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HomeMy WebLinkAbout1850 KENTUCKY PL - Building Permits ,1011 4,4c CITY OF COSTA MESA 44Dpe BUILDING DIVISION > • rr,' S DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F t / 11 I PERMIT o naRret`� PO4-00469 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT • Job Address: 1850 KENTUCKY PL Status: ISSUED Suite No Applied: 07/02/2004 Issued: 07/16/2004 Vicinity: Parcel Nunmber: 13904113 ISSUED BY: ML____ Applicant: RICHARD HENDRICKS Address: 1850 KENTUCKY PL Phone: 714-557-6903 COSTA MESA,CA Zip: 92626 • Owner: HENDRICKS, BRENDA S S%OS Address 1850 KENTUCKY PL \v Phone: i COSTA MESA,CA Zip: 92626-2211 �i '( 141 �� Contractor: OWNER-BUILDER Q`C Oj� V" Address: Phone: n�\6SJ D Zip: License: 000000 Arch / Eng: Address: Phone: Zip: License: SCOPE OF PERMIT REF:904-01202 ADD 128 S.F.TO EXISTING S.F.D.WORK TO INCLUDE:EXPAND EXISTING KITCHEN TO CREATE NEW BREAKFAST NOOK AND REPLACE WINDOWS THROUGHOUT THE RESIDENCE TO COMPLY WITH 1997 U.B.C,REQUIREMENTS. REF.:B02-01202 TO INCLUDE: I KITCHEN SINK FEE SUMMARY AMT QTY AMT QTY 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 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0 Dishwasher $0.00 0 Sewer Cap for Demo $0.0o 0 Wash Basin Set $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 244646(6/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT Mt EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES LIP TO ONE HUNDRED THOUSAND DOLLARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37050F THE LABOR CODE,INTEREST,AND ATTORNEYS 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 tome and effect.Llc.4 Class It Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that 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 subjectlaaapplicant to a civil penalty of not more than five hundred dollars($500).): / I (N 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 La 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 ontract Lice Laws. ❑ Lam - .r under c. Business and Professions Code for this reason: ,Signe i O at e. 7 — ( Own: •verified by drives icons°. ❑Yes ❑No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑Yes ❑No (Section 25505 of the Califomia Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑No (Section 25533 of the Califomia Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑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 a2ermit 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 In In 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 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑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. i .n. re Q d al O er(s) Date -� � /y nd/Or Aut orized Applicant ��, Date CODE it INSPECTION TYPE DATE INTITIALS CODE 1 INSPECTIONTYPE DAIS MODALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical �7� 1266 Pool Spa Final 208 Final Plumbing 7-2M-0r 61 E_ 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 oy(N MSs CITY OF COSTA MESA ivi9 BUILDING DIVISION $ DEVELOPMENT SERVICES DEPARTMENT PERM UMBER F1 I PERMIT 'toe. mto d•' M04-00364 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT • Job Address: 1850 KENTUCKY PL Status: ISSUED Suite No Applied: 07/02/2004 Issued: 07/16/2004 Vicinity: Parcel Number: 13904113 ISSUED BY: Applicant: RICHARD HENDRICKS Address: 1850 KENTUCKY PL Phone: 714-557-6903 COSTA MESA,CA Zip: 92626 Owner: HENDRICKS, BRENDA S SSA Address: 1850 KENTUCKY PL (�,`y.J yst.