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HomeMy WebLinkAbout218 Cabrillo St - Building PermitsPERMIT TYPE B_ROOF2 APN: 42539208 JOB ADDRESS: 218 B CABRILLO ST CM Vicinity: Squares: 1200 PERMIT NUMBER: B15-00183 STATUS: FINALED DATE ISSUED: 07/13/2015 ISSUED BY: BH Suite/Unit: B Valuation: $3,500.00 SCOPE OF WORK: REMOVE 12 SQ OF COMP ROOFING. INSTALL SAME. BACK HOUSE ONLY. NOTE: RESIDENTIAL RE -ROOF: For projects exceeding $1.000 in valuation final approval of permit shall not be granted until access to dwelling unit(s) is provided for verification of the installation of smoke and carbon monoxide alarms by the City Inspector. See Attachment w/Inspection Card OWNER: TOLMIE CONSUELO M PHONE: 949-214-6861 APPLICANT: KEN ALVARADO :RIVERSIDE, CA PHONE: (951) 905-5116 CONTRACTOR: BERRY ROOFING Address: 3226 KLUK LANEUnit: City/State/Zip: RIVERSIDE, CA 92501 ARCHITECT: ENGINEER: FEE SUMMARY Reroof Plan Check: $0.00 Reroof Permit Fee: $97.25 Reinspection Fee: $0.00 Bldg Std Admin Fund $1.00 Waste Hauling Per Project Fee: $0.00 Address:218 CABRILLO STREET Unit:UNIT A City/State/Zip: COSTA MESA, CA Address: BERRY ROOFING INC Unit: City/State/Zip: 3226 KLUK LANE License No. 691947 PHONE: 909-905-5116 CELL: License No. PHONE: License No. PHONE: 'OTAL FEES $98.25 HOURS FOR CONSTRUCTION ACTIVITY; EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays - 9:00 am thru 6:00 pm. Prohibitied all hours - Sundays and the following Federal holiday: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day CITY OF COSTA MESA oK"' HER? BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 • www.costamesacagov �. FOR INSPECTIONS CALL: (714} 754-5625 °�° PERMIT NUMBER: E12-001771/ PERMIT TYPE ELEC STATUS: ISSUED APN: 42539208 DATE ISSUED: 09/2512012 ISSUED BY: RIVID JOB ADDRESS: 218 B CABRILLO.StCM l SuitelUnit:. B Vicinity: r SCOPE OF WORK:ELECTRICAL PERMIT TO INSTALL (2) HARD WIRED SMOKE DETECTORS AT BEDROOMS; (1) COMBO SMOKEICARBON DETECTOR IN HALLWAY FOR A 6 OR LESS GROUP HOME, PER FIRE PREVENTION- CHERYL WILLS ' NOTE: FINAL APPROVAL OF PERMIT SHALL NOT BE GRANTED UNTIL ACCESS TO DWELLING UNIT(S) IS PROVIDED FOR VERIFICATION OF SMOKE AND CARBON MONOXIDE ALARMS BY THE CITY INSPECTOR. SEE ATTACHMENT WlINSPECTION CARD (RESIDENTIAL ONLY) OWNER: TOLMIE CONSUELO M•- 'Address: 218 CABRILLO STREET Unit:UNtT A PHONE: 949-214-6861 `Clty/StatelZip: COSTA MESA, CA APPLICANT: GURROLA, RICH Address: _ - Unit: PHONE: 310-836-8076 C [tylStatelZi p: CONTRACTOR: POWELL ELECTRIC CONTRACTORS License No. 631836 Address: 5625 W. WASHINGTON BLVD. Unit: PHONE: 800 660-8076 City/State: LOS ANGELES, CA ZipCode: 90016 CELL: ELECTRICAL PERMIT FEES Electrical Plan Check Fee` $0.00 Electrical Permit Fee: $42.80 Reinspection Fee $0.00 TOTAL FEES $42.80 . 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. CODE I, INSPECTION LYPE DATE INTMAL CODE A INSAEC10N TYPE DTE INTMAL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 7 201 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 WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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 a T,) 5 _ (This scam need not be mmpJeled A rhe permd is valued of one hundmd "ars (ti 100) or fess.) '7 d l 7 Poiirry'Number: ❑ 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 becomes to to the workers' compensation provisions of Section 3700 of the Labor od , 1 shall fort'th co ply with these provisions. K- 2 i"- rt Applicanrs'Si� lure GgVe--, 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 ($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. 