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HomeMy WebLinkAbout3170 HARBOR BLVD - Building Permits O'er F . CITY OF COSTA MESA „ 4. ► BUILDING DIVISION 4-r,;' „ ,I - DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F I �,�, �,,j- l PERMIT °, gh B01-00050 (714)754-5273 • Fax(714)754-4856 • www.ci.co- a-mesa.C. LDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 3170 HARBOR BL Status: ISSUED Suite: Applied: 01/16/2001 Vicinity: RESTROOMS Issued: 02/08/2001 Parcel Number: 41814102 • Zoning: Cl Cl • - Applicant: GOLRIZ, NASER ISSUED BY: Address: Phone: Zip: Owner: C J SEGERSTROM & SONS - Address %RASH&ASSOCIATES - ' ROWLETT,TX Phone: 'P 0 BOX 1600 Zip: 75030 .00;10000-, , Contractor: ACCORD CONSTRUCTION Address: 1440.5 STATE COLLEGE BL ” ' SUITE 6A Phone:` (714)284-0202 ANAHEIM,CA Zip: 92806 •License: - 517011 Arch - Eng: ' Address: Address:" • Phone: Phone: " Zip: License: License: - SCOPE OF PERMIT_ CTENANT IMPROVEMENT TO UPGRADE RESTROOMS TO MEET ACCESSIBILITY REQUIMENTS. \\\J FEE SUMMARY Plan Check: $40.83 Calc Valuation: $15,000.00 -Permit: $251.25 - Claim Valuation: $15,000,00 SMIP Res: $0.00 SMIP Corn: $3.15 • Other: $0.00 • - Inspection: $0.00 Total: $295.23 i , PLANNING &ZONING SETBACKS - MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 - ' Right -10-0 " / . ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-9', ,,,'' ' PARKING Existing: 0 . Required: 0 Proposed: 0 , ' NOTES: 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. I INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, rind required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this p�rmit, FOR INSPECTIONS CALL: (714)754-5626 V 2448-46(6'00) DECLARATIONS (Th 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: (Thi tion need not be completed if the permit is valued at one hundred dollars(SIX)or less.) z 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' t.---compensation laws of California,and ear:,that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. / _ . .--.9.__//1 49 I Applicant Signature: - OP i (—Date:. WARNING:.FAILURE-TO SECURE W- s9 -ENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLIARE 15100,000),IN •DITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that.l.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.Lie.0 1 ,570 It Class p ‘1,3 r' 10 Contractor's Signature: - — Date: / ,-�/ r0 O / G CONSTRUCTION LENDING ENCY: ❑ I hereby affirm that th a is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Names Lender's Address: Signature: - Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that(¢IpEXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or%ounty 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 14 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: d• Date: Owner ID verified by driver's license. ❑Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet In depth Into which a person Is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. I Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the 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 end pressure). . 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 25 ..._ ni_ 0 _._... . ...__ _ ...__ _. 4 If an RMPP is presently required,has Section 534 of the California Health and Safety Code been fully complied with? 0 Yes No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermlt for such construction or modification from the South Gorst Air Quality Management District or from any other air pollution control district or agency? 0 Yes LJ No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:1 certify under penally 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 Le 176r(s) jAnd/Or utut , Applicant..-• ( id. rQDF r, g1SPECTION TYPE / Oa aITmAL5 CODE If PI$pEcnON TYPE PETE MBA 1816 Fixed System Final Fire reventlon 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing • 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Well 212 Final Fire Prevention ' 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy y/z y o/ if 41111 Ms r 1 CITY OF COSTA MESA "1: BUILDING DIVISION •Y_' ''.rwrmsoen.; DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F 1 "'e".. 1 PERMIT •-� /E01-00116 - (714)754-5273 • Fax(714)754-4856 • www.ci.cost- esa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT • Job Address: 3170 HARBOR BL Status: ISSUED Suite No Applied: 02/08/2001 Vicinity: RESTROOMS Issued: 02/08/2001 Parcel Nunmber: 41814102 ' Applicant: GOLRIZ, NASER ISSUED BY: • Address: 1440 S STATE COLLEGE BL " SUITE 6A , , Phone: (714)284-0202 ANAHEIM,CA Zip: 92806 , Owner:, C J SEGERSTROM & SONS Address %RASH&ASSOCIATES ROWLETT,TX Phone: P O BOX 1600 Zip: 75030 B Contractor: ACCORD CONSTRUCTION _ - Address: 1440 S STATE COLLEGE BL ' Y' SUITE 6A - Phone: (714)284-0202 . ANAHEIM,CA Zip: 92806 License: 517011 - SCOPE OF PERMIT- , ELECTRICAL PERMIT FOR PGRADE OF EXISTING RESTROOMS FOR"DENNY'S".INSTALL 2 LIGHT FIXTURES&2 SWITCHES. REF:B01-00050 - , • 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 Elec[rical 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'kve/kw'-1 $0.00/ 0 Lighting Fixts $2.20 2 up to 50 kva/kw $0.00 . 