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HomeMy WebLinkAbout222 LILLIAN PL - Building Permits • 4 Y /< �` 2 FO 4•tGC uT j�OQ RICHARD LUIZ S F OA9A_ ei 5071 LOYOLA AVENUE WESTMINSTER, CA 92683 Report of P3/4-- Inspection • Project Name & Address Mytett-�L A LOLL A PlyeZ•-t-� :'__•� N'=be( P-0-1-0052-71 I nspec'.ion Type(s) (* U r lTit inspection. Date(s) �� - [ ) Periodic [ XXX J Continuous- ' Descri'oe Inspection Q ¢ Made, including Locations: —(t\ , 2t i Ct0�1 OF 1/4thi . A &t-S' Ce-4 4-41P —04 s. Tess Made: _ A:4/1' . !`LLQ Lk( ET)eti 1912r �r To:sl Inspection Time Each Day: - • D71e I43-O Hours Ls: !'.ems Requiring Correction, include uncorrected items previously listed • To the best of my knowledge, the work inspected was in accordance with the Building Department ^proved design drawings, speci icatio and applicable workmanship provisions of the U.B.0 :,.c:pt as noted above Signed: Date u I , C, B4O. # a• F,_ll Name. Richard T. Luiz Registration No. 1075691-49 Concrete FORM SI-a?.St 28 ..„,,,,,,, . * 41•10:1 7!$i''''''S'S TEST SPECIMEN AND COMPRESSIVE STRENGTH DATA SHEET PROJECT NAME: McCuSRer INSPECTOR'S NAME: Richard Luiz 1 ' PROJECT ADDRESS: x-222 l-Milan Place INSPECTOR'S LICENSE NO.: .N/A Costa Mesa,CA INSPECTOR'S SIGNATURE: N/A -- PERMIT PERMIT NUMBER: 664.-.00527:::---n SET IDENTIFICATION NUMBER: N/A CAST DATA(ATTACH DATA SHEET OF OTHERS WHEN AVAILABLE) CAST DATE 4/16/04 DESCRIPTION Concrele Groul Mortar ISholcrete Masonry Prism jOlher GUNITE CONTRACTOR SChWaIZ SPECIFIED F'r-PSI 2,000 CEMENT TYPE IV SUBCONTRACTOR Tri Force CAST BY Carlos ADMIXTURE N/A ENGINEER Cowen NO.OF SAMPLES 2 WATER ADDED N/A CONC.SUPPLIER N/A TOTAL YDS.PLACED N/A SLUMP N/A PLANT N/A TICKET NUMBER N/A AIR CONTENT N/A MIX DESIGN NO. 4 1/2.1 CAST TIME N/A AIR/CONC.TEMP. IN/A . LOCATION IN BLDG.: Bottom of the Swimming Pool NOTES: NR=Not Reported • Test specimens were 3-in. x 3-in. x 3-in. cube samples cast using wire mesh(no mold used). COMPRESSIVE STRENGTH DATA DATE SPECIMENS RECVD. 4/21/04 EQUIPMENT USED Forney DR2000 REPORT DATE 4/30/04 SN OF EQUIPMENT 99108 TECHNICIAN NAME C. Henriquez-Supervisor CALIB.I REGAL.DATE 2-04/2-05 SPECIMEN AGE AT TEST TEST SPECIMEN DIMENSIONS-IN.' AREA LOAD F'c BREAK IDENTIFICATION TEST DATE TIME1 2 3 4 SO.IN. LBS. PSI TYPE' NUMBER DAYS 5 6 7 a IhM 0004240A 14 4/30/04 5:12am 3.047 2.979 3.040 2.982 9.07 28.838 I 3.179 c 2.981 2.980 2.980 2.980 1.991 D0042403 14 4/30/04 615am 3.057 3.004 3.051 3.010 9.18 28,838 3,140 c 3.098 3.095 3.096 3.096 11.02) Avg. F'c14= 3,160 'Specimen dimensions 1 -4=width and length of each face at midheight;4 through 8.Specimen height at midwidth. 'Break type designation per ASTM C39 Figure 2:a=Cone.b=Cone and Split.c=Cone and Shear,n=Shear,a=Columnar COMPLIANCE WITH SPECIFIED STRENGTH I COMM • S:Complies i / AUTHO• ED IGNATU- 12JU2 VI 10600 Pioneer Boulevard, Suite G • Santa Fe Springs, California 90670 • (562)903-0032 Fax (562)903-3534 • 'F 9 CITY OF COSTA MESA < BUILDING DIVISION , %�. .,' : ,� DEVELOPMENT SERVICES DEPARTMENT • PERMIT NUMBER t1._sr�T�� • PERMIT 44b4PoRinel`#. B04-00527 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.caa..us UILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 222 LILLIAN PL Status: ISSUED Suite: Applied: 03/12/2004 Vicinity: Issued: 03/12/2004 Parcel Number: 43921205 Zoning: Applicant SCHWAR,JIM ISSUED BY: Address: P 0 BOX 28437 ' Phone: 714-630-6100 SANTA ANA,CA - Zip: 92799 Owner MCCUSKER, MATHEW Address 222 LILLIAN PL • Phone: 714-328-8500 COSTA MESA,CA Zip: 92627 Contractor SCHWARZ CUSTOM POOL Address: P 0 BOX 28437 Phone:, 714-630-6100 SANTA ANA,CA Zip: 92799 • License: 770413 Arch : Eng: Address: - Address: Phone: - Phone: Zip: License: License: SCOPE OF PERMIT INGROUND GUNITE POOL AND SPA.ALL STRUCTURES SHALL BE A-MINIMUM OF5FT FROM ANY STRUCTURE. FEE SUMMARY Plan Check: $208.81 Calc Valuation: $20,000.00 Permit: $321.25 --- - - --- - -- Claim Valuation: $20,000.00 SMIP Res: $2.00 SMIP Com: . $0.00 Other: $0.00 • Inspection: ' $0.00 , Total: , $532.06 - • 'PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 . Rear 0-0 ' Left 0-0 Right 0-0 ACCESSORY Front 0-0 ' Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: -0 Proposed: 0 NOTES: ;1r t 7 r,/: 11, 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 2446.45(6/00) WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of thefottowing'declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. '�-- ❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carder and policy number are: Carrier: Policy Number: (Th • need not be completed il1Ae permit Is valued at one hundred dollars($100)or less.) '°c7.1I certify that In the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should come subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisio s. T AppiSit:Slgrtet0te: Date: /2 •G WARNING:FAILURE TO SECUR WORKERS'COMPENSATION COVERAG IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000).IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commen ing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full forceerr—frac.uc.a Z l 0 41 seta s ry G S 3 Contrac"CsSpnemre:". —'f( Date---- 3 • I') • cm 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.). ❑ 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 drivers license. 0 Yes ❑No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more 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 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 Calif omia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes 0 No (Section 65850.2 of the California Government Code requires that the requested information be fumished 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 ❑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 8 (If yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. iiSIgnature eget Owner(s) Date 3 r_2 •01- An r Authprized+Applicant --'" ' CODE L INSPECTION TYPE DATE INIIlAL$ CODE I INSPECTION TYPE, PAIS Itis 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 Sign222 Final Site [6-/6-of u 204 Final Demolition 250 Final Building/Occupancy 6-IO� 4111 CITY OF COSTA MESA 4 BUILDING DIVISION > i-r+1DEVELOPMENT SERVICES DEPARTMENT P RMIT NUMBER v.Teo . PERMIT E03-00906 yc t (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 222 LILLIAN PL Status: ISSUED Suite No Applied: 10/02/2003 Vicinity: BATHROOM AND KITCHEN Issued: 10/02/2003 Parcel Nunmber: 43921205 • Applicant: CHRISTIANO, STEVEN R ISSUED BY: S� Address: 222 LILLIAN PL 7 _ - Phone: (949)548-7172 COSTA MESA;CA . Zip: 92627 " . 2 - . Owner: i CHRISTIANO, STEVEN-R Address 222 LILLIAN PL Phone: (949)548-7172 COSTA MESA,CA Zip: 92627 Contractor: OWNER-BUILDER Address: --Phone: Zip: License: 000000 SCOPE OF PERMIT CREATE A NEW BATHROOM WITHIN THE EXISTING SPACE IN BEDROOM#3 IN AN ONE-STORY SFD. NO SQUARE FOOTAGE ADDED TO DWELLING. - - ' 1 LIGHT FIXTURE(BATHROOM FAN),4 OUTLETS,4 SWITCHES, 1-RES APPL(DISHWASHER). 1 SERVICE TO 200A(REF:E01-00185). ' REF: B03-01704 , FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 -Busway/100 ft $0.00 0 Res.a/c package $0.00 . Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 - - Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 ' ' 0 up to 10 kva/kw $0.00 0 Lighting Fixts $1.10- 1 - - - up to 50 kva/kw $0.00 0 Recept Outlets $4.40 ;4 '- - - up to 100 kva/kw $0.00 . 0 Switches .