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: ❑ 1 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. Applicant's Signature Date Division of Industrial Safety Permit Number: SV � ,Y. 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 ❑ 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 LICENSED CONTRACTORS DECLARATION: 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gis 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 my license is in full force and effect. Lie` Conttactor ,Vnature, D'atii'' CONSTRUCTION LENDING AGENCY: ❑ 1 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).): ❑ 1, 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.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 (3107) 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 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 ❑ 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? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). G. 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? ❑ 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. Si nature of Legal er(s) Data AL gr&A.uthtirized 18plicant Dam + �[rlly f ,'Applicant tofill l'naall-spaces except those within -eLvy border lines and sign all appy pnate dettarations. PERMIT'NO TRACT NO. L07 NO. x UNIT ciTiM ol costa; �n CONS'f,RIfiCTION PER ?,,:�d 3 e ' , Fl�ect , ddress' 'r `� _ + `'' r ', TYPE OF'•CONSTRUCTiON NEW' ADD ALTERATION REPA1Ri .A .Applicant's Mailing:Address ai l8 �'-Cj42-lUl Oy'r' •� y max., �- i ❑`� CONVERSION ❑ ,DEMOLISH ❑ OTFfER Owner's Name, C L fi K 'TY]L MI E Pfione�a�5'§6 ', r r _ , t- A.P. � "" w a' DESCRIPTION OF WORK/USE OF BLDG. a r r,3ddressl L' 14t�,k1 iLC� ST. "r ' Y - j i S Main Building: . .. I 1 A�rc�h/Eng. C RA`G •H AM MIN License No. '� TYPE OF PERMIT GRADING OUNDATION STRUCTURAL T Front it '-b S t I Zone Accessory Building: Z 0 with section 7000) of Division 3 of the Business and Professions Code, and my license is in full orce and effect. License Cess �"' Licens- rlate Signature - ' 22 t0 [ il-CIr—It &Y - uWI-r L ❑ TENANT ELECTRICAL PLUMBING MECHANICAL -4PLUMBING FEES B Rear I ""LIF L—'L`*" _ � -`� 4-"r x3'- i PN Backflow Preventer Service Sink Vdress 'y . Contractor's NamP�Q A.01> 4.� _ _Phone �'ti 0`OTHER 4 A C Right �j ` I to rl7snr tn�n nn,y ann, �r _ "t f ' j- + +` 5 i 4.r! _ L N' Cooking'Unit _ 3 - PROJECT DESCRIPTION Sta FT 1 2 aG1 r OCCUPANCY , Drinking Fountains Solar Tank " Dishwasher , ±+5' i , G $_ Address (mailing) 4p ti CONSTRUCTION TYPE VALUATION $ cc ',. Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or' this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY; r I hereby affirm that there is'a construction lending agency for the performance Left I interceptOrs-Water Heater R - City Cit License Na. �• - ZONE QZ---- - GRADINGCU.YDS. ACRES Lender's Address Ping. Ref. —�'r-5� Parking Req./Provided 1' -at' Device.Boxes r, E Pole_ Light LICENSED CONTRACTOR DECLARATION 1 _ - Range 7031.5 %by any applicant for a permit subjects the applicant to a civil enalty of not more than five hundred dollars ($500), i ' ' I I, a5'Jowner of the property or n;y emptoyees.with wages as, their sole compensation, will do the work, and the structure is not intended-or'offered for .saie I(Section 7044, Business and Professional .Code_ -The Contractor's License Law does not apply to an owr of a property who builds or improves therson,(and who does such work hi self/herself-or. through his or'hec.Own employees,, provided that such Ir merits are' not intended or offered for sale. If, however,.the building or Impr vement is sold within one year of•com- pletion, the owner will have the burp n of proving he/she did not build or im- Me for the purpose of sale). -a ' i, a5 