HomeMy WebLinkAbout271 LILAC LN - Building Permits CITY OF COSTA MESA
47410111t: BUILDING DIVISION
st
. • (.1.bla I el KU nl DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
W.141. PERMIT
/05-00913
itbiboRmo'l
(714)754-5273 • Fax(714)754-4656 • www.ci.costa-mesa.ca.LLus-
tuTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 271 LILAC LN Status: ISSUED
Suite No Applied: 09/01/2005
Vicinity: Issued: 09/01/2005
Parcel Nunmber: 42615113
Applicant: SHAFONSKY, GINA NICOL
Address: 271 LILAC LN
Phone: 949-650-5444 ISSUED BY:
COSTA MESA,CA Zip 92627
•••••-r....;;'•
- • -4:arc
Owner: SHAFONSKY,:GINA NICOL;i. - •
Address 271 LIL,,p LI%,.• , - ,
Phone: 949-650-5444
COSTA MESA,CA Zip 92627
..•• • -
Contractor OWNER-BUILDER
Address'.
• • R
P
Phone:
Zip: • ',$.15
License:000000
• ' „.
•• .„5., 5 .....„4'i:e.CSCOPE OF PERMIT
1,991 SF INTERIOR ALTERATION TO EXISTING S.F.D.WORK TO INCLUDE ELIMINATE 1
EXISTING BEDROOM TO CREATE NEW MASTER SUITE AND CHANGE OUT!;52.SLIDING GLASS DOORS IN . ,
7...REAR BEDROOM AND FAMILY ROOM.REF.:B05-01458
' sy;
ELECTRICAL TO INCLUDE:14..,.LIGHT FIXTURES,17 OUTLETS,AND 4 SWITCHES.3'
• ,
•• • 1
CONVERT EXISTING 4 BEDROOM,2/BATH S.F.D.TO AS BEDROOM,2 BATH S.F.D.
• ,
FEE SUMMARY .
,t•
Quantity fl ?Quantity
• •
ISSUE FEE 55Temp Dist System/Lighting .5,5,, $0.00 0
Temp service test s kit, -$0.004
Res.a/c package ,30; $0.00 Standing Section
New Res(1-2units) $0.00 ' 0 Misc Electrical Equipment __ $0.00 -
New Rea".(3+units) 1,?5,,S),,,$0.00Z,5,- 0 Transformers up to 1 kva/kw $0.00;54,... 0
Pool/Spa '5- 0 up to 10 kva/kw :5-3$0.004:` 0 5:
Lighting Fixts '5-- ,3 5'4"$15.40 • 14 ."5 up to 50 kva/kw $0.00 5.' 0
Recept Outlets q$18701-.* 17 5, 5 up to 100 kva/kw $0.00.34 0
Switches *33' • $4.4e, 4 over,100 kva/kw $0.00 0
Non Res Appl ' $0.00 0 ' , Low Voltage Equipment $0.90
Res Appl 4$0.00 0 ..... Low Volt Wiring System $0.000„. _
Service to 200a $0.00 5-3,r '1- '$0.00 u0
Service to 1000a 6.5$0.00__ 0 Misc.Conductor $0.00
Service over 1000a " $0.00 - .3.tCircus(gen or ride) - $0.00 4$' 0
Motors to 1hp "I*5• 5:5,t $0.00 0 _Circus(mechyide"or lights) $0.003. 0,
Motors to 10hp ';:':"<5.$0.00•5 - 53%3 :`.5" Christmas Tree Stend 351:•„ ..-...: $0 00 .3 3 0
Motors to 50hp Fireworks Stand k:1- . $9.20,4 0
Motors to 100hp $000 0 Other Electrical.Fee 4..$0700&
Motors over 100hp $0.00, 0
Communication drops $0.00 0 Investigation Fee $0.00
Sub panel to 200a $0.00 0 .k”.„ Plan Check Fee ' $0.00
Pole Light Pkg $0.00 0 ',V5.5- ..,„ Reinspection Fee $0.00
Sign Circuits $0.00 0
Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $62.00
Intermed Pole $0.00
•
•
•
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: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-48(6/00)
_
DECLARATIONS U I (-`)
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.)
-CrLr rtify 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'
1 compensation laws of Calif. ,, 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 •rovisio-�
Appli Signature: - Ii� Oate:g. q— L . ns
y
'ORE TO Sh : — •-IN •— COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT it CRIMINAL PENALTIES AND CML RIVES UP TO ONE HUNDRED
SAND DOLLARE(5100,000),IN ADDITION •THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR INS E�TION 37060F THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is In full
force and effect.Lic.0 Class N
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that 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 a 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 fore permit
subj_/lyes e applicant to a civil penalty of not more then five hundred dollars($500).):
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
self 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
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 ElX(CCIIJJJJSryryFFLY CO{iTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code: :contractors License 1.. oe3t8t apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
.tomwane S liarit to the Contractors License Laws.).