� Phone: �J COSTA MESA,CA Zip: 92626-2211 P411)\Yr�J Contractor OWNER-BUILDER eC.0‘k U �� Address: -> Phone: �xQ�R�$ Zip: License:000000 SCOPE OF PERMIT REF:B04-01202 ADD 128 S.F.TO EXISTING S.F.D.WORK TO INCLUDE: EXPAND EXISTING KITCHEN TO CREATE NEW BREAKFAST NOOK AND REPLACE WINDOWS THROUGHOUT THE RESIDENCE TO COMPLY WITH 1997 U.B.C. REQUIREMENTS.REF.:B02-01202 TO INCLUDE:DUCT WORK(1 ZONE) FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU $14.80 1 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU $0.00 0 - Ventillation System $0.00 0 Repair/Alt Cooling/Heat $13.70 1 Evaporative Cooler $0.00 0 Inst/Rep.Recess Wall Htr $0.00 0 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 0 15 To 30 hp/1,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp/1,750 k BTU $0.00 0 Vent Fan/Single Duct $0.00 0 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 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(6/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California.and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lie.# Class# Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). 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 air d 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 subjee applicant to a civil penalty of not more than five hundred dollars($500).): .n:71,7 a4 ,owneriof the orty, o eloyhes wonth wages is their sole coos apply WILL DO THE WORK,and the ds rtis intendeder , oro who d for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to en 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•wner of properly who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors 'cense s.). ❑ I a" em. 'rider.a 5=% Ar •• Business and Professions Code for this reason: �� ( Sig ure: S _ �!��_ %a.. r ate: verified by driver's I' a se. ■ Yes ❑ o 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,talsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title B,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 hie 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 Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application aEermit 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 0 No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 6 (If'yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE 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 st law :nd city dinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the ebov. .- ed pr rty tori p ion.. es.I ea not to occupy or allow occupancy of any building authorized b this permit until final inspection. 1/4 /Signa're Of Legal Owner(s) `� - Date And/Or Authorized Applicant Date CODE I. INSPECTION TYPE PATE INTRULS CODE! INSPECTION TYPE PAIL IHRTIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 7'zq CR _ 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 04t11 Mics CITY OF COSTA MESA 44.a9 - BUILDING DIVISION >:J ,,' ikr DEVELOPMENT SERVICES DEPARTMENT PER NUMBER t. PERMIT 4,44-00778 ..PoagTh (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 1850 KENTUCKY PL Status: ISSUED Suite No Applied: 07/02/2004 Vicinity: Issued: 07/16/2004 Parcel Nunmber: 13904113 Applicant RICHARD HENDRICKS ISSUED BY: Address: 1850 KENTUCKY PL Phone: 714-557-6903 COSTA MESA,CA Zip: 92626 Owner: HENDRICKS, BRENDA S Y Address 1650 KENTUCKY PL Phone: EXTENSION SION COSTA MESA,CA Zip: 92626-2211 ALLOWED OWED Contractor: OWNER-BUILDER PERS Address: EXPIRES $ .61-1 a5 Phone: Zip: License: 000000 SCOPE OF PERMIT REF:B04-01202 • ADD 128 S.F.TO EXISTING S.F.D.WORK TO INCLUDE:EXPAND EXISTING KITCHEN TO CREATE NEW BREAKFAST NOOK AND REPLACE WINDOWS THROUGHOUT THE RESIDENCE TO COMPLY WITH 1997 U.B.C.REQUIREMENTS. REF.:602-01202 ELECTRICAL TO INCLUDE:5 LIGHT FIXTURES, 13 OUTLETS,5 SWITCHES AND RELOCATE SERVICE UP TO 200 AMPS. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $5.50 5 up to 50 kva/kw $0.00 0 Recept Outlets $14.30 13 up to 100 kva/kw $0.00 0 Switches $5.50 5 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $30.50 1 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus(mech ride or lights) $0.00 0 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(6/00) I. DEICLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. My workers'compensation Insurance carder and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND GVIL FINES UP TO ONE HUNDRED THOUSAND DOLIARE($100,003),IN ADDmON 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.4 Class 4 Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjec a applicant to ar civil penaltyof not more than five hundred dollars($500).): I;as owner of the property,or my employees with wages as their sola compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. ( '7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the properly,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License L: s.). ❑j.a nder%-. / �usiness and Professions Code for this reason: Signa•_ �__ �S-�-i 02229:--7/4075/ ejn: erified by driver license. 'Y Yes ■ Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: . ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes ❑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 0 No (Section 25533 has onf the hand all iHealthaBand Safety hazardous Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any quantity yequal 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 Califomia 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 aEEermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑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 ate laws d city or ' ces relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the e Ibed pr rty for' s ction p e$. not to occupy or allow occupancy of any building autho7zeeddbb this/perrr it until final inspection. rSignature Of Legal Owner(s) C Date And/Or Authorized Applicant Dale CODE 0 INSPECTION TYPF PAN INTITIAL$ CODES INSPECTION TYPE Mk INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 7-al r -Q 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 IA • CITY OF COSTA MESA • F BUILDING DIVISION }:l , DEVELOPMENT SERVICES DEPARTMENT PER T NUMBER F 1ris PERMIT 44 `e B04-01202 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT • Job Address: 1850 KENTUCKY PL Status: ISSUED Suite: Applied: 07/02/2004 Vicinity: KITCHEN Issued: 07/16/2004 Parcel Number: 13904113 Zoning: Applicant RICH HENDRICKS ISSUED BY: Address: 1650 KENTUCKY PL Phone: 714-557-6903 COSTA MESA,CA' Zip: 92626 Owner: HENDRICKS, BRENDA S EXTENSION Address 1850 KENTUCKY PL Phone: • ALLOWED COSTA MESA,CA Zip: 92626-2211 - I PER Contractor: OWNER-BUILDER Address: EXPIRES g • '• Phone: Zip: License: 000000 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT _ ADD 128 S.F.TO EXISTING S.F.D.WORK TO INCLUDE: EXPAND EXISTING KITCHEN TO CREATE NEW BREAKFAST NOOK AND REPLACE WINDOWS THROUGHOUT THE RESIDENCE TO COMPLY WITH 1997 U.B.C.REQUIREMENTS. • FEE SUMMARY Plan Check: $163.31 • Calc Valuation: $14,327.20 Permit: $251.25 Claim Valuation: $0.00 SMIP Res: $1.43 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 - Total: $415.99 - PLANNING &ZONING <; SETBACKS, ' _ • MAIN STRUCTURE-Front 0-0 Rear, 17-0 - Left 411 • Right 0-0, ACCESSORY Front 0-0 Rear 0-0 Left 07 0 Right 0-0 -, PARKINGExistinc: 0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§1,12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(WOO) • 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. O I have and wilt 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 ere: Carrier: Policy Number: (This section need not be completed it the permit is valued at one hundred dollars($100)or less.) O I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that 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.