owner of the property, am,e c)usively contracting with licensed con- tractors to construct the project (Sectin 7044, Business and Professions Code: The :Co tractor's License -Law .does not apply to an owner of property who builds Cootractor's and_'wh11 contracts for such projects with a con- tractor(9g license pursuant to tfie_Co3ractor's License Law). I am aware that proof Of their Worker's Comp�e tIII p� insurance should be provided to me. - - Reinspection Fee $15 Issue Fee _ $ 3 $ Sign - 1 hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: s - D za B Ap Planning Notes: ROTIn F11P 017VIAT virnTimpurvi- Duct - Under Ground IM with section 7000) of Division 3 of the Business and Professions Code, and my license is in full orce and effect. License Cess �"' Licens- rlate Signature - - -4PLUMBING FEES T Bar Sink . Showers - )R KERS' COMPENSATION DEC R TION ,ereby affirm that i have a certifi to of onsent to self -ins certificate of Workers' Compensation Insura ce, a certified copy thereof (Section 3800, Lab., C.) t . Policy No. t173�2� Company a✓i�i� �� �: copy is hereby furnished. Backflow Preventer Service Sink Backflow Irrigation Sewer Cap ELECTRICAL Bathtubs Sewer Connection Automatic Washer Construct ion Po le Sub. _Qcertified Divisio '% Certifi d cop Is f ed with the ciMMPEA4ATION Date Applican �`� EXEMPTION FROM.WORKERS' C DECLARAT ON.-� section need not be completedt is for one hundra ($100) or i tW less). V ; � 2 tt^\1] 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 -- Clarifiers Solar Collectors(This Cooking'Unit Dishwasher- Solar Piping Meter El up to 100 amps ' , Drinking Fountains Solar Tank " Dishwasher lWorkers' Compensation Laws of California. t, l Date Signature Floor Drains Swimmirig Pool w/Spa " , NOTICEo-If, aftermakingthis declaration, you should become subject, to the $_ S�Sb Panel _ FloorSiriks Urinal , Fan ',. Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or' this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY; r I hereby affirm that there is'a construction lending agency for the performance Gas Service,Outlets Water Closet �' Ifl - $ interceptOrs-Water Heater $ of the work for which this permit is issued (Section 3097,; Civ. C.) Lender's Name Kitchen Sink Water Service Fixtures. Lender's Address OWNE_t BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law ,for the following reason (Section 7031.5 Business and Professional Cade: Any.city or county .which requires.a.per�nit.to-construct, alter, improve, demolish or repair any struC tureprior to its issuance, als requires the applicant for such permit 'o file a1§ignee' statement that he/she licensed pursuant to the provisions'of tie Cdntlactor's License Law (Chapter (commecing with Section -7000) of .)ivisioni;(3 -of'the Business and,�Profe ions Code) or that •he]she' is'exempt - therefrom and the basis for the atlegeq exemption. Any violation of Section - '!Jj Lavatories. it - Auto -Wash Device.Boxes r, P—Trap } ,. •..- Laundry;Trays ' Pole_ Light ` RpOf drains' r, - Outlets - Range 7031.5 %by any applicant for a permit subjects the applicant to a civil enalty of not more than five hundred dollars ($500), i ' ' I I, a5'Jowner of the property or n;y emptoyees.with wages as, their sole compensation, will do the work, and the structure is not intended-or'offered for .saie I(Section 7044, Business and Professional .Code_ -The Contractor's License Law does not apply to an owr of a property who builds or improves therson,(and who does such work hi self/herself-or. through his or'hec.Own employees,, provided that such Ir merits are' not intended or offered for sale. If, however,.the building or Impr