•�A
I am.13;,• �der sec. Business and Professions Code for this reason:
l a,... Date: �Y-`_Qtr-.
e• drivers license. ❑Ves 0 Notwerp Licedse Na \ iiM e j`• j__
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,Op 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 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? ❑Ves 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? lD Yes u No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
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 ORIZATION OF ENTRY:I sanity under penalty of perjury that I have read this application and state that the information given is
correct. I ag to comply'l i9Lall..ts and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-desc .a•ro ry or insv-!all .Lgr„ agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
pi
< :* )?. —
And/Or Authorized Applicant Date
SODS• INSPECTION TYPE PAL tornAL$ CODE( INSPECTION TYPE PATE =ALI
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing ,may
200 Final Re-Roof 210 Final Electrical Z—23-0.6W C
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
01 CITY OF COSTA MESA
41.!!!!! :\
BUILDING DIVISION
F ' ,� DEVELOPMENT SERVICES DEPARTMENT PP RMIT NUMBER
�aike PERMIT M05-00494
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
MECHANICAL PERMIT
•
Job Address: 271 LILAC LN Status: ISSUED
Suite No Applied: 09/01/2005
Issued: 09/01/2005
Vicinity:mber
Parcel Number: 42615113
ISSUED BY:
Applicant: SHAFONSKY, GINA NICOL
Address: 271 LILAC LN =-
• "Phone:"949-650-55144
COSTA MESA,CA 'Zip 92627
Owner: SHAFONSKY GINA NICOL
Address 271 LILAC LN .atmos-_ ,�s-E ___ y „�y.
•
s, ° a Phone 949-6505444 „
': . �-
COSTA MESA,CA`s v Zip: 92627
Contractor, OWNER-BUILDER '
Address
RR
Phone
•
Zip: ,'.`.
License;000000
SCOPE OF`PERMIT _ u�
r 1,991 S.F INTERIOR ALTERATION TO EXISTING S.F.D.-WORK TO INCLUDE:ELIMINATE 1
EXISTING BEDROOM TO!CREATE NEW MASTER SUITE AND CHANGE OUT 2 SLIDING,GLASS •
DOORS IN REAR BEDROOM AND FAMILY ROOM.REF.:B05-01458 "' 5 .,, '
"' -- �7 �MECHANICAL TO INdLUDE: 1 VENT FAN
CONVERT EXISTING 4 BEDROOM 2 BATH S.F.D.TO A 3 BEDROOM,2 BATH S F D
FEE SUMMARY "' *„ s
Quantity Quantity
ISSUE FEEi $2350 `8" z,� 'Repair/Alt$Absorbtion Unit e 4 „i",." $000 ' 0a _
Inst FAU< .,100-k BTU , $0 00 0 = _- 4.Repav/-Alt Refrigeration Unit "'? $0 00 0."
Inst FAU.>100 k BTU ` ' r -$0.00' 0 Ventillation" System ^ .`$0.00 0
Repair/Alb Cooling/Heat 4 '-"$0.00 ° 0 Evaporative Cooler =$0.00 0..r
Inst/Rep..,Recess Wall Htr,, $0.00 0 Commercial Incinerator '1.2:24,14.` ' :`$000 0.`
Refrig Sys;<100 k BTU 0,,$0.00 0 Domestic Incinerator >$0.00 0`
Refrig Sys;>100 k BTU' ' ,i` $0.00 0 - Compressors/Absorption Systems v b -z- •
Gas Piping $0.00 0 - Up to 3 hp/100 k BTU -t "' =$0.00::..;..0
Factory Fireplace k$0.00 0 '` 3 To45 hp/500 k BTU '•$0 00 0
Hood w/Mech Exhaust = f'$0 00 0 x ' z 48; 15 To 30;hp/1,000 k BTU ' ,,,,,� $0.00- 0
VAV Box "°' $0.00 0 s.•- '"' - ?. '30 To 50 hp/,1,750 k-BTU- $0.00 0
Vent Fan/Single Duct $7,.25 g"1 ,mv", %& '"Ove'r 50 hp'%Over 1,750,BTU '$0:00 0
Appliance $0 00 a0 'dye ,-'boilers -
Fire Dampers $0.00
Smoke Dampers ' "$0 00 0 �a (se. 3 Too15 hp ,_ - ' . , $0.00 0
Inst or Relocate Appl Vent-:- +,$0 00 0 e:- 15 to 30 hp
Air Handlers< 10000cfm - $0 00 0 s 'x r30 to 50 hp $0.00 0
Air Handlers> 10000cfm e $0.00 0 � Over 50 hp °;y'a • $0.00 0
Floor Furnace ' $0.00 0 "" fr,,�Other Mechanical Fee
Floor or Suspend Heater $0:60 - 0 a,;, _Investigation Fee $0.00
�'"• ..� �`Plan"Check Fee
,_ $0.00
.;,;yam _Reinspection Fee,, $0.00
TOTAL CALCULATED FEES $30.75
•
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 c) I n
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 earner and policy number are:
Cartier: Policy Number:
(This section need not be completed if the permit/s valued at one hundred dollars($100)or less.)