# Class# Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). 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 end the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant fore permit subjects the ' ant to a civil penalty of not more than five hundred dollars($500).): I as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or Improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors • ense .). --�I aidop der se Business and Professions Code for this reason: . • 'Sign] Date: � ,Owner I1 verified by driver's li a e. Yes 0 No Driver's License No. xpires: 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). O As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this Application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 0 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 NTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. ee to com with II e laws a ity or ' ces relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the ab -des • ed pro r• coon pu s.I y of to occupy or allow occupancy of any building authorized this permit unt' final inspection. ef Signa ore f Legal Owner(s) Date And/Or Authorized Applicant Date CODE I INSPECTION TYPE D9TE 1NTt1IAL$ CODE It INSPECTION TYPE DAM MMUS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 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 7'"` 'I' at, "geb240,c2-/t /c,es • ' lJ /1(.671/774 fC. t r / Sa Gla 9,24-a� __ 7/ L/ - 9k/- loot Mt. Fd Liezu - C/7/ 11 of Z//sac 6br O. /(2e,e7 co-57/3_ Asa G'4-, 2_4 z F - - ek775/4 _ - ._. - <7- alj ��/her /Let/ 4i7 _sc_7L /�dcic (�«!' L �frSo vlllGC—_-7�a Lee/_ ek �ec-Trcc- _ S q�'c—j - 4, - se''dye-=t �!✓Gl Jam'--/7'iv/ it! , 106 l/U�s - /.d/ i ---�' t_ Aid 4 ale/et7sio-n 4 F- 2?- or - - %V __ phis— Gri _ .G{e _ _Gc -79.-2-7.._e 7_< ---- - - - - -- - -- -- - - - -Zan - — ( 2Geii�GG5 • op" F CITY OF COSTA MESA BUILDING DIVISION s• : �: - DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER •F t /f t PERMIT 4.+1�!P1603-01031 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 1850 KENTUCKY PL Status: ISSUED Suite: Applied: 06/17/2003 Vicinity: ROOF Issued: 06/17/2003 Parcel Number: 13904113 Zoning: Applicant: HENDRICKS, BRENDA S ISSUED BY: Address: 1850 KENTUCKY PL Phone: 714-557-6903 COSTA MESA,CA Zip: 92626-2211 Owner: HENDRICKS, BRENDA S Address '1850 KENTUCKY PL - Phone: - - COSTA MESA,CA Zip: 92626-2211 Contractor: OWNER-BUILDER Address: Phone: Zip: License: 000000 Arch : - Eng: Address: Address: • • Phone: Phone: Zip: - License: License: SCOPE OF PERMIT TEAR OFF EXISTING ROOF. INSTALL NEW SHEATHING,30#FELT,AND 30 YEAR COMPOSITION SHINGLES.2000 S.F.INCLUDES ATTACHED GARAGE. • FEE SUMMARY Plan Check: $0.00 - Calc Valuation: $4,000.00 Permit: $97.25 Claim Valuation: $4,000.00 SMIP Res: $0.50 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 - • Total: $97.75 • PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: .0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. • INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2448.46(6/00) DECLARATIONS WORKERS'CbMPENSA ION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: r ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) t1 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/pr visions,Jes_ • / 7 Applicant Signature: .? Date: O ' / — 0 WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS 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.