vement is sold within one year of•com- pletion, the owner will have the burp n of proving he/she did not build or im- Me for the purpose of sale). -a ' i, a5 owner of the property, am,e c)usively contracting with licensed con- tractors to construct the project (Sectin 7044, Business and Professions Code: The :Co tractor's License -Law .does not apply to an owner of property who builds Cootractor's and_'wh11 contracts for such projects with a con- tractor(9g license pursuant to tfie_Co3ractor's License Law). I am aware that proof Of their Worker's Comp�e tIII p� insurance should be provided to me. - - Reinspection Fee $15 Issue Fee _ $ 3 $ Sign - MECHANICAL FEES D za B Ap Boiler. - Hood or Type I ❑ - Canopy Type I I ❑ - Duct - Under Ground Duct - Structural Refrigeration System ❑0-100,000 BTU ❑100,000 BTU Duct -Ventilating Exhaust System ❑ Multiple ❑ System Repair/Alteration a. Firepl7 .6c: $Iti:ICBO = 't Fire Dampers r r ' ❑ la exempt under Section -B. & P. C. for this reason Date Owner I hereby certify that have read this application and state that the above information is correct, 1 agree to comply with all city and county ortlinances t+^� Heat' System &Ducting' F 0 000 BTU ❑ 100,000 BT a''...- •-�"-�?-; - - Registers -- ` and state la s relating to b titling ConstructlDn, and hereby authorize repre - sentative5 o thi city ter upon the above-mentionetl property,"for inspection put s. l; ft Signature Date Drivers' LIc ns or SS - _ _ - n ` Reinspect on Fee $15 Issue Fee CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant Pink - Accounting • f,. (& enrod - Assessor 1 EVELOPMENT Bu - Reinspection Fee T SERVICES REQUIREMENT �L-- ning Approved By ate ELECTRICAL FEES Automatic Washer Construct ion Po le Sub. Date Transformer _ 15-50 KW ❑ 50+;KW Cooking'Unit pat Meter El up to 100 amps ' Dishwasher ' Meter. over 100 amps , Dryers +❑Gas ❑Electric $_ S�Sb Panel ' Fan Motors ❑0-1 HP Ell %,-A.U. $ _ V-� 4 ISSUANCE $ Inc. Solar 09-15 HP El 16-15+ 25% Fixtures. ELECTRICAL Microwave cc Device.Boxes r, '50°6 ,$ Pole_ Light $ Outlets Range W Switches $ Sign - $ Garbage Disposal 25% $ Standing Sections Generator ❑0.5 KW El 5-15 KW; - T ash -Compactor " EVELOPMENT Bu Reinspection Fee $15 Issue Fee SERVICES REQUIREMENT �L-- ning Approved By ate Approved By Date plication Issued 8y pat SUMMARY OFF ES 6 ' BUILDING PERMIT $ • r. -SMTP $_ PLAN CHECK $ -PERMIT' ' PLUMBING $ _ V-� 4 ISSUANCE $ PLAN CHECK 25% NERGY P C: C$T^ ,'! ELECTRICAL �GRADLNG s�$1 PLAN CHECK '50°6 ,$ _ MICROFILM $ W MECHANICAL $ TOTAL FEE $ PLAN CHECK 25% $ `~ � ''.9NSTRUCTION AND PLANNING. POOL & SPA ti 'Date APPROVALS P it , : '. J ernii,,+ Date Inspector APPROVALS; Permit Inspector mpo.rary El PtricalwS4Vice or Pole 52. Pool & Equipment Location r: tv 0 1. 142 . 'Soil Pipe-U6drgrnd. X42. er Apr 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit -Ur vdrgrnd. 55. Electrical Bonding C f 5. Steel Reint6rcemd'ht"i ;;C�W 56. Rough Plumbing & Pressure Test 6. Electr-'_ I UFEk Grn"d-�,,�, 57. APPROVAL TO COVER-GONITE 7.'f ooil" p9s 58. Electrical Conduit -Undrgrnd:l 8.-,FoLAQn 59. Gas Pipe, 0 Undrgrnd., Test- 9.'�Vat U d eP,i�e- n rgrn r Leo 60. Backwash Lines, P -Trap, 0 Undrgrnd, 10. StruEtural Floor System, --A 61. APPROVAL TO DECK 11...-Proerty Sewer Lin *& Wouse Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Eliactrical-Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval Rough Wiring Sign 68. APPROVED FOR PLASTERING 1 RougAElectrical-T Bar Ceiling 69. 