I certify that in the performance o the' •rk 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, 'fY-' •:t if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these proVTSi .--
Applicant Signature: — • Date: CI, ‘ ' l
WARNING:FAILURE TO SECURE •ORKE- •• P' SATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN n•• ION 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 lull
force and effect.Lic.# Class#
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business end 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 he applicant to a civil penalty of not more than five hundred dollars($500).):
as owner of the property,or,r-ny 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;Lew does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or.through hie or her own.emplyees.proGldedithat 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 wilphaCe 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 pursuanthe Contractors License Laws.).
❑ I am exempt `.. . Business and Professions Code for this reason:
Signature: SST'
Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more then thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety,as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑Yes 0 No
(Section 25505 of the 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? 0 Yes 0 No
(Section 25533 of the Califomia Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature end pressure).
3 Does or will the 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 ❑No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit 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 LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If yes',the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? 0 Yes 0 No
-.—._..(__
B (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 COMPUANC • • ORIZATON 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 -II st• s and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described pr for in- . • .n•e•.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signa,1.7%.,el Owner(s) Date
And/Or Authorized Applicant Date
CODE I INSPECTION TYPE PEI INRRALS CODE! INSPECTIONTYPE DAM
/______g
1616 Fixed System Final Fire Prevention 206 Final Mechanical 3 r.73'46
1268 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof _ 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition . . 250 Final Building/Occupancy
dog MF 9 CITY OF COSTA MESA
4 BUILDING DIVISION
F ,. DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER
4. 1110(-111
PERMIT
se P05-00673
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa3i-LMBING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 271 LILAC LN Status: ISSUED
Suite No Applied: 09/01/2005
Issued: 09/01/2005
Vicinity:
Parcel Nunmber: 42615113
Applicant: SHAFONSKY, GINA NICOLl
Address: 271 LILAC LN
ISSUED BY: �.i
Phone .949-650-5444
COSTA MESA,CA - ''S' -Zip 92627, e'
owner: SHAFONSKY GINA NICOL t; ' ''
Address 271 LILAC LN '' A' €' .
Phone 949.650 5444 •
COSTA MESA CA .3` 't,.,r . ' Zip: 92627 r `•",„„ ,
R'a'r✓' ' •• . v..
Contractor OWNER-BUILDER r
Address. �F`
t
�; Phone. • \'`P
Zip ,
•License 000000, #
41,, '-L '' .., , - ' .' SCOPE OF PERMIT4'" ,., m. -
,1,991 SF.INTERIOR'ALTERATION TO EXISTING S.F.D WORK TO INCLUDE:ELIMINATE':] ,
s i EXISTING BEDROOM TO CREATE NEW MASTER SUITE AND CHANGE OUT 2 SLIDING GLASS DOORS_ IN
REAR BEDROOM AND FAMILY ROOM.REF.:B05-01458 r ". r ` ,1
TO.INCLUDE r",t,'-••
a A
.. �y * H i �S fair -,o,,,,,•,. Yt'i - '
r CONVERT EXISTING 4 BEDROOM;2 BATH S F D.,TO.A 3 BEDROOM,2 BATH S F.D. `, •,,r,l•
:,.. axFEE SUMMARY - & a
AMT ,,QTY` -,4„;;;;L:,\.• ,..:,2„,„,....1:,,,- ',Tv AMT ,� A. v AMT . QTY
ISSUE FEE ,'$23 50 -Nr' Laundry Tub/Washer- -=a-�$0 00 0 . " Sump Pump „ . „ $0.00: 0
Backflow irrigation c ', $0.00 • 0 Landscape Irrigation $0.00 r 0 l • Swimming Pool r $0.00 0
BackflowPreventer ,$0 00 0", i-'' P-Trap c$000 0 Trap Primera ' • $0.00 0
Bathtub `'$9 80 1 Pressure Regulator - ai$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}' $000 *,- 0‘ I Receptors .. -;n $0.00 0 VacuumBrkr Bkfow(5•+) $0.00x 0
Dental Units __ $000 0 "` Septic Tank.l 3 ,`{.$0.00 0 Wash Basin `', t$19.60 2