# Class# Contractor's Signature: Date: i CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that 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).): GI"1 owner of the Professions ions elo es onth wages is their sole conot apply WILL DO THE WORK,and the structuresimis not intendeder , offered ho 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 en 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: j4l4i�t! 7/ ©i/c-i4" r , 'a Expires: /1-2y•0 Verification of Ownership by(type of doe ent,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑Yes ❑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 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes 0 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 ❑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 inspecti purpos .I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. l� -/7- 03 Signature Of Legal-6r(s) ` Date i And/Or Authorized Applicant Date ;ODE I INSPECTION TYPE gdff. INTI1AIa CODE! INSPECTIONTI'PE PEI II.1ti 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final e • 208 Final Plumbing 200 Final Re-Roof 7-2z- 3 (13t 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 \AR plicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. <i<9 - '3 I P R. IT NO. • UNIT NO. ," CITY OF /MESA CONSTRUCTION/ � PERMITA/ �E 3 g (�( = '� A.P.# o(-((— 013 zone g� Project Address / a•5Q JC g� /u!�Ky �4�C-G '~ .�y� ^,,/ T.VPE OF CONSTRUCTION v.% NEW In ADD U ALTERATION . REPAIR Main Buil. ng: Accessory Building: Applicant's I•iailing Aibdresso '3'2S �. /v74/30[ 5'�e Ay" Z �/f��i K!l - :�.JCONVERSION ❑ DEMOLISH ❑ OTH Front � � `— O Owner's Namep �-Tf} .Pall Phone l.!• j N /6 eNTu!!.Ky PLid_ •DESCRIPTION OF WORK/USE OF BLDG. U/Y/TG DAl Address QQ �(/�/ // I Arch/Eng. rJ /-r DArn_S License No. 7/2/e-7 PE OF PERMITnee❑ GRADING FOUNDATION LKSTRUCTU RAL G 1/p..2iA C'AC IA GA-T:DEA) �/'hd, O TENANT ELECTRICAL" PLUMBING ❑ MECHANICAL• Ping. Ref. # Parking Req./Provided E t or's Name ' C � Ad • Phone 3r% �� OCCUPANCY O .Se mg Hest- Q[e/e, PROJECT DESCRIPTION SQ. FT. ��� Planning Notes: ' H � !�� M 9R CONSTRUCTION TYPE VALUATION$ I/, • T 'ty License No. s/� t✓ ZONE GRADING CU.YDS. ACRES I LICENSED CONTRACTOR DECLARATION S. I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: /:!c. /Et- e!• 70 PO- 3�fQp, with section 7000) of Division 3 of the Business and Professions Code, and iiiiii V `• j � my license is in full rte an. effect. q ,L �,/�• /2C-427)s ELECTRICAL FEES D tent Class �-S Lieenfe No f7c 3..T�‘ t I_iii Dale R ' .� Signature `Iia _tt .moi_-�� PLUMBING I FEESAutomatic Washer ■ .'nWORKERS' COMPENSATION DECLARATIONBar Sink Showers Construction Pole Sub. Cooking Unit Meter "V 1 hereby affirm that I have a certificate of consent to self-insure ora certificateof Workers' Compensation Insurance, or a C¢fLlfied copy cher'• (SectionBackflow Preventer Service Sink Po0Q Lab. C�) / ■up ver ss Policy Np1p(4�sher,r furnished.Company -1,--.-, j a-- Backflow Irrigation Sewer Cap ■ Q,Certified copy Is hereby the • ■ ■ �. �$ Certified copy led with the city B a(iing Divi .n. , 7 Bathtubs Sewer Connection nn Date --/.0 Applicant . .--en- �.- A%L_iL% EXEMPTION FROM WORKERS' sE. _■ 1- -/ -CO MPEN-ATION DECLARATIONIII Clarifiers Solar Collectors (This section need not be completed if the permit Is for one hundred ($100) or ■• ■ , less). Dishwasher Solar Piping lli I I certify that in the performance of the work for which this permit is issued I • Microwave shall not employ any person in any manner so as to become subject to the• Solar Tank Workers' Compensation Laws of California. Date Signature DrainsSwimming Pool�JSpe Device le Light NOTICE:If,after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks Urinal Range comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY Gas Service • Sign I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097 Civ. C.) H.GGa.r.tbcahgeespi7saiKw