1�001_/SPA SYSTEMS FINAL 19. Rough heating & Air Conditioning FIRE' DEPT. REQUIREMENT APPROVALS Permit +_ 20. Rough Factory Fireplace Al 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas E�'Oil 23. Gas Pipe -Rough & Test 72, Underground Flush 24, Roof Framing 73. Undergrnd. Storage Tank Gas El Oil C 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 111gle y 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: s ir AT 34, FinaliHeating & Air Conditioning zri PAR SP04 35. FinalG`6s Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing C/" L _L 39. Water Service -Final !Aj 40. Gas Service -Final 41. Solar.'Dor6'es'fic-Final -42. Backflow Preventer A V3. Backflow Irrigation, -:44. Landscape Irrigation System '.45r�-Sound Attenuation 46. Handicap Regulations > 47. FINAL STRUCTURE & BUILDING - bre OL 48 .Special Requirements Completed sn IJIL� _L -49. Electric Release to Edison .50. Gas Release to Southern California Gas CQ OCCUPANCY , , U 1. CERTIFICATE ur No. Date i Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. P MIT NO. TRACT Np LOT UNIT NO. CITY OF COSTA MESA /CO_NSTRUCTION PERMIT .2 — � ,� hp,ff. A, 1h7V' �°�: � A,P. # Project Address � �&r k L_ 40 Applicant's Mailing Address Owner's Name —T?!f—.4,A1-e Phone Address :ZA* G+ai61.1c.W Arch/Eng, License No. Address !!—_ Contractor's Namplkwo ^Phon e IA—At-1 fee:. Address lmailing) 3$5i City License No- LICENSED CONTRACTORDECLARATION 1 hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of 'Division 3 of the Business and Professions Code, and my license is in f 11 force and effect. d5 —7 License C ss Lic N 7 DateSignature WORK NSATION D RATION I hereby affirm that I have a certlf tate f consent to self -incur or a Certificate of Workers' Compensation Insur or, a= certified copy thereof (Section 3800, Lab. C.) rPolicy No. Company �.i Certified copy is hereby furnished. . LJ 'Ce tit ed copy is filed with the city Building Division. Date Applicant EX MPTION FROM WORKERS' COMPENSATION DECLARATION (This section need not be completed if the permit is for one hundred ($100) or less). I certify that in the performance of the 'k for which t permit is issued, 1 shall not ploy any person in any m n r as to c e su 'ect to the Workers' o e cation Laws of Callfo la"NJ Date t Signature NOTICE: If, after making this declaratl u should be ome subje to the Workers' Compensation provisions of- he or Code, you must f thwlth comply with such provisions or th s per it shall be deemed yoked. CONSTRUCTION LENDING 'AGEN Y I hereby affirm that there is a construct n lendi g agency for the per rvn ante of the work for which, this permit ed (Section 3097 Civ. C.) Lender's Name Lender's Address OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional 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/she is licensed pursuant to the provisions of • the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom -arid the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for a permit subjects the. applicant to a civil . enalty of not more than five hundred dollars ($500). 1, 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 (Section 7044, Business and Professional Code: The Contractor's 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 employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of com- pletion, the owner will have the burden of proving he/she did not build or lm- rov e for the purpose of sale). .1, as owner of the property, am exclusively Contracting wlth licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such oroiects with'a can- traCtor(s) I1Cen5e pursuant to me Contractor's License Law). I am aware that proof of their Worker's Compensation Insurance should be provided to me. Cl I am exempt under Section B. & P. C. for this reason TYPE OF CONSTRUCTION L%1TNEw L ADD L ALTERATION LJ REPAIR ❑ CONVERSION ❑ DEMOLISH ❑ OTHER DESCRIPTION OF WORK/USE OF BLDG. 11- LW A6I-L. %T TYPE OF PERMIT GRADINGFOUNDATION STRUCTURAL 1:1 TENANT ❑ ELECTRICAL r7 PLUMBING ❑ MECHANICAL ❑ ,OTHER PROJECT DESCRIPTION SQ. FT. OCCUPANCY CONSTRUCTION TYPE VALUATION $ 3 (04t-0- dr�o ZONE GRADING CU.YDS. ACRES Remarks: Reinspection' -Fee $15 Boiler Duct - Under Ground Duct - Structural Duct - Ventilating Exhaust System 0 Multiple ❑ Firepl/Fact. Bit. ICBG =h' Date Owner PLUMBING Bar Sink Showers Backflow Preventer Service Sink Backflow Irrigation Sewer Cap Bathtubs Sewer Connection Clarifiers Solar Collectors Dishwasher Solar Piping Drinking Fountains Solar Tank Floor Drains Swimming Pool vv/Spa Floor Sinks Urinal Gas Service, Outlets Water Closet Interceptors Water Heater Kitchen Sink Water Service Lavatories Auto -Wash P—Trap Laundry Trays Roof Drains Device Boxes Reinspection' -Fee $15 Boiler Duct - Under Ground Duct - Structural Duct - Ventilating Exhaust System 0 Multiple ❑ Firepl/Fact. Bit. ICBG =h' Date Owner Heating System & Ducting I hereby certify that I have read this application and state that the above ❑0.100,000 BTU 0100,000 BT' Information is correct. I agree to comply with all city and county ordinances and state la s relating to building Construction, and hereby authorize repre- FEES sentatives of is city to ter upon the above-mentioned o rty for Transformer D 15-50 KW 0 50 + KW I.p e �( Signature Da Cooking Unit Drivers' License SS .' Reinspection Fee $15 Dishwasher Meter ❑aver 100 amps 0865-46, rev. hite - Building; Canary - Applicant; PinAccounting; Goldenrod - Assessor -Issue Fee MECHANICAL Hood or Type ❑ Canopy Type I ! ❑ Refrigeration System 1:10-100,000 BTU ❑100,000 BT System Repair/Alteration Fire Dampers Registers Issue Fee S Main Building: 17,2 L. E T Front B Rear A C Right r/ K Left Ping, Ref. # Planning Notes: A-„ ! G Zone k L r Accessory Building: �Z a N N G R Parking Req./Provided E f M 01 00018578-00013680 T01" 104,45 DATE. 11/04/38 TIME: 10:55 WW' s n I -ti S ELECTRICAL FEES FEES Automatic Washer Construction Pole Sub. Transformer D 15-50 KW 0 50 + KW Cooking Unit Meter El up to 100 amps Dishwasher Meter ❑aver 100 amps Dryers DGas ❑Electric Sub Panel Fan Motors 00-1 HP 01%-$ F.A.U. Inc. Solar D9-15 HP -1-116-15+ Fixtures Microwave ~ Device Boxes Pole Light Outlets Range _ Switches Sign Garbage Disposal Standing Sections Generator ❑0-5 KW ❑5-15 KW Trash Compactor Reinspection Fee $15 Issue Fee $ 3 DEVELOPMENT SERVICES REQUIREMENTS: + I 4Zoning Approved By Date I "� Date Building Approved By 1Z 1, ,'Application Issued By Dat $ S FEES'',' BUILDING PERMIT PLAN CHECK PLUMBING PLAN CHECK 25% ELECTRICAL PLAN,CHECK 50% MECHANICAL PLAN CHECK 25% SUMMARY OF FEES $ (V -00 SMIP $ S� $ 10• PERMIT $ ISSUANCE $ r $ ENERGY P.C. $ $ GRADING $ $ MICROFILM $ $ TOTAL FEE $ $ 01 00018578-00013680 T01" 104,45 DATE. 11/04/38 TIME: 10:55 CONS'T'RUCTION AND PLANNING APPROVALS Permit # Date , 'Inspector POOL &SPA APPROVALS • Permit # 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"Iectricat Conduit; Undrgrnd. 55.. Electrical Bonding l 5. Steel Reinforcement.FE., j/ C7"� 56. Rough Plumbing & Pressure Test ; %I 6-;;ElectricalUFER.Grnd•.,r L 57. APPROVAL TO COVER-GUNITE 7. Footings ., I I ZV�I 58. Electrical Conduit-Undrgrnd.P B. ,Foundation - • 59. Gas Pipe, ❑ Undrgrnd., Test - j l 9. Water Pipe-Undrgrnd. f 60. Backwash Lines, P -Trap, ❑'Undrgrnd. 