- $4.40-, 4 > - " - over 100 kva/kw $0.00 - 0 Non Res Appl -., $0.00 0,. 'Low Voltage Equipment $0.00 0 Res Appl $4.75 1 ' Low Volt Wiring System/Ckt $0.00 0 Service to 200a $30.50 ' "1 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 ,- Misc.Conductor $0.00 0 Service over 1000a $0.00 0 - Circus(gen or ride) $0.00 0 Motors to 1 h $0.00 0 - Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 ' '- Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 - 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 • 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 n ! r-\ WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: 0 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 Il the permit is valued at one hundred dollars($100)or less.) cartity that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provision L Applicant Signature: .a.( Date: -2 -a 3 WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE(S100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class If Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under c. Business and Professions Code for this reason: Signature: ..-.--,® ) _ Expires: L/"Z"On Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person Is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any 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 (II yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and 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 oses.I agree t to occupy or allow occupancy of any building authorized by this permit until final inspection. /a -2-^o3'. Signature Of Legal Owner(s) Date And/Or Authorized Applicant Date ODE t INSPECTION TYPE PATE IN C, CODE. INSPECTIONTYPE PAlt INTTTIAL@ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing ��� 200 Final Re-Roof 210 Final Electrical -01 201 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 CITY OF COSTA MESA a ' BUILDING DIVISION r- %4'. ,1 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER �. • " • PERMIT -+->a-mrr*s4. ✓PO4-00176 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT . Job Address: 222 LILLIAN PL Status: ISSUED Suite No Applied: 03/12/2004 Issued: 03/12/2004 Vicinity: Parcel Nunmber: 4392120$ ISSUED BY: Applicant: SCHWAR,JIM Address: P 0 BOX 28437 Phone: 714-630-6100 - SANTA ANA,CA Zip: 92799 Owner: MCCUSKER, MATHEW Address 222 LILLIAN PL Phone: 714-328-8500 COSTA MESA,CA Zip: 92627 Contractor: SCHWARZ CUSTOM POOL • Address: P 0 BOX 28437 - Phone: 714-630-6100 • SANTA ANA,CA Zip: 92799 - - License: 770413 Arch / Eng: - -- j - - ' Address: - " . Phone: . Zip: .. - - - -License: - • ' SCOPE OF PERMIT INGROUND POOL AND SPA. REF B04-00527 - -. . _FEE SUMMARY AMT OTY AMT - t.OTY 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 - $60.75 1 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 $0.00 0 / /' NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California/statutes and related regulations. (Ord. No.92-28,§1, 12-21-92) d/ ti 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. rYY// INSPECTIONS: In order for the Work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 !✓{. 2446-46(WOO) / • )r DECLARATIONS f) 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 sell-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: (7)/s-section need not be completed if the permit is valued at one hundred dollars($100)or less.) t ...lid certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that If I should become su ject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant gnature: L�/ Date: 3 • !2 '64 WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN&A AND SHALL SUBJECT Ni EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOUARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby.affi :then 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, .