0 Recept Outlets - $0.00 , 0 up to 100 kva/kw , $0.00' - 0 ' Switches $2.20 -2 over 100 kva/kw- -' $0.00 '% 0 Non Res Appl $0.00' ' M , Low Voltage Equipment, ' ., $0.00 '"0 ,' �' Res Appl • $0.00 , 0 Low Volt Wiring System/Ckt I $0.00 ' 0 Service to 200a . $0.00 0 Misc.Conduit $0.00 / 0" Service to 1000a $0.00 0 Misc.Conductor $0.00"i, 0 Service over 1000a $0.00 0 Circus(gen or ride) Motors to 1 hp $0.00 0' Circus(mech ride or lights) ' $0.00 0 Motors to 10hp $0.00 - 0 Christmas Tree Stand " ' $0.00 0 Motors to 50hp $0.00 • " 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee • $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $27.90 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned , for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes,,and,all j required Inspections and final approval must be obtained.Failure to obtain Inspections and final approval will result in the expiration of this patine i FOR INSPECTIONS CALL: (714)754-5626 (V 2446-46(6/00) ( DECLARATIONS T_ 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 salon need not be completed i1 the permit is valued at one hundred dollars($100)or less.) -gr I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions Applicant Signature_ -— lDlte: -.L -/Yrh6 W ARNING'FAILURE TO SECURE ORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE 15100,000 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.lhatlam 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.Lk.a) I ( „Class N. _etit r I Q Contredors Signature: /1. / 7 __Date: �' Q� s i U _____ F __ CONSTRUCTION LENDING AG: CV: ❑ I hereby affirm that there'-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 Cgnstruct,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 Iicensed/ptrsuant 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 compietidri;.ingowner-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: 7 r Date: Owner ID verified by drivers license. 0 Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet In depth into which a person Is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,lalsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safely,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 Cale 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 o1500 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). _.._.p _ __. bazar.._..__ __ 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 Fan RMPP is presently require4 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 riPermit for such construction or modification from the South Cnnct Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications to 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 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by Califomla Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal er(s) Date �p/.i1 cAnd/Or.Auth plant. -_- Date ,. CODE t INSPECTION TYPE ME =La NV INSPECTION TYPE __ gall. MIITMLs 1616 Fixed System Final Fire Prev ntion 206 Final Mechanical 1268 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical - -B 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 ,501 144 CITY OF COSTA MESA • - 4, ►q® BUILDING DIVISION j w __ �ik ! DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER t.I '/.."�1.1 t PERMIT J � J P01-00092 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 • ` UMBING PERMIT • Job Address: 3170 HARBOR BL Status: ISSUED Suite No Applied: 02/08/2001 Issued: 02/08/2001 Vicinity: RESTROOMS Parcel Nunmber: 41814102 ISSUED BY: Applicant: GOLRIZ, NASER Address: 1440 S STATE COLLEGE BL . , SUITE 6A Phone: (714)284-0202, ANAHEIM,CA Zip: 92806 Owner: C J SEGERSTROM & SONS . Address %RASH&ASSOCIATES ROWLETT,TX Phone: P O BOX 1600 Zip:" 75030 Contractor: ACCORD CONSTRUCTION Address: 1440 S STATE COLLEGE BL SUITE 6A • Phone: (714)284-0202 ANAHEIM,CA Zip: 92806 License: 517011 - Arch / Eng: - - - • Address: Phone: - ,Zip: , .. License: SrnPF F PERMIT , , " •LUMBING PERMIT FOR HANDICAUPGRAD• OF RESTROOMS FOR"DENNY'S". INSTALL 2 FLOOR ••- •'- r - , I- •• • H BASINS,&3 WATER CLOSETS. �EF: B01-00050 FEE SUMMARY ' AMT , QTY < AMT QTY ,' ; Y, ' ' ' AMT QTY ISSUE FEE $23.50 ' Laundry Tub/Washer $0.00 0 , -Sump Pump.' / / / $0.00 0 Backflow irrigation $0.00 '0 Landscape Irrigation $0.00 0 - - 7 Swimming Pool , $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $19.60 2 Bathtub $0.00 0 , Pressure Regulator $0.00 0 . Urinal $19.60 2 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 $39.20 4 Dishwasher $0.00 0 _. Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $19.60 2 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) $29.40 3 Drain, Roof $0.00 0 Shower $0.00 0 Water Heater/vent $0.00 0 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $0.00 0 Sink,kitchen $0.00 0 Water Softener $0.00 0 Gas(Over 4 outlets) $0.00 0 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 • TOTAL CALCULATED FEES: $150.90 NOTICE: The work authorized by this permit :1.1911111111ENTENaSREZIA1000NOMONS 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 i 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 l// - 2446-46(6/00) • DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ 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 thiilpermit is Issued. My workers'compensation Insurance carder and policy number are: Cartier: - Policy Number: (This section need not be completed it the permit is valued at one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit is Issued,I shall not employ any person in any manner so as to become subject to the workers' —compensation laws of California.and gree that if I should become subject to the workers compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Q o Applicant Signatu /re:' C Date: _ /6 / 6 ( `WARNING:FAILURE TO SECU E W COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),I 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.lam.