10. Structural Floor System �# L i 61. APPROVAL TO DECK l 11. Property Sewer Line & House Connd'ction _ 4 62. Backwash Receptor -Final 12. Sewer)Cap j 63. Heater & Vent Final 13. Roof Drains .7 64. Plumbing System •Final : -14. Rough Plumbing,' 65. Electrical -Final r 15. Rough Electrical -Conduit 66. Solar System -Final 1@. Rough Electric Wiring 67. Fencing & Access Approval 17.1 Rough Wiring Sign 68. APPROVED FOR PLASTERING 18° Rough'flectrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19IRough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20.E Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Aas Pipe -Rough & Test 72. Underground Flush .24.. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25.; Roof Sheathing 74. Overhead Hydro 26.-T-Bar.Ceiling (Structural) & Monocoat 75. Dry Chemical 27.'Frametand Flashing 76. Dry Standpipe 26. Lathing &,Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing rr HEALTH DEPT. REQUIREMENT 31. PlasterBrownCoat ?t 79. FINAL INSPECTION 32, Electrical Power Meter -Final 80., FOOD CERTIFICATE ISSUED 33, Final'Electric Notes: 34. Final Heating & Air Conditioning f S 35. Final Gas Pipe -Test , 36. Hood or Canopy } �C 3T FinahFactbw Fireplace ' 38. Final Plumhing r - 39. Water Service -Final' - 40. Gas Service -Final + 9 41. Solar Domestic -Final • . 42, Backflow Preventer s %; 43. Backflow Irrigation— 44..Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE &[BUILDING 48. Special Requirements -Completed 49. Electric Release to Edison - - 50: Gas Release to Southdrn California Gas Co 51i. CERTIFICATE OF OCCUPANCY No. Dade •'�' %• , CITY OF COSTA MESA BUILDING DIVISION a f 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 www.costamesaca.gov FOR INSPECTIONS CALL: (714) 754-5626 / ' PERMIT NUMBER: E12 -00175t,/ PERMIT TYPE ELEC STATUS: ISSUED APN: 42539208 DATE ISSUED: 0912512012 ISSUED BY: RMD JOB ADDRESS: 218 A CABRILLO STI'CM Suite/Unit: A Vicinity: SCOPE. OF WORK:ELECTRICAL PERMIT TO INSTALL (2) HARD WIRED SMOKE DETECTORS AT BEDROOMS; (1) COMBO SMOKE/CARBON DETECTOR IN HALLWAY FOR A 6 OR.:LESS GROUP HOME; PER FIRE PREVENTION- CHERYL WILLS. _- NOTE: FINAL APPROVAL OF PERMIT SHALL NOT BE GRANTED UNTIL ACCESS TO DWELLING UNIT(S) IS PROVIDED FOR VERIFICATION OF SMOKE AND CARBON MONOXIDE ALARMS BY THE CITY INSPECTOR. SEE ATTACHMENT WIINSPECTION CARD (RESIDENTIAL ONLY) OWNER: TOLMIE CONSUELO M ;, 'Address: 21'$ CA6RILLO,STREET Unit: UNIT A PHONE: 949-214-6861 r' CitylStatelZip: COSTA MESA, CA., APPLICANT: GURROLA; RICH - 1. Address: unit: PHONE: 310-836-6676• CitylStatelZip: CONTRACTOR: POWELL ELECTRIC CONTRACTORS License No. 631836 - Address: 5625 W. WASHINGTON BLVD. Unit: PHONE: 800 660-8076 City/State: LOS ANGELES, CA ZipCode: 90016 CELL: ELECTRICAL PERMIT -FEES `E Electrical Plan Check l=ee: $0.00 Electrical Permit Fee: $42.80 Reinspection Fee $0.00 TOTAL FEES $42,80 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. 9QQEE INSPECTION TYPE 49I€ INTn1ALS CODE p. INSPECTION TYPE DAM INTIT1ALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical �o/lam DA 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 Building/Occupancy WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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 I have and will maintain workers' compensation insurance, as required by 1wion 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 a 05;—j7gn sea bn need nor be completed lane permit rs valued of one hundred"ars (SIOD) or fess.) Policy Number: [7 ❑ 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 becomesub' t to the workers' compensation provisions of Section 3700 of the Labor d A I shall forthw omply with these provisions. 7q, - j 5- /L Applicant's Sign re rDale` r 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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. l jt:idg#" lass tf r•. s /lJ _.ar . Q -Z..1Z;J Z t! ontr o 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 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 appy 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.