Dishwasher ,,;$0 00 ✓0 :' Sewer Cap for•Demo =r r$0.00 -0 Wash Basin Set , $0.00 0
Drain,Floor • ^''$0 00 ,2-;10 Sewer Connect . $0.00 <0 .,.,Waste-and Vent System , r' $0.00 0
Drain,Rainwater $0.00 "0 a °a Sewer Private Line _ , $0.00 0 .,, •) Water Closet(Toilet) $9.80 1
Drain, Roof $000 . 0 Shower r ,,.2..*.:- $9.80 :r••'•.1 +.,Water Heater/vent $0.00 0
Drinking Fountain , $0 00 0 Sink bar ,s$0 00 0 % Water Piping(Inst or Rep.) $0.00 0
Expansion Tank ."s .a$000 0,0 • Sinkcommercial 'aa `$000 "0 , Water Re-pipeil: $0.00 0
Gas Earthquake Valve $000 ,-' 0 Sink FloorZ:., r $000 0 �, Water Service X' $0.00 0
Gas(1-4 outlets) 'x$000 = <y-
0 ,� , _-Sink,kitchen _ •, ,$0.00$'- 0 !,,,`,•••� Water Softener $0.00 0
Gas(Over 4 outlets) $0.00 -:-, 0 ` ', ,.s
-- Sinkervice/mop $0.00 -0., OTHER r', $0.00
Gas Repipe $0.00 0 Spa(private) .w- „#'-`l• $0.00 :c0 ti,, VIOLATION $0.00
Gas Service $0.00 -'µ0 4Spa(public) a $0.00 ' '0 -rr:PL'AN CHECK $0.00
Interceptors(Grease,Oil) $0.00 0 • • , REINSPECTION $0.00 0
Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $72.50
COMMENTS/SPECIAL CONDITIONS
•
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
•
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
•
2446-46(6/00)
DECLARATIONS (._) 1 -1
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Cartier: Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
certify that in the performance of the ork for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Califomi and ree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provisions.
Applicant Signature: Date: t' t `OS
WARNING:FAILURE TO SECUR 1P SATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($l00,000).IN ADDITION TOME 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#
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commenting 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
subjerthe 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 yea,comple•4o•6154 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,( l_(-IVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
CodeTrEtiejcontract• License + gra not apply to an owner of property who builds or improves thereon,end who contracts for such project with a contractor(s)
license Pursuant to C Contr. ;t5 se Laws.).
tl
❑ I am exempt u iii,=r .e . Business and Professions Code for this reason: _
�vc
Signature: sI --1:111.-1:111.�_�� d
Owner ID = ' �:T.: cense. ❑Yes 0 No Drivers License No. _ �• Expires: C-2L' I()
Verification• e ership by •e 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? 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).
.t..r..r lento f re ul.i D occupant
p n ne
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 agpermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? IJ 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? ❑Yes 0 No
(If yes',the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑Yes 0 No
B (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 ORIZATION 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 a s 7t= .• s and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for ins.ectio' r agree not to occupy or allow occupancy of any building authorized by this permit II final inspectio
— Ncam
•' gal Owner(s) Date
• • • Autho':d Applicant Date
SODS L INSPECTION TYPE DEE 1101041.5 coos t INSPECTION TYPE DATE RfIIDALE
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing 2—Z3-06
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
sc
�. ". • CITY OF COSTA MESA t
4 BUILDING DIVISION
F � DEVELOPMENT SERVICES DEPARTMENT P IT NUMBER
PERMIT B05-01458
.8
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.SIaHLDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 271 LILAC LN Status: ISSUED
Suite: Applied: 09/01/2005 -
Vicinity: MASTER BEDROOM AND FAMILY ROOM Issued: 09/01/2005
Primary Occ: R-3 Dwellings/Cong Res<10 Type of Construction: V-N
Parcel Number 42615113 Zoning:
Applicant: SHAFONSKY, GINA NICOL
Address: 271 LILAC LN
Phone: 949-650-5444 ISSUED BY: _
COSTA MESA,CA Zip: 92627
Owner: SHAFONSKY, GINA,NICOL `' >`^
Address 271 LILAC LN ...4.4<...:,;."•P,,,',.
'',Phone' .949-650 5444 a
COSTA MESA,CA § - Zip 92627`S �,�
Contractor: OWNER BUILDER��
Address :aft- „
Phone K
3 r .
