HomeMy WebLinkAbout2163 Kristin Ln - Building Permits CITY OF COSTA MESA
o5`""'F BUILDING DIVISION •
>F``nWerTha.a�'�,,,, 41 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
. FOR INSPECTIONS CALL: (714)754-5626 ,�1
PERMIT NUMBER: P09-00117
•
PERMIT TYPE PLUM STATUS: ISSUED
APN: 93132407 DATE ISSUED: 09/09/2009
ISSUED BY: KJB
•
JOB ADDRESS: 2163 KRISTIN LN CM Suite/Unit:
Vicinity: -
SCOPE OF WORK: CHANGE OUT STORAGE TANK WATER HEATER. SAME LOCATION.
•
OWNER: LAY, KEVIN Address: 2163 KRISTIN LN
PHONE: 949-574-9659 City/State/Zip: COSTA MESA,CA
APPLICANT: LITTLEFIELD,SCOTT . Address: 24707 SAN FERNANDO RD :
PHONE: 888-611-4328 City/State/zip: SANTA CLARITA,CA
CONTRACTOR: AFFORDABLE WATER HEATERS AND PLUMBING License No. 627368 1.4 1
Address: 24707 SAN FERNANDO RD
PHONE: 661-259-7131
City/State: SANTA CLARITA,CA ZipCode: 91321 CELL:
ARCHITECT: License No. PHONE:
ENGINEER: License No. PHONE:
PLUMBING PERMIT FEE SUMMARY
PLAN CHECK FEE: $0.00
PERMIT FEE: $35.80
TOTAL FEES: $35.80
<•7
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
CODES. INSPECTION TYPE DATE INMIALS CODES INSPECTION TYPE, DATE INITIAL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical /
1266 Pool Spa Final 208 Final Plumbing /U
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
WORKERS'COMPENSATION DECLARATION: Owner ID verified by driver's license. 0 Yes ❑No
I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires:
O I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-properly tax bill or deed):
compensation, as provided for by section 3700 of the Labor Code, for the
•
performance of the work for which this permit is issued.
gI have and will maintain workers'compensation insurance, as required by •
DI ISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
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 ' I hereby certify that no excavation five(5)or more feet in depth into which a
number are: •
person is required to descend,will be made in connection with work authorized
Carrier: �""`I f� by this permit,and that no building structure,scaffdding,falsework,Cr demolition
or dismantling thereof,will be more than thirty-six(36)feet high. (Chap.3.2,Gm
(This sectun need not be completed The perms( valued at one hundred dollars(5100)atess.)
�e2,An 2,Sec. 341,Title 8,California Administrative Code).
Policy Number: 7-001 0 L?](r)c/
0 As owner-builder, I will not employ anyone to do work which would
O I certify that in the performance of the work for which this permit is require a permit from t e Division of Industrial Safety,as noted above, unless
issued, I shall not employ any person in any manner so as to become subject such person has a p it to tl such work from the division.
to the workers' compensation laws of California, and agree that if I should e- 9/q/O
become subject to the workers' compensation provisions of Section 3700 of ,porn's Signature Date
the Labor Code, I shall fort th com y with these provisions.
q(9 /05 Division of Industrial Safety Permit Number:
Applic m' tgnawre Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency respo se to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑Yes J No
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons,or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is in full force and effect. Ceffect. (� a registration form for acutely hazardous materials? 10 Yes 10 No
Lic.# (#'L 0 3 _ Class# I Co (Section 25533 of the California Health and Safety Code, with some
CPT,—f— Q exceptions, requires registration with the Costa Mesa Fire Department by
'C l �5 each business which at any one time has on hand a quantity of acutely
Contra Signature Date 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name: hazardous materials)? 0 Yes a No
(Section 25534 of the California Health and Safety Code provides that the
Lender's Address: _ 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.
Signature Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes ❑No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes ❑No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Government Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits).
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 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes 0 No
applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes",the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
❑ I, as owner of the property. or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec. 7044,Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No
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 8. (If"yes", attach certificate of compliance from the appropriate air pollution
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
0 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH / (�
city ordinances regardi Hazard s Materials and Emissions.