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.Lie.p "j/ 7 e/ Lclass._a-/O r ...d c Contractor's Signature: - C Date: ' J d' C CONSTRUCTION LENDING AGENCY ❑ I hereby afflrm 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: r Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that 1 am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or count 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 statem nt 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 thanlive hundred dollars($500).): ❑ I,as owner of the property,or my employees—WitIvages 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. 0 Yes ❑No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more then thirty-six(36)feet high.(Chap.3.2,Grp 2,An 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 Safely Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature end pressure). 3 Does or will the apoiicanTor present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application azEermit 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 pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes ❑No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). t or other __._ _.._ _. 7 If a pattram the South iscast Air Desry bygement DistrictHeor other air gold tion coon 4l 303 be or aade?y Is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No' 8 (If'yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: 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 end 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 Ot -ga,•fner(s) D to �- lit And/OrA ''dApplicant �� 1. Det CODE I INSPECTION TYPE PATE IDIS CODE( IBSPECTIONTYPE gdIE BMW 1616 Fixed System Final Fire Prevention 208 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 3-:So-or I�IIY 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 - y ��b CITY OF COSTA MESA • 49 BUILDING DIVISION °a, PERMIT NUMBER F ('•,,,7� � I DEVELOPMENT SERVICES DEPARTMENT PERMIT +1y,_ J• t kboaas°6 / V M01-00074 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 • MECHANICAL' PERMIT Job Address: 3170 HARBOR BL Status: ISSUED Suite No Applied: 02/08/2001 Issued: 02/08/2001 Vicinity: RESTROOMS - . Parcel Number: 41814102 ISSUED BY: Applicant: GOLRIZ, NASER Address: 1440 S STATE COLLEGE BL SUITE 6A Phone: (714)284-0202 ANAHEIM,CA - Zip: 92806 - Owner: C J SEGERSTROM'& SONS Address: %RASH&ASSOCIATES - ROWLETT,TX Phone: , P O BOX 1600 Zip: 75030 Contractor: ACCORD CONSTRUCTION Address: 1440 S STATE COLLEGE BL SUITE 6A Phone: (714)284-0202 ANAHEIM,CA Zip: 92806 , License: 517011 Arch/Eng: Address: Phoney - • - ' Zip:- _ . • _/ • License: / E OF PERMIT PERMIT FOR. NDICAPSTROOMS FOR"DENNY'S". INSTALL 2 REF: B01-00050 , FEE SUMMARY Quantity ., - - - ,Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0' Inst FAU<100 k BTU $0.00._ 0 , Repair/Alt Refrigeration•Unit• ' $0.00 0 Inst FAU>100 k BTU $0.00 0 Ventillation System ,//% $0.00 0 - Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler / - $0.00 0 Ins//Rep.Recess Wall Htr $0.000 Commercial Incinerator , - $0.00 0 Refrig Sys<100 k BTU • $0.00 . 0 Domestic Incinerator ' $0.00 0 Refrig Sys>100 k BTU $0.00 - 0 Compressors/Absorption Systems- ' Gas Piping $0.00 0 Up to 3 hp/100 k BTU , - / - $0.00 0 Factory Fireplace - . $0.00 0 3 To 15 hp/500 k BTU $0.00 0 Hood w/Mech Exhaust $0.00 r 0 / 15 To 30 hp/1,000 k BTU -%i $0.00 0 VAV Box . $0.00 0 ' 30 To 50 hp/1,750 k BTU ` • '-' - $0.00 0 Vent Fan/Single Duct $14.50 --2 Over 50 hp/Over 1,750 BTU-, $0.00 0 Appliance $0.00- 0 Boilers Fire Dampers $0.00 0 - Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 • 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers< 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $38.00 COMMENTS/SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all, required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(8/00) 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: Cartier: Policy Number: (TN est' need not be completed lithe permit is valued at one hundred dollars($100)or less.) Ccertify 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' e compensation laws of California,a d agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisiQQQ0003 -Applicant Signature - j Date: _) Ir Q / a -WARNING:FNLURE TO SECURE RS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TOONE HUNDRED THOUSAND DOLLARE(SI CO,0cO IN DITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm thati.am livens=- .der provisions of Chapter 9(commencing with Section 7000)of Division 3 of.the.Business and Professions Code,and my license Is In full force and effect.lic.N, i if Lciass.a" e�q !',Ili Contractor's Signature: • / • `Date: J r8/ Q I C CONSTRUCTION LENDIN •GENCY: 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: Lenders Address: Signature: Date: a - OWNER-BUILDER DECLARATIONS:_ _ I hereby affirm that under penalty of perjury that I it EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:My 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 i 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 Cage: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.). O 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. 1 Business and Professions Code for this reason: Signature: •v Date: Owner ID verified by driver's licens. 0 Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ___ _ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑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 withr❑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 aapermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 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 thy 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 a Ow r(s) 9n! Date IAnd/Or uth Plicant_ / Def BODE I I7I6PFCTION TYPE Oa 291111E65 CODE If INSPECTION TYPEPAIL In,A-6 1616 Fixed System Final Fire Pre ntion 208 Final Mechanical ,' l•30'01 ,-1V 1266 Pool Spa Final 208 Final Plumbing _ 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy