HomeMy WebLinkAbout1044 WESTWARD WAY - Building Permits Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
PE IT O. TRACT NO. LOT NO. UNIT NO. 0'
CITY OF COSTA MESA^ CONSTRUCTION
� PERMIT J�J1 Y7 Q [� A.P.# ( Zone
Project Address �r;L/�-I ��I/p���/r�//�Cl�� 1 / ! D 7
�tifi7 L S Main Building: Accessory Building:
Applicant's Mailing Address UIkr..� �) // TYPE OF CONSTRUCTION LJ NEW L I ADD LI ALTERATION JSREPAI R E Z
Owner's Name IA '/4 Phone 0�5'4J ? ❑ CONVERSION ❑ DEMOLISH ❑ OTHER ' T Front 0
Dif/ I DESCRIPTION OF WORK/USE OF BLDG: A Rear N
Address
ww I C Right N
Arch/Eng. License No. TYPE OF PERMIT ❑ GRADING FOUNDATION U STRUCTURAL . K G
Address �Q�M / ❑ TENANT ❑ ELECTRICAL PLUMBING ❑ MECHANICAL $ . Left R
Contractor's Nam- L- .r ," �L•� /i P/Ilpne/� l ✓ S ❑ 'OTHER Ping. Ref.# 1 Parking Req./Provided E
2 P?r� liCi r,l v PROJECT DESCRIPTION SQ. FT. OCCUPANCY PlanningNotes: Q
Address(mailing) / i r M
CONSTRUCTION TYPE VALUATION $
City License No. 735 ZONE GRADING CU.YDS. ACRES - T
LICENSED CONTRACTOR DECLARATION S.
I hereby affirm that I am licensed under provisions of Charter 9(commencing Remarks:
with section 7000) of Division 3 of the Business and Professions Code, and
my license is in full •rc- and effect. ELECTRICAL FEES
license lass _ / ici,se o. ����
Date _ 37W Signatur-A7. toe._ - PLUMBING FEES Automatic Washer I Transformer 0 15-50 KW
WORKERS' COMPENSATION DECLARATION` Construction Pole Sub. 0 50+KW
reby affirm that I have a certificate of consent to self-Insure or a certificate Bar Sink Showers
Norkers' Compensation Insurance, or a certified copy thereof (Section Cooking Unit Meter pup to 100 amps
"•, " Backflow Preventer Service Sink
1J0, Lab. C.In � ���,/ .
Policy No.7�/qg/r `� Company �/' p_zsta( Backflow Irrigation - Sewer Cap Dishwasher w. Meter Dover 100 amps
_ $ertifie copy is hereby furnished. Dryers ❑Gas ]Electric Sub Panel
£Certified copyed with the city m9 v si n. Bathtubs Sewer Connection
Date E7 Applicant sA / Fan Motors❑0.1 HP ❑1'h-8
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Clarifiers Solar Collectors
(This section need not be completed if the permit is for one hundred ($100)or •
I Dishwasher •7 O F.A.U. Inc.Solar 09.15 HP ❑16-15+ -
lecs). ( Solar Piping O� Q
I certify that in the performance of the work for which this permit is issued, FI%lutes
shall not employ any person in any manner so as to become subject to te Drinking Fountains Solar Tank Microwave
Workers' Compensation Laws of California. Device Boxes , . Pole Light
Date Signature Floor Drains Swimming Pool w/Spa
NOTICE: If,after making this declaration,You should become subject to the
-
Workers' Compensationprovisions of the Labor Code, you must forthwith Outlets Range
Floor Sinks Urinal 9
comply with such provisions or this permit shall be deemed revoked. -
CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet Switches Sign .
I hereby affirm that there is a construction lending agency for the performance .
of the work for which this permit it issued (Section 3097 Civ. C.) Interceptors Water Heater Garbage Disposal Standing Sections
Lender's Name .