LICENSED CONTRACTORS to construct the project(Sec. 7044, Business and 9( ! Q 7
Professions Code:The contractors License Law does not apply to an owner of ignature Date
property who builds or improves(hereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
❑ I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: 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 etre__
al/Owner( 7/4749i Date
Signature Date etr– //"/g G
3057-46(3I071 A utnonzed Applicant Date /
f•
CITY OF COSTA MESA
BUILDING DIVISION •
QQQ
Ft' • 77 FAIR DRIVE,COSTA MESA, CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
4. FOR INSPECTIONS CALL: (714)754-5626
PERMIT NUMBER: E09-00222
PERMIT TYPE ELEC STATUS: ISSUED
APN: TPN009021 DATE ISSUED: 08/25/2009
ISSUED BY: • BJK
•
JOB ADDRESS: 2163 KRISTIN.LN CM Suite/Unit:
Vicinity: EVERGREEN H0A DRIVEWAY ISLAND
SCOPE OF WORK: RELOCATE THE EXISTING ELECTRIC SERVICE PEDESTAL(FOR LOW VOLTAGE LIGHTING)IN THE COMMON-AREA
FOR"EVERGREEN HOA."
1 SVS TO 200A
OWNER: EVERGREEN HOA . Address: CARE OF JUDY BLANKINSHIP Unit:COSTA MESA,CA
PHONE: City/State/Zip: 2163 KRISTIN LN
•
APPLICANT: THOMAS,TIFFANY Address: 2166 KRISTIN LN Unit:
PHONE: 949-874-3660 City/State/zZip: COSTA MESA,CA
•
CONTRACTOR: OWNER-BUILDER License No. 000000
Address: Unit: . PHONE:
City/State: ZipCode: CELL:
ELECTRICAL PERMIT FEES
Electrical Plan Check Fee: $0.00 •
Electrical Permit Fee: $54.00
Reinspection Fee , $0.00
TOTAL FEES $54.00
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No.92-28, §1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
CODES. INSPECTION TYPE DATE INMIALS CODES INSPECI10N TYPE DATE INTITIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical _
1266 Pool Spa Final 208 Final Plumbing Q �y
200 Final Re-Roof 210 Final Electrical CiliW({/ E
•
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
WORKERS'COMPENSATION DECLARATION: Owner ID verified by driiver's license. Y s 0 No ��
I hereby affirm under penalty of perjury one of the following declarations: Driver's-License'No.' - -Expires: 3
0 I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or d ed):
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 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
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 ❑ I hereby certify that no excavation five(5)or more feet in depth into which a
number are: 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
Carrier: or dismantling thereof,will be more than thirty-six(36)feet high. (Chap.3.2,Grp
(This section need not be completed d the permit is valued al one hundred dollars($100)or less.) 2 Art 2,Sec.341,Title 8,California Administrative Code).
Policy Number:
❑ As owner-builder, I will not employ anyone to do work which would
O I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above, unless
issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California, and agree that if I should
become subject to the workers'compensation provisions of Section 3700 of
Applicant's Signature Date
the Labor Code,I shall forthwith comply with these provisions.
Division of Industrial Safety Permit Number:
Applicants Signature Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑Yes 0 No
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safely Code requires, with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEYS FEES. Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
LICENSED CONTRACTORS DECLARATION: 500 pounds, or a volume of 55 gallons. or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is in full force and effect. a registration form for acutely hazardous materials? 0 Yes 0 No
Lic.# Class# (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
Contractor's Signature Date 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued. (Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name: hazardous materials)? 0 Yes 0 No
(Section 25534 of the California Health and Safety Code provides that the
Lender's Address: 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.
Signature Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes 0 No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? ❑Yes ❑No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Government Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits).
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 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes ❑No
applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes", the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the Califomia Health and Safety Code).
❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec. 7044, Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California
License Law does not apply to an owner of properly who builds or improves Health and Safety Code Section 42303 been made? ❑Yes 0 No
thereon,and who does such work himself or herself or through his or her own
8. (If"yes", attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
/) I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH
city ordinances regarding Hazardous Materials and Emissions.
