C.L. OF STREETS GC
TOTALTOTAL FEE $
MAXIMUM 4 FT. FENCE MAY BE PLACED ON DOTTED LINES —— — ---
MAXIMUM 6 FT. FENCE MAY BE PLACED ON SOLID LINES USE REVERSE SIDE FOR DETAILS
F.
-OWNER FOSTER, Brenda a MAR 14-195DATE 11-29-57
JOB ADDRESS 268 Walnut Street BUILDING PERMIT NO. 6157
GxE_Nl�E@@RAL CONTRACTOR Owner Builder VALUE $ 50.00
1l{P.713 LOT TRACT FIRE ZONE DESCRIPTION OF WORK Stake Fence
t UP TYPE ZONE • PLAN NO. 6157
INSPECTIONS DATE SUBCONTRACTO i ( /I PERMITS ISSUED
DATE NUMBER
Trenches Forms Steel l - At
Floor System //////JJ 1 ✓
Steel Reinforce Chimney Re-Rod i f / t J J!. 6, G 6 !\ /
Bond Beam ,t1' 1`
'' j'( (,�i (� l.1
Frame and Flashing
Lathing, In Out 4/4p 1'
I 9-/ e -,
Plaster, brown coat \ ./ _ t Y /,2
Underground soil W/G Pipe Test /1( f i,
Top Out //1 l ....e
Furnace I/ Lf / 1 / -
' Gas Vents "v /n,
Rough Plumbing p}/' ,J'-1 " v/ _
Cesspool Septic Tank - I 11
IJ' / /1%
Prop. Swr. Line House Con. St. Swr. ,. VI (/ c /1/ t
Sprinkling System - ,✓ ,t/ V `y 11v
I ip° Final n C]/ A / , /
1 ming-Fixtures, Final l/" A i 1�I'-!
Final Gas Test 15 Y
Construction Pole U //I
Underground Power v
Rough Wiring
Fixtures, Final -
-OCCUPANCY _
Form 210-5M-1-57 bi57
COSTA MESA BUILDING DEPARTMENT J I 6157
P. O. BOX 317•
COSTA MESA CALIFORNIA - ., -,n:
FOR APPLICANT 0, I • IN �-,p
C.L. OF STREET'r I - p d7 .
BUILDIN.G5ADDRESS e-
__,,,..--PROF! LINE _ _ _
Owner 449 ,• '
--- -- r - -
Int 61A-FUR / ) -.
10 FT. FOR 60 FT. —STREET-J-1 rg0 FT. STREET
i Mail Addressdr �yc Li -*C��u�
I I I I City eo Yh 0 _0._ Ph. No. 7Z-C-7--C-
'
L-C' I APPROVED I Contractor l-ti-?• L..' Ph. No.
CTti CV 'rn..-A MESA I l
PLAardNNING DEPT. Address
SUBJECT'TO ELUC. DEFT. REG. _50FlI IF FRONT City Lic. No. _ State Lic. No.
IOF PROP. 1_ — _
I50 FT- J w b //t - /3 3 - b
D 1TF 1i4 fJl Size of Lot fi 4-0
No.
I- BY PLAN TLCH. mI II--• Setbacks: C/L Street ' , Rear 0
Ia z N
m __1 ¢ a Side Yard - Right n / Left i
u~i r \ a Type of Fence
\ALLEY QR PROP LINE ai �-(� P. �'c_t- .
o. I
F=": - - - - - - -- --� I hereby acknowledge th I have read t is s applicatioif and state
-I m !L.,.
that the above is correct and agree to comply wit all City Ord-
I 1 j N_p inances and State Laws regulating building '.nstruction.
.
I-- +a, Signature �f� it " , —
10 I of Permittee S
(p '� I Agent
^ 3
7 s IN._ / o ' FOR OFFICE USE ONLY
FT. w 40 _
J -w -- FT IPermit No.
o . I I Ks7
K 60 FT ST. Received by Date Received Date Issued
a
I I r/�-y- ,r7 //-029 S7
II50 FT ST. I 1
t, _ _ PROP. LINE -- - I` - - 1_ — _ _ - - - I t, I VALUATION l�
\\\'- �// r �A 0-0
Permit Fee $ O� •
$ ,3--o" Plan Check $
C.L. OF STREET---.„ 1. 0-0
TOTAL FEE $
MAXIMUM 4 FT. FENCE MAY BE PLACED ON DOTTED LINES —— — ---
MAXIMUM 6 FT. FENCE MAY BE PLACED ON SOLID LINES USE REVERSE SIDE FOR DETAILS