Standing Sections nterceptors Lender's Name �-s2�/.Lender's Address (.0/t.i/ ■ Trash Compactor OWNER BUILDER DECLARATION �+ y� •'•� I hereby affirm that I am exempt from the Contractor's License Law for the Sl./�•_/.y,;,�• �QO/ p� following reason (Section 7031.5 Business and Professional Code: Any city or . county which requires a permit to construct,alter,improve,demolish or repair Laundry Trays . any structure, prior to its issuance, also requires the applicant for such permit Roof Drains MI• 11111,A1to 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 . -® Reinspection Fee $15 Issue Fee $S. "• 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). ■ . $ 3 DEVELOPMENT SERVICES RECIUIREM , -. _ LJ If as owner of the property or my employees with wages as their sole .Zoning Approved By Date compensation, will do the work,and the structure is not intended or offered 11A IMES for sale (Section 7044, Business and Professional Code: The Contractor's Building Approved By �/ //i Date nE License Law does not apply to an owner of a property who builds or improves - - — Application Issued By �T!fi',./ L!/��' Ante thereon, and who does such work himself/herself or through his or her own .� Hood or Type I ■ pP � ��/�--- Oat: 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- Canopy Type II ■ SUMMARY OF EE' pletion, the owner will have the burden of proving he/she did not build or im- 'Duct-Under Ground prove for the purpose of sale). ' /..24)BUILDING PERMIT $ /. •op SMIP $ _ . 77 ❑ I, as owner of the property,am exclusively contracting with licensedCHANIDuct-Structural Refrigeration System CAL FEES Buconstruct the project (Section 7044,Business and Professions Code: PLAN CHECK $ PERMIT The Contractor's License Law does not apply to an owner of property who • 00-100,000 BTU 0100,000 : PLUMBING $ q • 00 ISSUANCE $ builds or improves thereon.and who contracts for such.oroiects with a con- ENERGY P.C. $ tractor(s) license pursuant to tne Contractor's License Law): I am aware that , ■ Multiple ■ sPLAN CHECK 25% $ proof of their Worker's Compensation insurance.should be provided to me. ' ELECTRICAL $ T5-. 00 •GRADING $ ❑ I am exempt under-Section B.& P.C.for"th's reason • • =• •: �, MICROFILM $ ` PLAN CHECK 50% $ Date Owner - - • - • isters III MICROFILM $ TOTAL FEE $ .1Sv. 77 I hereby certify that I have read this application and state that the above ■1 •s sss : ■ ss Iss : PLAN CHECK 25% in to nils Gelatin. I agree to comply wit h'a,1 dy and y county rite repre- , I $ and state laws relating to building construction, and hereby authorize repre- sentatives of .. s -city Co enter p the above-mentioned property-fQr • Inspection our--s. ,f/�jC' Signature 4 Arad.. a ..id..-....i--• Dat--_ _ Drivers-License or SS 9e - ,;: $15 . Issue Fee $ 3 II DI CDDw0557-DCC'+D2 a Tor DATE: 04/19/37 iIlE. U$ 04 `'., 0865-46,rev. 5/88 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor CONSTRUCt'. • , LANNING POOL& SPA APPROVALS! t# Date Inspector APPROVALS "Permit•# Date Inspector is 1. Temporary.Electrical Service or Pole s • , 52. Pool & Equipment Location _923 Q • 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. ,Etectrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. • 55. Electrical Bonding 5. Steel Reinforcement ''';', 56. Rough Plumbing & Pressure Test 40 /I/ ///!!D Gry�a�"/, /! 6. 'Electrical UF ER GrndY' I 57. APPROVAL TO COVER-GUNITE \ ((( F 7. .Footipgs 58. Electrical Conduit-Undrgrnd. 8:2Foundation ` ' 1 59. Gas Pipe, 0 Undrgrnd.,Test . 9. Water Pipe-Undrgrnd. ( 60. Backwash Lines,P-Trap, 0 Undrgrnd. 