U NSED CONTRACTORS to construct the project(Sec. 7044, Business and
Professions Code: The contractors License Law does not apply to an owner of Signature -- Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
❑ I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: 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.dCS \ `�'�j`
egal Um� l.k ) U I
•
Sgnewree'
3057.46(3/07)
Andlor Authorized Applicant •Date:7a.-
City of Costa 914esa cBui&ding Division
} 77 Fair Drive, Costa Mesa, CA 92626
Costa Mesa 714-754-5273 / Fax 714-754-4856
OWNER BUILDER VERIFICATION
Permit # 509 '00222--
Disclosures & Forms for Owner- Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your name listing^yourself as the builder of the
property improvements specified at2\(0 .�`C\S�Sltl � 1COSka CCA/ 24)27 1/P,4 C 1 l��'Q
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you
aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of
each provision, signed, and returned this form to us at our official address indicated. An agent of the
owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting
authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
B ilde ' building permit that erroneously implies that the property owner is providing his or her own labor and
material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any
injuries sustained by an unlicensed person and his or her employees while working on my property. My
homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder
an• am aware of the limits of my insurance coverage for injuries to workers on my property.
lib 2. I understand building permits are not required to be signed by property owners unless they are
-sensible for the construction and are not hiring a licensed Contractor to assume this responsibility.
le . I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that
I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his
or r name instead of my own.
4. I understand Contractors are required by law to be licensed and bonded in California and to list their
lic n e numbers on permits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors,
nd he total value of my construction is at least five hundred dollars ($500), including labor and materials, I may
be considered an "employer" under state and federal law.
6. I understand if I am considered an "employer" under state and federal law, I must register with the state
an federal government, withhold payroll taxes, provide workers' compensation disability insurance, and
contribute to unemployment compensation for each "employee." I also understand my failure to abide by these
laws may subject me to serious financial risk.
'a
p 7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family
-sidential structures cannot legally build them with the intent to offer them for sale, unless all work is performed
by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of
the work is performed under contract with a licensed general building Contractor.
3148-30 CALBO Jan 1, 2009 OB Packet template 1 of 2
t
i . 1
'l-, 8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable
or any financial or personal injuries sustained by any subsequent owner(s) that result from any latent
co truction defects in the workmanship or materials.
9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal
Rev nue Service, the United States Small Business Administration, the California Department of Benefit
Payments, and the California Division of Industrial Accidents. I also understand I may contact the California
Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information
.abo t licensed contractors.
g.10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand
t at am the party legally and financially responsible for proposed construction activity at the following address:
a1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will
!fie by all applicable laws and requirements that govern Owner-Builders as well as employers.
412. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
i o mation I have provided on this form. Licensed contractors are regulated by laws designed to protect the
public. If you contract with someone who does not have a license, the Contractors' State License Board may be
unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against
unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed
Contractor or employee of that individual or firm is injured while working on your property, you may be held
liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible
for verifying whether or not those Contractors are properly licensed and the status of their workers'
compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner
and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's
driver's license, form notarization, or other verification acceptable to the agency is required to be
presented when the permit is issued to verify the property owner's signature.
Signature of property own l L C- k1 Date: i 6
Note: The following Authorization Form is required to be completed by the property owner only when
designating an agent of the property owner to apply for a construction permit for the Owner-Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I
hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents
necessary to obtain an Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled
out the above information and certify its accuracy. Note:A copy of the owner's driver's license, form
notarization, or other verification acceptable to the agency is required to be presented when the permit is issued
to verify the property owner's signature.