Lender's Address Kitchen Sink Water Service Generator 00-5 KW 05.15 KW Trash Compactor
OWNER BUILDER DECLARATION -
I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash
following reason (Section 7031.5 BusInes4 and Professional Code: Any city or
county which requires a permit to construct,alter,improve,demolish or repair P—Trap Laundry TraVs
any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he/she is licensed pursuant to the provisions of Roof Drains
t^^Contractor's License Law (Chapter 9 (commencing with Section 7000)of
'skin 3 of the Business and Professions Code) or that he/she is exempt Fee Reinspection
!from and the basis for the alleged exemption. Any violation of Section P $15 Issue Fee $ 3
.1.5 by any applicant for a permit subjects the applicant to a civil
enalty of not more than five hundred dollars($500). I DEVELOPMENT SERVICES REQUIREMENTS:
LJ I, as owner of the property or my employees with wages as their sole Reinspection Fee $15 Issue Fee $ 3
compensation, will do the work, and the structure is not intended or-offered Zoning Approved By Date
for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES Building Approved By Date
License Law does not apply to an owner of a property who builds or improves — _
thereon, and who does such work himself/herself or through his or her own Application Issued By Date 6 /
employees, provided that such improvements are not Intended or offered for Boiler Hood or Type I ❑ OD
sale. If, however, the building or improvement is sold within one year of com- Canopy Type II 0
pletion, the owner will have the burden of proving he/she did not build or im- Duct- Under Ground SUMMARY OF FEES
prove for the purpose of sale). BUI LDING PERMIT $ SMIP $
D I, as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System PLAN CHECK �j•/�
tractors to construct the project (Section 7044,Business and Professions Code: $ �/J,'� O7sISSU IT T/ —
The Contractor's License Law does not apply to an owner of property who Duct-Ventilating 00-100,000 BTU 0100,000 BTU PLUMBING [� Jr. �Ly ISSUA NCE $
builds or improves thereon.and who contracts for such oroiects with a con- $ —
tractor(s) license pursuant to the Contractor's License Law). I am aware that Exhaust System ❑ Multiple❑ System Repair/Alteration PLAN CHECK 25% $ ENERGY P.C. $
proof of their Worker's Compensation insurance should be provided to me. ELECTRICAL $ GRADING $
❑ I am exempt under Section B.& P.C.for this reason Firepl/Fact.Blt. ICBG# Fire Dampers
PLAN CHECK 50% $ MICROFILM $
Date Owner Heating System& Ducting Registers
I hereby certify that I have read this application and state that the above ❑0-100,000 BTU D100,000 BT MECHANICAL $ TOTAL FEE $
information is correct. I agree to comply with all city and county ordinances PLAN CHECK 25% $
and state laws relating to building construction,and hereby authorize repre-
sentatives of this city to ente u•bn the above-mentioned property for
Inspection pure•may '�9 9
Signature l�.� _I
Reinspection Fee $15 Issue Fee $ 3 dal '1CO2'120-00023127 TOT i.0 1
• -- _ i.,:TE: O:r/10/Ei TIi7E: 16:27
0865-46,rev. 5/88 White - Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor
1 .
_ 1 ,
CONSTRUCTION AND PLANNING POr •'<SPA
APPROVALS Permit# Date Inspector APPROVALS rermit# Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement •
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4.-Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
8.-Foundation - 59. Gas Pipe, 0 Undrgrnd., Test
9:Water Pipe-Undrgrnd. 60. Backwash Lines,P-Trap, O Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection . 62. Backwash & Receptor-Final •
12. Sewer Cap • 63. Heater & Vent-Final
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
6 Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
. ti
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
J
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
'201. Rough Factory Fireplace APPROVALS Permit#
21. Dycts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil
•
23. Gas Pipe;Rough & Test r, 72. Underground Flush
• 24. Roof Framing • 73. Undergrnd.Storage Tank 0 Gas ❑Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric - Notes:
34. Final Heating & Air Conditioning
35. Final Gas Pipe-Test
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing 3/j741 GID
39. Water Service-Final
40. Gas Service-Final
41. Solar Domestic-Final
42. Backf low Preventer
11
43. Backflow Irrigation
44. ,Landscape Irrigation System r ,
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING
48. Special Requirements Completed
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co =r�
51. CERTIFICATE OF OCCUPANCY •
"''•
No, Date •
•
ApoREssomimlo 1042 WESTWARD WY tiNT: CITY OF COSTA MESA - BUILDING PERMIT
m
ElF CVfl4: WESTBLUFF HOMEOWNERS ASSO 7PERM NO: B 071693
ADDBEss: 1042 WESTWARD WY
COSTA MESA, CA "eq/q /05 PERMIT NO: B 071693 PLAN CHECK NO: N GOVT; N SUPP: N
MroL.MAIUNO ADDRESS: CONSTRUCTION TYPE: 5-N PERMIT TYPE: STR PURPOSE: OTH
• • f
ARCHITECT ORENWIEER: LIC NO: JOB DESCRIPTION : T/OFF ,REROOF W/TORCH-ON BUILT-UP ROOF SQ FT: 5,600 . •
ANCIL OR ENG.'S ADDRESS: WIT: - i---` .