'7. ,,V..-
Zip: _ License: 000000
Arch . Eng: «
Address Address:
•
Phone ,yt •• $ : Phone:,4.,
:;.-1 ,:s.-`" ,' License rfa� e 1YLicense:
- '
SCOPE OF PERMIT 4a0,,
312 S.F.•INTERIOR:ALTERATION TO EXISTING S.F.D.WORK TO INCLUDE:ELIMINATE 1 EXISTING BEDROOM TO CREATE NEW MASTER SUITE A
CHANGE OUT 2 SLIDING GLASS DOORS IN REAR BEDROOM AND FAMILY ROOM. tt:t ' ? c'''
CONVERT EXISTING
.:•,o 4 BEDROOM 2 BATH 5--I-F-6"70: A 3BEDROOM2`BATH S F D"'
r•4-.% ,,,,,..4....,
a'r . :-.",„,41.44,?++ a$s T.`'
.:'-FEE SUMMARY
Plan Check $254.31� , Calc Valuation -, $2s 000.00
Permit: '$391 25� s h . Claim Valuation ' icts,i . $25,000.00
SMTP Res $250 ;f„ <z .
SMIP Com: $0.00„,,,. �" � '
Other: .$0:P0 ate
Inspection 50:00, '
-Totalif. ' $648.06 -.-..7,..Q,:',;'4F-1--,-
�''a'; PLANNING & ZONING r.
r
SETBACKS "
MAIN STRUCTURE,Front ,0-0 r Rear 5„.6;z:6
„ t Left,.ar0 0 ,Right
ACCESSORY Front 0-0- Rear 0-0' ' Left 0-0 y_,:➢ Right �,0,-0
PARKING Existmq 0 :Required;red 0 r Proposed 0 •
'o. ▪ a ,w. ., .r
. 4 ▪ n .✓tiL ti
•
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 bet 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)
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. • .
❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued.
My workers'compensation Insurance carrier and policy number are:
Cartier: Policy Number:
(This section need not be completed If the permit Is valued at one hundred dollars($100)or less.)
Ogficertify that in the pedo the:ri 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 C:(je la e • :•.--.— at if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with the - sit.
WO:FAILURE • ' • - 'r~t COMPENSATION C OVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML RNES UP TO ONE HUNDRED
THTYISAND DOLLAR -` IN ADOrm•• 0 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.Llc./I 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).
Lenders Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS: •
I hereby affi aA pder perlajOrof perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any 000nty whiKrequires 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 sign et-bent thigh)), 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 an r ions CQdq)or that'tiewr.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 applita�{t to a ci l enalty of}riot more than five hundred dollars($500).):
r as owner of the props or msemplo'yees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec.
044,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.). '
r12%---- 9s-owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
1%Code:The contrac•rs 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 pursue, t•the Contractors License Laws.).
❑ I em ex:,Wt -•:-.------ Business and Professions Code for this reason:
rExplie
s S 21- I A
Verification o e- nership• (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? 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 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 Califomia 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 aconstruction 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 Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
_
. __._.._......._____.__._..._ ol
8 (If"ye-S4,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 A •-• •TON 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 la. an. city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection p ryose•.I :• ,--- o occupy or allow occupancy of any building authorized by this permit until final inspection.
igiiatare.4 .rf".• er s)."..^h' .i'D ,.,..+a.
it
An:''?".nzed Applicant Date
CODE. fNSPECTION TYPE PAM =ALI CODE I INSPECTION TYPE RAIL INI TW A
1616 Fixed System Final Fire Prevention 206 Final Mechanical
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 I,�
204 Final Demolition . 250 Final Building/Occupancy 3-ti-t
•
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. _ • .