Property Owner's Signature: Date:
3148-30 CALBO Jan 1, 2009 08 Packet template 2 of 2
`00' MF 9 CITY OF COSTA MESA
4
BUILDING DIVISION
'F • DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
1.041k- • PERMIT
ibo,artm P07-00284
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 2163 KRISTIN LN Status: ISSUED
Suite No Applied: 05/04/2007
Issued: 05/04/2007
Vicinity:
Parcel Nunmber: 93132407
Applicant: IPRANOSIAN, HEROS ISSUED BY: t
Address: 3840 MIRA LOMA AVE . . . -
Phone" 800-997-2743
ANAHEIM,CA , Zip: 92807
•
• Owner: BLANKINSHIP,JUDY E
Address 2163 KRISTIN LN l - ,
Phone:
COSTA MESA,CA Zip: 92627 '
•Contractor: RAPID-PLUMBING
Address: 3840 MIRA LOMA AVE
Phone: 800-997-2743 ' •
ANAHEIM,CA Zip: 92807
'License" 521992
SCOPE OF PERMIT
REPLACE WATER SERVICE -
• 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 -$0.00 0 . Wash Basin Set $0.00 0
Drain, Floor • $0.00 0 Sewer Connect $0.00 -0 Waste and Vent System $0.00 0
Drain, Rainwater - . $0.00 0 Sewer Private Line -"$0.00 0 Water Closet(Toilet) $0.00 0
Drain, Roof $0.00 0 Shower $0.00 0 Water Heater/vent . $0.00 0
Drinking Fountain - $0.00 0 Sink,bar - ' : • $0.00 0 Water Piping(Inst or Rep.) $0.00 0
Expansion Tank $0.'00 0- Sink,commercial - •$0:00 0 Water Re-pipe ' $0.00 0
Gas Earthquake Valve • $0.00 0 Sink,Floor $0.00'`, 0 Water'Service ' $9.80 1
Gas(1-4 outlets) $0.00 , . 0,, .-,•-,,,.,g Sink,kitchen $0.00 :-..0- - 'Water Softener $0.00 0
Gas(Over 4 outlets) $0.00- 0 --t';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: $33.30
. COMMENTS I SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord. No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
fora period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
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.
j 0 --3:My w and will maintain workers'u ntecompensation insurance,u required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
t 'Mytivorkefr�s'comp nsation Insurance carrier end policy number are: /� q C� zoo Came'r' r FanoL c r c .dkyif+lumber:_i 3 0 /Sc2 — ZO0 4
pbie.secffon need not be completed if the permit is valued at one hundred dollars($100)or less.)
❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,and agrae.that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
WAR�com I w�hese-provl Ions. �t
AppUcaz ntSignature: ryf$/}7 Dat 6 •5__L_ ,—
ING::FAILURE TO SECURE WORKERS' E T10N COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EM0 ERMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDITION T COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
areby.affirm•thatIamiicensediunder provisions of Chapter 9(commencing with Section 7000)of Division 3 of e,Busines .ar Pryfessions Code,and my license is in full
fforce{and a ecL:Uc..e_—_c,`,� dg 9 `2 Clasaa ' .5 (p
Corm actoripISi>)nature: cr-D Date:: 5 —/i _f
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered 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.). •
El I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: • Date:
Owner ID verified by driver's license. ❑Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec,
341,Title 8,Califomia 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 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 0 No
5 Does or will the applicant or present or future building occupant require far the work which is the subject of this application tmermit 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 Govemment Codo 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 El 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 Califomia Health and Safety Code Section 42303 been made? ❑Yes 0 No
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPUANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature egal Owner(s) Date
Arg -Ab-- -- S-—:-....k., -._.cp 7
AnWOr`A' orized Applicant 1.___� Ilifiglate-.,- - —4..
V
LODE♦ INSPECTION TYPE DAIS IMIIDALS CODEC INSPECTION TYPE OATS 1NTRIMLS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing ,7/
`7-d7 Q N
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
_I 9791 6/06/79 6-75.,-- 89. 15 'lit
- • COSTA MESA BUILDING-SAFETY DEPARTMENT APPLICATIONPOR STRUCTURAL PERMIT "' "'
-P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
RECEIVED BY PERMIT
TATO 48186
For Applicant to Fill in Completely — Use Ink Only /' 1�1
BUILDING A.P. NO. £ (€3 .o '/! SOY V. /b
ADDRESS 1 E
ism € //
OWNER OR /QGNC. / ADDBUILDIRENG55 li(//�[(�
TENANT �,4CAc/f j' /
UNIC
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TR.NO. LOT BLK.
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CONSTRUCTION/� , /
LENDER /�/.I C/T� tvCRAsL �/
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ADDRESS
JVALUE
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USE W�TTL�-� $ARCHITECT / [. �Drn TEL vOR ENGINEER .J. SL6iNt_2 NO. £ 2e8/9aZONE !A
ADDRESS TYPE GROUP i
APPROVED
CONTRACTOR 4'/4N/alt / /6441.,(A./
BY DATE
i
ADDRESS 54..c..
TEL.