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 305746 (3107) 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: ❑ 1 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. Applicanl's Signature Division of Industrial Safety Permit Number: Date 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 ❑ 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 Y 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 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 ❑ 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? ❑ Yes ❑ No (Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ 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 ❑ 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 Hate CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that 1 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. Sfgnaturgnf egal owners) Date AUU1ati7ed Applicant CITY OF COSTA MESA BUILDING DIVISION uw-111�Lw�l 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 • www.costamesaca.aoFOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: E12-00186/ PERMIT TYPE ELEC STATUS: ISSUED APN: 42539208 DATE ISSUED: 10/08/2012 ISSUED BY: RMD r z,_ JOB ADDRESS: 218 B CABRILLO STYCM ry SultelUiit:.. B Vicinity: SCOPE OF WORK: ELECTRICAL PERMIT FOR THE INSTALLATION OF (1) SMOKE DETECTOR AND:(1):ELECTRO MAGNETIC SMOKE ACUATED DOOR CLOSER FOR UNIIT, ;"B" FOR A'6 OR'LESS GROUP HOME; PER FIRE 'PREVENTION- CHERYL WILLS. NOTE: FINAL APPROVAL OF PERMIT SHALL -NOT BE GRANTED UNTIL ACCESS TO DWELLING, UNIT(S) IS'PROVIDFD FOR VFRIFICAT 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. 6E INSPECT<ON 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition 2&M INTMALS CODE f INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final BuildinglOccupancy DATE II TrUL$ WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations:' © 1 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. 1 , - ❑ 1 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: (This section need not be completed d the permit a valued at one hundred dollars (S100) or less.) Policy Number: ! certify that in the performance of the work for which this permit is ssued. 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 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant's 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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # �" ` 7 D{, 9 CClass 4' J Contractor's Signature Data CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees. provided that such improvements are not intended or offered fog 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 appy 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 mason: Signature 305746 (3107) Date Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:' - F-1 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 S, California Administrative Code). ❑ As owner -builder, 1 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. Applicant's Signature Division of Industria! Safety Permit Number: Date 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 ❑ 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 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 ❑ 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? ❑ Yes ❑ 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 California Health and Safety Code Section 42303 been made? ❑ 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 Dale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) ❑ Ie KArW rAutherizedApplicant kDate