r
• C 10,F•COSTAMESA ••CsN,TRUC, ON—ER IT - PERNlY1/N ���,/ TRACT NO. : jLOTNO. UNIT NO: - 8460 I2/09/86 2De:5D ' TL
/// i� l7T��11 TTUU rrII 1
.'¢CI Adnt's Mas - - Lam'-= NEW LJIADD U ALTERATION U REPAIR r,' ' • 1
t tet'• '� TYPE OF CONSTRUCTION ' ❑ -
+Applicant's Mailing ess .tit! _ - A P # _ _ _ _ • _ _ _ I Zone _
1 III CONVERSION' ❑•DEMOLISH ❑ OTHER
•Owner's Name aer' PhoneDESCRIPTION OF WORK/USE OF BLDG.' • - -
` Address t -� 1 ! S Main Building: Accessory Building:
Z
Arch/Eng: ' License No. - TYPE OF PERMIT ❑ GRA,DING E1 FOUNDATION El STRUCTURAL . E Front I I , O
Address (('''�� � • _ ❑ TENANT'❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL B Rear , • I N
Contractor's Name r"-'-' �' Phone ❑ OTHER ! _ ,- /1 - 1 i �A _- -- - - •_ _ _ ._ - - I
•
I PROJECT DESCRIPTION. SQ. FTX _/[�OO ' OCCUP Y C Bight I ' N
I Address( •
mailing) 1 l K _ I
G
t I - � i CONSTRUCTION TYPE - VALUATION,$ ' O'U s Left , ' -
R
City License No. f' JJJ�✓✓� ZONE GRADING CU.YDS. ACRES' ' '
• LICENSED CONTRACTOR DECLARATION , - Ping. Ref.# • , i Parking Req./Provided 4
E
I hereby affirm that I am licensed underprovisions of Charter 9 (commencing • - - < - Q
Remarks: I Planning Notes: M
with section 7000).of Division 3 of the Business.and Professions Code,and ' ' •' - '
' my license is in full force,znd'effect. , , - - • - T
i • I 1 i :� I _ - s
I License Class - • License No. • - • , ,
Date Signature • PLUMBING - ' __FEES ` v I .I . - •• •
WORKERS' COMPENSATION DECLARATION l Showers ELECTRICAL • ' FEES
hereby affirm that I have a certificate of consent to self-insure or a certificate . Bar Sink: - - - -
Workers' Compensation Insurance, or a certified copy thereof (Section - - - -
.Boo, Lab. C.) { Backflow Preventer - Service Sink Automatic Washer- Transformer-0 15-50 KW -• :
Policy No. ' - 'Company Backflow Irrigation! . Sewer Cap - �� '❑ 50+ KW' A,
I B Certified copy is hereby furnished. I I. _ - - - - • w Construction Pole Sub
Certifietl copy is filed with the city Building Division. Bathtubs _s •$ewer Connection
CookingUnit Meter ❑up •
to 100 amps
Date •t':Applicant ' - - . - , _ -' •
• EXEMPTION FROM WORKERS'COMPENSATION DECLARATION •
Clarifiers - i , Solar Collectors - - Dishwasher Meter Dover 100 amps - _
i (This section need not be completed if the permit is for one hundred ($100) or _ _ -
less). Dishwasher'- - - • : Solar Piping - • , Dryers-❑Gas DElectric Sub Panel !
I certify that in the performance of the work for which is permit is Issued, I . - ' - -
shall:not employ any person.in any manne so s to c e bja t to t , Drinking fountains ' l - Solar Tank • Fan Motors 00-1 HP ❑1/ 8 `
Worker}} C entpn Laws of Celiforni /q/� _ - '
Date// -7'_- Signature �r Cr i( y Floor-Drains - Swimming Pool w/Spa • • - i F.A.U, ' •
NOTICE:If,after making this'declarati n, you should bee me subject to t -__ • _ _ Inc:Solar 09-15 HP 016-15+,
- "Workers'-Compensatiorn provisions of the Labor Code. you must forthwith Floor Sinks Urinal Fixtures ' Microwave. .
comply with such' provisions or this permit shall be deemed revoked.
• CONSTRUCTION LENDING AGENCY 1 Gas Service ,Outlets Water Closet• ' •
Device Boxes
I hereby affirm that there'is a construction lending agency for,the performance I Pole Light' u •
of the work nor which this permit is issued (Section 3097'Civ. C.) Interceptors Water Heater '
Lender's Name p Outlets 1 Range
Lender's Address _ • _I ) ,- , Kitchen Sink +__ _ _ , ,-Water Seivice4 _. ,_ . , . . . Switches ._ ._ Sign ' ' ' - - - - - ---i
- fOWNER BUILOER;DECLARATION - I .
I hereby affirm that I am exempt front the Contractor's License'Law:for the Lavatories • Auto-Wash j •
I following reason (Section 7031.5 Business and Professional Code: Any city:or - i ' Garbage Disposal •
$Landing Sections
county which requires a permit to construct,•alter,improve,demolish or repair P-Trap , LaundryTrays I
any structure, prior to its issuance; also requires the applicant for,'such permit y Generator ❑0.5 KW ❑5-15 KW Trash Compactorr
• to file a'signed statement that he/she is licensed pursuant to the provisions:of Roof Drains ' ' 1
the Contractor's License Law(Chapter 9(commencing with Section 7000) of I - • - •
Thivision 3 of the.Business.and Professions Code).or that he/she is-exempt_ , . . __ - _
erefrom and the basisifor the alleged,exemption. Any violation of Section • i I - -
• 431.5-by any applicant for a permit subjects the applicant to a civil - ' ' i
ee alty of not more than five hundred dollars ($500). / . ' - • • •
1/J I, a•
s owner of,the,property a• •• e Invrrc wiih_aagesa&-their-stile ' Reinspection Fee $15 • j: I Issue Fee $ 3 - I - - - - - '
,S ' �Tempea4aS• will do the work,and the structure is not intended or offered - -- " ' Reinspection Fee 'I. $15 Issue Fee , • - $ 3
��; for.sal€ (Section 7044,:Business and Professional Code: 'The Contractor's MECHANICAL' I -.FEES ' I
License;Law does not apply to an owner of a property who builds or improves .
• thereon, and who does such work himself/herself or through his or her own - . - 'DEVELOPMENT SERVICES REQUIREMENTS: I .
employees, provided that such improvements are not intended or offered for l Boiler Hood or Type I ❑ - i
sale. If; however;the building or Improvement is sold within one year of com- Canopy Type II 0 _ 'Zoning Approved By _ Date
• foletion,:the owner will.have the burden of proving he/she did not build or im- Duct-Under Ground -- i Building Approved By - - 1 Date
i `�rove for the purpose of sale). r. I • '
.1'as owner of the property, am exclusively contracting with licensed con- DuctStructural Ref/i eratinn System t a• t. 1 Appi cation Issued By t ` r I Dat (�
l , tractors to construct the project (Section 7044,Business and,Professions Code: .•.' o , , . _
' The Contractor's License Law does"not apply to an,owner of. property_who , ' Duct-Ventilating00-100,000 BTU ❑100,000 BTU 1 y - : : SU V O FEES i '
builds'or improves,thereon, and who contracts for such projects with a con- - _ - -• - pK) '
i tractor(s)ficense pursuant to the Contractor's License:Law). I:am aware that ' , ' I R G U BUILDING PERMIT $ "/ --SMIP - " $ 'I f S-0,-
• Exhaust System ❑ Multiple ❑ System Repair/AlteratEA P
S7-0,-
Proof of their Worker's Comp¢nsation insurance should-be provided to me: -_ •' ♦. - _
• 0-I am exempt under Section - - 'B-& P.C.for this reason Firepl/Fact:Bit..ICBO# Fire Dampers ,�nconiotete I��`• lctl'UIiS - PLAN CHECK Sr. .- - i.PISS UAN CE $i'•i tom'
• _ - - _ - I c - ce PLUMBING . _ $-
• f!�jl1,// ..„. Heating9 Registers. - - / -' to i 1 - 'ENERGY P C �$.,'
Date • ���� Owner i >� System&Ducting Re asters• ^ • i PLAN CHECK L25%• $_ - 'i
I hereby certify,that i have read this application and state at the above'- - , ❑0-100,000 BTU ❑i00,000BTL DateI b , ,, • u GRADING ,,$ -
information is correct. I agree to comply with all city and county ordinances - - ✓Ol • o / ELECTRICAL - $
'and state laws,relating-to buildiconstruction, and hereby authorize repre-- - 50%- - MICROFILM • $
I sentatives of thi ny en gu••n t• a tionetl pr7opert (( rr - - - 1 `• -PLAN CHECK $ I
i inspection.purp> I c' •� y i ' /'; •Date/L-7�U G_ - • -. .LMECHANICAL ' :-$ - TOTAL FEE $ ._ J1
• Signature .RI - j
' -Drivers' License or SS#: ��
- Applicant; Pink -Accounting; Goldenrod -Assessor - - - -- -- - - -r —T
CONSTRUCTION AND PLANNING .. POOL&SPA
..
APPROVALS Permit# _ Date Inspector APPROVALS Permit# Date Inspector
1..Temporary Electrical Service or Pole 52. Pool & Equipment Location •
•
2. Soil Pipe-Undrgrnd. . 53. Steel Reinforcement i , •
3. Electrical Conduit Utility-Undrgrnd. 54. Forms ' • .
4.-Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement: 56. Rough Plumbing & Pressure Test -
6. Electrical OF ER Grnd. ' 57. APPROVAL TO COVER-GUNITE ,
7. Footings 58. Electrical Conduit-Undrgrnd. - -
8. Foundation - - 59. Gas Pipe, 0 Undrgrnd.,Test
9. Water Pipe-Undrgrnd. . 60. Backwash Lines, P-Trap, 0 (Jndrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK '
11. Property Sewer bine & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 4 63. Heater & Vent-Final .
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final
•15. Rough Electrical-Conduit 66. Solar System-Final
16. Rough Electric Wiring • 67. Fencing &Access Approval •
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough'Electrical-T Bar Ceiling 4 - 69. POOL/SPA SYSTEMS FINAL
19.' Rough Heating & Air Conditioning FIRE DEPT- REQUIREMENT
•
20. Rough Factory Fireplace APPROVALS Permit# -
21.,Ducts, in Structure 70. Underground Hydro ! .