CLAIM VALUE: 5, 600 , 00 CA_LC=VALU •I ,u, 0 5, 600. 00 GROUP OCC: R-1 /
tarmADTarSNAIIE: EVERGREEN ROOFING . ( 714 ) 529-7427
CONmACTOWSMMIIIG 1175 ORANGEWOOD DR COMMENTS: ADDRESS INCLUDES 0422-1048 STWAR5REROOF 25005F-4 UNIT APARTME •
ADOREss: BREA CA actio, 679865 ************************** * *sr******ser**4*r**********r*e,****r*,*.**t*x3******_
92621 WIT: Z ON ING REQUIREMENTS v:.f'i;'._' ;' ':_ f .imp
LICENSED CONTRACTORS DECLARATION:I hereby elfin,under penalty of perjury that 1 em licensed provisions d Cheper D SETBACKS
(commencing with Section 7000)of Division 3 d the Busiest.and Professions Code.and my eve'..' fu . ..and ended. -'
cmuc.NQo.:060741 Lk.CLASS: C39 LIG.NO.: • 865 XP: 11 /95 - MAIN BUILDING ACCESSORY BUIL bING- t
• Data. J 3b c)� D«aad« �z,.. FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
LEFT: FT IN RGHT: FT IN LEFT; FT IN RGHT: FT IN
OWNER BUILDER DECLARATION:I hereby Shin under penalty d perjury that I em exempt from the CordradOe License Law la the
'41.ffdlownp reason(Radion 7031.5 Business and Professions Code:Any ay a county whih requires a Pednd to censlw,abr. PARKING REQ: PROV: PARCEL: 93523039 INE: REF NO:
�edemdnh.a o repany structure,pr's to is issuance.also requires the applicant for such permit to Rb W a signed aenanl that he a she
is licensed pursuant lo the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Direion 3 of the PLANNING NOTES>
Business and Professions Codec a that he a she is exempt demean and the basis to the alleged exemplum My violation d Sedan ' >
7031.5 by any applicant fore panne abpds the applicant to•evil penalty d not man then the hundred doers Pp>). ******************************************************************************* '
p a maadfor sal tallee(Sachin 7044 employees and Pro essiaawages nsCode::ThThe Cam License Lm.e m alta�yto°oaanOwnerure it of intended
D E V E -L O P M E N T S E R V I C E S R E Q U I R E M E N T S
who bold,a Mamma thereon.ad who does toll work «through his k himself or heed ough other own employees,provided that such '
n
inprovemee are not interdedaOffered for sale.If,however,thesulding orimprovement'a sold within one Year dwmplelan.the ZONING APPROVED BY : DATE: .
owner-Wader der will have the bueeedpvwhphe«Ne did rat oImpro improve the purpose ofsob). •
•
0 I,as owner of the Nasty,em sadsi'*cvured mp with bond rnroadurs to commrd the peed(Sedan 7044,Business and
Professions Code:The Contactors Lienee Law does not appy man owner d properly who builds or improves demon ed who BUILDING APPROVED BY : DATE:
connects for nut peva with a mntreba(s)leaned pnuad to the Contractors License Law). . r
o lam eaampunder ee on: B.AP.C.,AnYbnsaan: APPLICATION ISSUED BY: •
' . DATE: 3130 (-0
Dae own. LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT :Y
I do hereby sanity that I am aware el and undersand the requirements d Cidamia Health and Slay Code Sedans 25505.25533,and
35M,and Na I ix any Muni buildup occupant will f viii n(alms one)need to comply who said pate odes sad the requirements b
aperrM for construction or modification horn the Ai eapenwl District.Residential aMntlsnappl ewe comp from dee BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING •
pa.>oah.. PERMIT 81 .00 . 56
Dee: Apdkat: SMIP/NON-RES
WORKER'S COMPENSATION DECLARATION:I hereby Sit,.under penally of Perim). e d o the loeowi/de amen: ISS U
ISSUE FEE •
o the e and MI maintane en moticonsent to esteem bwhere wipe am on.asprovided fa Wsamoo3 mdlne Labs BUILDING-DIV > PERMIT ISSUE PLAN-CHECK TOTAL PAID DUE
Code,for the performance of the work for which this yams is issued.
0 Ihem and wlmaintain workee
workers'compensation required eLaborCode,ortheperformance p rformanal the TOTALS > 81 . 56 0, 00 0. 00 81 , 56 81 . 56 00
work for which this permit is issued.My waken'compensation iwure ce aria end party number are:
• Carder: REVENUE DIVISION TOTALS--> COLLECTED: 81 .56 OVER/SHORT: . 00
Policy Number: BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN-CHECK
(This section need not be competed 1 the permit is for one hundred do0arr IMO)or less) 81 . 00 . 56
p I tenth that in the paforme ce of the work for which this permit is issued.I Nall ..• . n any'mann oro as to -
become wbledlolfewaon
workers' ewe ofCaibmie.and I .
.. • . sutjed to the workers' ************************************************************************10******
compensation provisions of Section 3700 d ted Leber Cede,I Nell fanhv9 with ,• • ,. I N D I V I D U A L F E E BREAKDOWN
Dae: k�3° - /.J * icem: -N-- '
waning:Fallon tosecure totters'comp sSdon enflame eunlawful,and shall subject an emplane to criminal penalise and TYPE QTY DESCRIPTIO .N UNIT COST TOTAL COST
gall fines w to one hundred thousand dollars(stag000),M addition to the coat of confepe satiorL dames as podded tor In
s.pdw37aorthe tSoread.,Imwwa
Interest and SFR 5600 REROOF BY VALUE RESIDENTIAL NOZONE 1 . 00 5, 600 . 00
CONSTRUCTION LENDING AGENCY: I hereby elfin under penalty of perjury the there is a oxstnnion ending agency for the END OF FEES
Performance of the wort for which the parols issued(Section 3097.Cid.C). .
LENDER'S NAME: •
LENDER'S ADDRESS:
I certify that I have read this application and side that the above kdomation a coned,I tares to comply with all city and county adiwices
and eatelaws*hong to eaeding connrdice and hereby authorize npresemetiesd the city to enter upon the above'mentioed property �• V L- ,_
for ssPeaion• Moses. Irl•-ilii
J psi �` - bA - %�' 01 n;._7ii1, -6:U"•?: L TOT gI.56
-e-< i Date: .�- 3G� -93 r:ATE; '' _
i•S:tit":.c 1;';:f•
Signature d• •.nVApploenVContreda • t
secs._.•WP\ Who.--it.ki...A CMrv,n...._Fila rwnwwlrFent,,Pink-Revenue:Goldenrod-Avwwvv
•
1,' 'S' CITY OF COSTA MESA ,
4 BUILDING DIVISION
)'f____ 4' DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
'. PERMIT
atD4.�ax`art'9o"fr P03-00433
•
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 1044 WESTWARD WY Status: ISSUED
Suite No Applied: 07/09/2003
Issued: 07/09/2003
Vicinity: \�J
Parcel Nunmber: 93523038 ISSUED BY: ��.J -
Applicant: SZABO, KEVIN
Address:
Phone:
Zip: • V
',
Owner: FARLEY, WALT ' Si>k '1
IIP
Address . 1044 WESTWARD WAY oA"ni
Phone:
COSTA MESA,CA Zip: 92627-3998
Contractor: COAST ROOTER PLUMBING HEATING &AIR CONDITIONING
Address: 2737 S CRODDY
STE D Phone: (714)241-1414
SANTA ANA,CA Zip: 92704
License: 529127
Arch / Eng: .