6 /(o ('q �o ., uW . i 10. Structural Floor System ' , 61. APPROVAL TO DECK b�/�� ;0 41- - , 11..Property'Sewer Line & House Connection 62. Backwash & Receptor-Final 7 fffr 191/1 12. Sewer Cap „ ) , ^- t, I ; , 63. Heater & Vent-Final 13. Roof'Drains - - ,, ', 64. Plumbing System - Final Q W- 14. Rough Plumbing 65. Electrical-Final • 15. Rog Electrical-Conduit 66. Solar System-Final 1 ?:: • 16: Rough Electric Wiring 67. Fencing & Access Approval - Y1 i1]i Rough Wiring Sign 68. APPROVED FOR PLASTERING '-,-r1 (j at- �18. Rough Electrical-T BarCeiligg•,: 69. POOL/SPA SYSTEMS FINAL (9a 119. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT -20. Rough Factory Fireplace - ' APPROVALS Permit# •21'. Ducts, in Structure ill I 70. Underground Hydro te ,22..DVentilating "i e-i 71. Product Piping 0 Gas 0 Oil '23. Gas Pipe-Rough&Test s72. Underground Flush 24: Roof FramingP. • T, r, 73. Undergrnd.Storage Tank O Gas El Oil 25. Roof Sheathing 74. Overhead Hydro 26. T-Bar Ceiling (Structural) &;Monocoat 75. Dry Chemical 27: Frame,and Flashing 76. Dry Standpipe 28. Lathing 8/Siding1 f 77. FIXED SYSTEM FINAL :1 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing /` HEALTH DEPT. REQUIREMENT t. 31. Plaster Brown Coat// 79. FINAL INSPECTION . 32. Electrical Power Meier-Final - 80. FOOD CERTIFICATE ISSUED //�� 1 33. Final Electric .r Notes: 6� f-8? v/c- 00,/,/ '-0 34. Final Heating & Air Conditioning /fry Lf Ane-,/ 7 /tilh'96r 0A 35. Final Gas Pipe-Test ,3th46:4-J 04 7A/A9 l7J'VnQn J 36. Hood or Canopy � '37: Final Factory Fireplace . 38. Final Plumbing 39. Water Service-Final • - 40. Gas,Service-Final _ tri '41. Solan Domestic-Final I.42. Backflow Preventer". ` - j' Ey) I f• J 43. Backflow Irrigation_ t r • "44. !Landscape Irrigation System r. ;'. 45. Sound Attenuation ' - / '' �. 46. Handicap Regulations ' 47. FJNAL STRUCTURE'& BUILDING 1 • - 48. Special Requirements Completed e" 49. Electric Release to Edison - ...--- /... a_ • -56. Gas Release to Southern California Gas Cols+ - 51. CERTIFICATE OF OCCUPANCY: - /' I'.1 'I-.- '" No. Date iz- ' '/ tf 1 FEE RECEIVED F., 12033 ACL: MAY 16 1960 COSTA MESA BUILDING-SAFETY DEPARTMENT FINANCE DEPT. P. O. BOX 917 COSTA MESA. CALIFORNIA CITY OF COSTA MESA For Applicant to FM In Completely APPLICATION FOR PERMIT TYPE OR PRINT BUILDING BUILDING ADDRESS 1850 Kentucky Place COSTA MESA. CALIFORNIA For Office Use Only ( RECEIPT NO. r 1RyL(D.S2 OWNER Vermont Avenue Land Co. , Inc. I CCC����AAp$$f I ��Jr�AI , AMAIL DDRESS 419 E. 17th St. REcel I I'�jP�� DATE le / 1960 7 MAY 1 7 CITY Costa Mesa N,;i 8-1159 BUILDING ADDRESS OR ENGENEEjr1son & MiddlebrooREo. COSTA MESA. CALIFORNIA . ADDRESS Garden Grove • FIRE ,/ V_l _ ZONE TYPE YYY GROUP ((( CONTRACTOR Dike & Colegrove, Inc. APPROVED BY DATE ADDRESS 419 E. 17th St. ZONING rt NO.OP USE OP NEW Gif�1 foals. ZONE CITY Costa Mesa R_1 I PLANE 2 I BUILDING W/ att gar. TE LEGAL SIC.NO. 167293 No: Li 8-1159 DESCRIPTION Lot 45, Tract 3648 SIZE A l M I NO. OF BLDGB 12V NOW ON LOT none OF LOT 551A.P.NO. none USE OF none YARDS EVES EXISTING BLDG APPROVED ALLOWED SETBACK LINE PROM (CENTER LINE ST.) ---,t CENTER OF STREET 701 REAR YARD 501 FRONT 5 /11I FT. IN. SIDE YARD I LEFT 51 I RIGHT 71 R.SIDE '/ FT. IN. DESCRIPTION OF WORK X L.SIDE , 5 FT. IN. NEW I X II ALTERATION I II ADDITION I REAR .FC) FT. IN. REPAIR I D MOVING I (DEMOLISH I ABY W. W. L. D. DATE 5-13-60 SUILDmG1560 sq.ft. ROOMS 7 1 W✓ ! SIZE U STORIES //// EXTERIOR WALLROOF COVERING stucco I COVERING comp. USE OF BUILDING AND WORK TO BE PERFORMED Single family residence and attached garage. Plan 20A I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING BUILDING CONSTRUCTION. VALUATION PERMATUR OF Dike & Colegrove, Inc. PERMIT FEE $ 36'00 N _ $ 16,101.00 PLAN CHECK $ 18.00 4 AUTHORIZED AGENT v ��-' g 00 TOTAL FEE S 54.