CITY 7Ana-t- NO.
—
vr.F STATE CITY APPROVED SETBACKS
LIC.NO. a9 Qo19 LIC.NO.
1.1 1SIZE NO.OF BLOCS (FROM C/LST
L OF LOT NOW ON LOT FRONT
Q USE OF �}
EXISTING BLDG. It SIDE J FT. ......-
Ca
Ca �
FSeparate permits are required for L.SIDE 5 FT.
C electric,plumbing and heating wort REAR
(y 34) FT.
I.., USE OF BUILDING AND WORK TO BE PERFORMED PLANNING ACTION
-CCI n / may. t /J
Cow al. �..r aey`ti. _ L Z—�� I nwROVED/U�Z?/7D
APPROV4(j.Q /,!y�/�• Il 8- 8 - 79
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CC DATE
C
W
0m hereby acknowledge that I have read this application and state n
yd that the above information is correct and agree to comply with
D. all laws regulating building construction, and I shall not employ i
Z any person In violation of the workman's compensation laws of s-t /�t/��� o
= the State of California. rte} ) SQ. FT. ��'t '7 p — m
/ N
I hereby certify that I am properly licensed as a contractor under 111
the State of California Business end Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR a1
Chapter 9, and that suc licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: e
am exempt from the visions of the State of California Business VALUATION PERMIT FEE E xt ry
end Professions Cod ivision 3,Chapter 9. �1 L ,n ` y
�6 i= o
Signature of PLAN CHECK E 'n (�
o ` \
Permittee // / S Sia TAX $ c.
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or
Autho ized Agent Date 7/`/',r TOTAL PAID $ c U
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COSTA MESA BUILDING-SAFETY DEPARTMENT APPL CATION Folje§TROatlias PERMI'll 72.00 TL'
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 -
REC D BY PERMIT
For Applicant to Fill in Completely — Use Ink Only �/+t///`No
BUILDING /�/J �•.� ,� A.P. NO. eV/s,— 0 Y /o 9 'y`'/t
ADDRESS /�1/� - /Ci raga- BUILDING J�� �� �+
OWNER OR t£G/•,s Lis 1 PicAia/LI. ADDRESS �LV�_ //�C�IC�F�, O�
TENANT IIII���JJ� //TT
UNIT OR
MAILING ADDRESS Ju'// Ili,, c/c� R—, SPACE NO.
JJ TR.NO. LOT , iBLK.
TEL.// , ,,5pg
CITY � ,c/�, NO. tlJ3-2P NEW 1/ADD ALTER REPAIR MOVING DEMOLISH
CONSTRUCTION
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LENDER
BRANCH ,,//
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OWNER 44criten ) CPLD
ADDRESS / VALUE
ARCHITECT TEL. USE E
OR ENGINEER NO.
ADDRESS ZONE giliTYPE GROUP
APPROVED '�/�
CONTRACTOR BY DATE D l/ 7
ADDRESS
TEL. •
CITY NO.
FlSTATECITY APPROVED SETBACKS
pH. LIC. NO. LIC. NO.
SIZE NO.OF BLDGS. (FROM WI_STREET)
0. OF LOT NOW ON LOT _FRONT FT.
Q USE OF
to EXISTING BLDG. R.SIDF FT.
to
F Separate permits are required for L.SIDE FT.
electric,plumbing and heating work.Ci REAR FT.
W
F USE OF BUILDING AND WORK TO BE PERFORMED PLANNING ACTION
HE
D
DATE
-C APPROVED
7 APPROVED
} Y DATE
.d
a
W
0 I hereby acknowledge that I have read this application and state• N
p„/ that the above information is correct and agree to comply with
W all laws regulating building construction, and I shall not employ i
Z any person in violation of the workman's compensation laws of
S the State of California. m
I hereby certify that I am properly licensed as a contractor under SQ. FT. N
D
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR o
Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: —
am exempt from the pr sions of the State of California Business $ N
T
VALUATION PERMIT FEE
and Professions Code, ision 3,Cha er 9. ���
m
en
Signature Of /7 PLAN CHECK $ o
Jf� E
Permittee �- S TAX $ LL
Authorized Agent Date IT/� 7 f .. TOTAL PAID E /7 2,0o