Address:
Phone:
Zip: .
License:
SCOPE OF PERMIT
WATER HEATER CHANGE OUT. _
FEE SUMMARY
AMT QTY AMT QTY AMT QTY
ISSUE FEE $23.50Laundry 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 $12.30 1
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
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)7545626
2446-46(WOO)
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
wor r which this permit is issued.
ave 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: SCAT
-a STAa 'an)O Policy Number: Via 11:3 0- 0.3
(This section need not be completed/Y 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, .nd agree tha ' sho Id become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provisions. ' /q ��
Applicant Signature: 4 � Date: (/I)'
WARNING:FAILURE TO SECURE WORKER- •• PEN • •"COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($10OOW),IN ADDITI• 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.# 45:5;41-f-%4/9--
Ta-eif Z77 ! � Class# C-3 b Onc-.
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
o I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: _ Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have.the burden of proving that he or she did not build or improve for purpose of sale.). •
❑ .I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑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:
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? ❑Yes ❑No
(Section 25533 of the Califomia Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑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 apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ 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? ❑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 Califomia 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 or...arty for inspectio purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
• aturetplJ,agal Owner(s) ^ _ /J \ate
Yi/ / i "'LJ
And/Or Authorized Applicant ate
CODE f INSPECTIONTYPL PATE 1NTITIALS CODE. INSPECTION TYPE PAIL 1NTMALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical I�
1266 Pool Spa Final 208 Final Plumbing �le'O� VAC
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
--- �L CITY OF COSTA MESA _, -
4 ,-- BUILDING DIVISION
> ti' ' ,, DEVELOPMENT SERVICES DEPARTMENT P$MIT NUMBER
4 ; • PERMIT E03-00785
'moo dP
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT •
Job Address: 1044 WESTWARD WY Status: ISSUED
Suite No Applied: ' 09/02/2003
Vicinity: ATRIUM Issued: 09/02/2003
Parcel Nunmber: 93523038
Applicant: FARLEY, WALT ISSUED BY:
Address: 1044 WESTWARD WAY
Phone: 949-650-5526
COSTA MESA,CA Zip: 92627-3998 - -
��.,
Owner: • FARLEY, WALT _ -
Address' '1044 WESTWARD WAY
. _ Phone:
COSTA MESA,CA Zip: 92627-3998
•
Contractor: OWNER-BUILDER
Address:
•
Phone:
- Zip:
' License: 000000
SCOPE OF PERMIT
RELOCATION OF A LIGHT FIXTURE IN CONJUNCTION WITH THE 63 SF ATRIUM ENCLOSURE WHICH
WILL BE USED AS PART OF THE DINING ROOM IN AN EXISTING TWO-STORY SFD.A RETRACTABLE
.CLEAR ROOF WILL BE INSTALLED,WALLS WILL BE FINISHED AND NW FLOORING WILL BE ADDED.
' NO OTHER WORK AUTHORIZED WITH THIS PERMIT. , - • ,
•
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 $1.10. 1 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 $0.00 0 Misc.Conduit $0.00 0 •
Service to 1000a - $0.00 0 Misc.Conductor $0.00 0
Service over 1000a $0.00 0 Circus(gen or ride) $0.00, 0
Motors to 1 hp $0.00 0 - - , .Circus(mech ride or lights) $0.00 0
Motors to 10hp $0.00 -' , 0 Christmas Tree Stand - $0.00 0
Motors to 50hp $0.00 0 Fireworks Stand , - $0.00 0
Motors to 100hp $0.00 0 _ Other Electrical Fee $0.00
Motors over 100hp $0.00 0 "
•
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
2446-48(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.
❑ 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 ction need not be completed 1f the permit Is valued at one hundred dollars($100)or less.)
I certify that in the performance of the work for w ' 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 the f I s ould become subject to the workers'compensation provisions of Section 9700 of the Labor Code,I shall forthwith
comply with these pro�isin/^ ,4 .
vi
Applicant Signature: ( f l t �-{ Date: t ?,
WARNING:FAILURE TO SECUAE�W`OR'KERS'COMPt*ISA ON COVERAGE IS UN FUL AND SIVALL SUBJECT AN EMPLOYER TO CRI I PE TIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARS(S100.000).IN ADDITION TO THE COST OF COMPENSATION, AMAGES 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.it Class e
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: 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 Cale)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
d 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.). •
lar 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 ' 'nse Laws.).
❑ I em exempt and'r sec. / y_ Business and Professions Code for this reason:
Signature: _ / r �r
. Expires: SIM
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 flied with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the Califomia Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greeter then 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 en 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 Calif omia Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Pi Yes 101No
(Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 07 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
6 (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 MID 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 at. - .ws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-des/pprib props for' spec.on p rpose- agree not to occupy or allow occupancy of any building authorized by this permit til fine ' sp .
f r I r (T
Signature Of Legal Owner.. yDas
And/Or Authorized Applicant Date
CODE t INSPECTION TYPE MTh INTITIAL5 CODEC INSPECTION TYPE MI ltir18$LE
1616 Fixed System Final Fire Prevention 206 Final Mechanical /n/
1266 Pool Spa Final 208 Final Plumbing _ o'
200 Final Re-Roof 210 Final Electrical 9"2(1 0 3 'i/�
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 Bullding/Occupancy
; . r .
•
r
CITY OF COSTA MESA
44BUILDING DIVISION
-a ,.' DEVELOPMENT SERVICES DEPARTMENT RMIT NUMBER
11.11K4PERMIT
4�m B03-01482
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa. a_usNG PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDIJob Address: 1044 WESTWARD WY Status: ISSUED
Suite: Applied: 09/02/2003
Vicinity: ATRIUM Issued: 09/02/2003
Parcel Number: 93523038 Zoning:
Air
Applicant: FARLEY, WALT ISSUED BY: /0'A
Address: 1044 WESTWARD WAY •
Phone: 949-650-5526
COSTA MESA,CA" Zip: 92627-3998
Owner: FARLEY, WALT
Address X1044 WESTWARD WAY
Phone:
•
" COSTA MESA,CA Zip: 92627-3998
Contractor: OWNER-BUILDER
Address:
Phone:
Zip: License: 000000
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
ENCLOSE 63 SF EXISTING ATRIUM AREA TO BE USED AS PART OF THE DINING ROOM IN AN EXISTING TWO-STORY SFD.A
RETRACTABLE CLEAR ROOF WILL BE INSTALLED,WALLS WILL BE FINISHED AND NW FLOORING WILL BE ADDED.
NO OTHER WORK AUTHORIZED WITH THIS PERMIT.
• FEE SUMMARY
Plan Check: $81.41 Calc Valuation: $5,821.20
Permit: $125.25 Claim Valuation: Woo
\,SMTP Res: $0.58
•
SMIP Corn: $0.00
Other: $0.00
•
Inspection: ' $0.00 .
Total: $207.24
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
244648(WOO)
A
DECLAIATICNS o :r y S.v
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 carder and policy number are:
Carrier: Policy Number:
(Thiiss,9ection need not be completed if the permit is valued at one hundred dollars($100)or less.)
CY. I certify that In the performance of the work for which this permit Is Issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,end ogre: - if I sh uld become subject to the workers'compensation provisions of Sectin 3700 of the Labor Code,I shall forthwith
comply with these provis.ns. / - p/f
Applicant Signature: ._._/ / , Date: ' (/ 2 o 3
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COV GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI TES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARS($boo.000,IN ADDITION TO THE COST OF ENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR 000E,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 a
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).
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 ha 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
lId 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.).
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 ex�emaltt und�°eJJJ s c. Business end Professions Code for this reason:
Signature: W �( ,U� _
, /xpires: /2/7/n7cf-/
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 feel 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 ❑No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Flre 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 an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently rag-tilted,has Section 255341 the Celifemia Health and Safety Code been fully complied with? ❑Yes 0 No
5 Does or wit the applicant or present or future building occupant require for the work which Is the subject of this application aermit for such construction or modification
from the South Coast Air Quality Management District or Irom 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).
,__ ___,_ __._.__..__e__..__... ..__..._ ._._.._ _._._..._...._._.�_._..__._ —
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).
_ _.._ _s__._ _ ._ ._. _ ._ .._.i. the _._ _.._..
7 a icpaetiofrom alle South Coast res prescnbed
n ed Management Healthal or anddhSr et pollution control district03be or agency is required for the work which is the subject of this
application,have of the disclosures prescnbetl by Californiaia Safety Code Section 42303 been made? CI 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
corect.I agree to comply with to laws
ssppaaand city ordinances relating to building construction,and authorize representatives of the City of to Mesa to enter upon the
above-d ri prope f I pe�plies.I agree not to occupy or allow occupancy of any building authorized by this permit un' final i paten.
f/v gmature Of Legal ner(s) v/,y D e LnJ
And/Or Authorized Applicant Date
;ODE L INSPECTONTYPE PATE MALE CODES INSPECBON TYPE PATE MALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1268 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 '772&
J/ f./,��
203 Final Sign 222 Final Site -I`/. ,fA3
204 Final Demolition 250 Final Building/Occupancy
4.
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
APPLICATION FOR STRUCTURAL PERMIT
For Applicant to Fill in4 f etely' selit k Only
Off
m le 7 RECEIVED BY DATE RECEIVED DATE ISSUED
BUILDING //r,)
ADDRESS
/avLLC-^� A.�!�- CSI �1 03 PERMIT NO.
OWNER • 1 �V (7S
MAIL "� BUILDING
ADDRESS 2 a /(J' -ry ADDRESS r -...40. (y/ 0/�� i
�1., ,pI
TEL TRACT '� tea~ OCK
CITY -�/ /�9' q NO��.�-i- r1. 10Y J6�OLISH
CONSTRUCTION n // NEW ADD ALTERtPAIR IMO ItJG s
LENDER //ll p T l/
BRANCH ,yr- �I I O ( /i] `4�
ADDRESS
/ /.�L 4- /✓W ` OWNE R'jyl1,�)A�l//,1 �'!!7„-
non
a .� VA UE
ARCHITECT �J A TEL. /� USE/'A4/ At
OR ENGINEER (7 , „Let; NO TEL./
G�/��f/j��� FIRE T
ADDRESS fes¢ ���j" ZONE TYPE / GROUP J..•
APPROVED
CONTRACTOR elLa t BY DATE
ADDRESS ///JJJttt���yyy �/� ///JJt
TEL. 1!/)E�/(/,/ IPLAIS� BUILDIN
Fe
CITY TENO. .iCC�_.! v1
F STATECITY YARDS APPROVED YARDS ROVED
LIC.NO.26g 2,2) LIC.NO. MAIN BUILDING AC�/ESSO BUILD!
I.7 SIZE �� INO.OF BLOCS. (FROM C/�.S E 1 /
0. OF LOT NOW ON LOT FROM 411141 FT." G �y-IJ-- FT.
USE OF j/'
Ca EXISTING BLDG. R.SIDE / F FT.
CO
FSeparate permits are required for L,SIDE T FT.
electric,plumbing and heating work.
[Osl REAR 0,9
/7
, FT.
E.. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
Q _MAIN SLOGS. �]/ / ACCESS BLDOS. �7
DATE
I:
) ff�� C.0 P �/(Q .43 APPROVED/ / —7t
—AAPPROVED�w gper
SATE /� z1 77
W OLD FOR SPEC I_aI RE^J!'2EMENTS
t
0 I hereby acknowledge that I have read this application and state n
Z that the above information is correct and agree to comply with m
L all laws regulating building construction, and I shall not employ
Z any person In violation of the workmates compensation laws of
= the State of California. ,� � /�� �/� ce
1 hereby certify that I am properly licensed as a contractor under SD. FT. t , f([�7 w
the State of California Business and Professions Code, Division 3, TH AMOUNT SHOWN UNDER VALUATION IS FOR m
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: 0
am exempt from the provisions of the State of California Business VALUATION PERMIT FEE $ st
and Professions Code, Division 3,Chapter 9. in
to
PLAN CHECK $ rn
Signature of c
Permittee $ TAX $ u.
U
Authorized Agent TOTAL PAID $