22. Duct ,'Ventilating 71. Product Piping 0 Gas 0 Oil
23:Gas Pipe-Rough &Test 72. Underground Flush
24. Roof Framing 4 73. Undergrnd.Storage Tank 0 Gas 0 Oil
, 25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling'(Structural) & Monocoat 75.,Dry Chemical •
27. Frame and Flashing- ' r 76. Dry Standpipe -
28. Lathingii Siding 77. FIXED SYSTEM FINAL .
' 29. Insulation - - 78. FIRE PREV. FINAL ' '
30. Drywall Nailing • HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat ' 79. FINAL INSPECTION .
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes:
34. Final Heating & Air Conditioning -
35. Final Gas Pipe-Test •
36. Hood or Canopy
37. FinalFactory Fireplace - '
38. Final Plumbing '
39. Water Service-Final. . .
40. Gas Service-Final '
41. Solar Domestic-Final
42. Backflow Preventer -
43. Backflow Irrigation i
44. Landscape Irrigation System FXPIRED
45. Sound Attenuation I nlpl a inspections I
46. Handicap Regulations Lam T
.'.
47..FINALSTRUCTURE & BUILDING •
i
48. Special Requirements Completed .
49. Electric Release to Edison „!, '
/'
50. Gas Release to Southern California Gas Co / .
51. CERTIFICATE.OFOCCUPANCY� '
No._ Date , , J'
ry
FEE RECEIVED
, i_ 14368
r;�APR 261S31
COSTA MESA BUILDING-SAFETY DEPARTMENT U FINANCE DEPT.
P. 0:BOX 317 COSTA MESA. CALIFORNIA CSI? OF COSTA MESA
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
ADDRESS 271 .Lilac Lane
COSTA,MESA. CALIFORNIA For Office Use Only
OWNER Irving C. Jordan I RECEIPT NO. I L P8RjA1T.,O.�
ADDRESS 3700 Newport Blvd. RECE�VeD BY I CAW-/,31VF�D/ I -lIAPP ISSUED
(fe•,DIJ C•
CITY Newport Beach NobR38811 BUILDING 7 it
ADDRESS
ARCHITECT
OR ENGINEER D. Southworth NoL185161 COSTA MESA. CALIFORNIA ,, /
ADDRESS Costa Mesa - FIRE V T!�`y
ZONE TYPE v GROUPo9-- /UJJ
CONTRACTOR Cer free , APPROVED
BY DATE
-I
ADDRESS Same " ZONING - ,
ZONE In1�/ I NO.OF USE OF NEW J
CITY 11 \ I PLANS )— I BUILDING i i/a2/11 J '
STATE p TEL- on 8811 «\ /�/
LIC.NO. B1-825 7 NO. DESCH!- ION bq —. -��—�� - " 4•-'-
SIZE //_/1 I J.
5 I NO. OF BLOCS. 0 - . C rw`_P�.1.--r 8 u�' l
OF LOT ZOO* x 1. I NOW ON LOT A.P.NO. 1j/ R ^/ St,--If]-- (�},H
1
USE OF YARDS EVES
EXISTING BLDG. APPROVED ALLOWED
SETBACK LINE PROM (CENTER LINE ST.)
CENTER OF STREET • REAR YARD FRONT SS-Ft IN.
SIDE YARD I LEFT 5 1 O it
I RIGHT 51 CII R.SIDE •5FT. IN.
DESCRIPTION OF WORK L.SIDE SFT. IN.
NEW I X II ALTERATION I VI ADDITION I REAR 1/3 FT. 11 N. /
II MOVING I II DEMOLISH APPROVED I l� 7 ' `. DATE y ./
REPAIRI BY
.?\
BUILDING NO. OF / - ? ,
SIZE ROOMS 7 STORIES 1 1 L �: C-- `rte
EXTERIOR WALL ROOF /�� `�— " L ^�/r/�/c�tir -.
COVERING StL1C0 I COVERING Shingles /,
.USE OF BUILDING AND W•RK TO BE PERFORMED
Res. w :tt
Plan y'/1508A I 1675 sq. ft.
- J 421 Sq. ft.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM.
THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
PURPOSE OF ESTABLISHING A PERMIT PEE ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING •
BUILDING CONSTRUCTION. / VALUATION
SIGNATURE OF�1�ry 111 A.,6 0‘. \ C�^ PERMIT FEE $ 37.00 N
PERMITTEE . v �-h- R
� $ 17,X33 PLAN CHECK $ 18.50
AUTHORIZED AGEN79 p
TOTAL FEE - • 0 a
v