# 7 76 4 13 Class j) CS Contractore' ignature: Cy , --,::D2 / 3 • 12 • al 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 Ucense 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 Ucense Law does not apply to an owner of properly who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors Ucense 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 drivers license. 0 Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the 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 California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 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 ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes U 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 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 Califomia Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not t0 occupy or allow occupancy of any building authorized by this permit until final inspection. Signature f L al Owner(s) Date ' 12 'a� And/ AuthoonzedApplicant Date _ LODEINFECTION TYPE PALE minas LODE. INSPECTION TYPE PATE 1NTmALS • 1616 Fixed System Final Fire Prevention 206 Final Mechanical 6-/frol OieT 1266 Pool Spa Final 208 Final Plumbing -_ 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy i1„" "'N r CITY OF COSTA MESA 4 BUILDING DIVISION > :� , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER tj t t PERMIT o le 1M04-00122 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 222 LILLIAN PL Status: ISSUED Suite No Applied: 03/12/2004 Issued: 03/12/2004 Vicinity: Parcel Number 43921205 ISSUED BY: Applicant: SCHWAR,JIM Address: P 0 BOX 28437. / • ' ' Phone: 714-630-6100 . , SANTA ANA,CA , Zip: 92799 Owner: MCCUSKER, MATHEW Address: 222 LILLIAN PL ' Phone: 714-328-8500 COSTA MESA,CA Zip: 92627 , Contractor: • SCHWARZ CUSTOM POOL Address: P 0 BOX 28437 Phone: 714-630-6100 " SANTA ANA,CA Zip: 92799 ' License:770413 SCOPE OF PERMIT INGROUND POOL AND SPA.REF B04-00527. - - FEE SUMMARY Quantity Quantity ISSUE-FEE $23.50 - Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU $0.00 0 • ' Repair/Alt Refrigeration_Unit $0.00 0 _ Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler I $0.00 0 Inst/Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys<100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys>100 k BTU ' $0.00 0 Compressors/Absorption Systems Gas Piping , $0.00 0 „Up to 3 hp/100 k BTU , $0.00 0 Factory Fireplace $0.00 0 . ''• 3 To 15 hp/500 k BTU $0.00 0 Hood w/Mech Exhaust - $0.00 0 ,, .I _ 15 To 30 hp/1,000 k BTU : - $0.00 0 , VAV Box . $0.00 0 - . 30 To 50 hp/1,750 k BTU . $0.00 0 Vent Fan/Single Duct , 'Over`Over 50 hp/Over 1,750BTU . $0.00 0 Appliance -$10.65 '1 Boilers Fire Dampers $0.00. 0 ' Up to 3 hp $0.00 0 Smoke Dampers . $0.00 - 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent - $0.00 0 15 to 30 hp $0.00 0 Air Handlers< 10000cfm - $0.00 0 - 30 to 50 hp $0.00 0 Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee - Floor or Suspend Heater $0.00 0 Investigation Fee . $0.00 • Plan Check Fee $0.00 , Reinspection Fee $0.00 -TOTAL CALCULATED FEES $34.15 ;4l L ' j 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 n 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 carrier and policy number are: Carrier: // Policy Number: r (Th/s,section need not be Completed it the permit is valued at one hundred dollars($100)or less.) certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Appticant.Sfgnature: pate:�'^y^"�3 �- WARNING:FAILURE TO SECURE WO RS' PENSATION COVERAGE IS UNLA FUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOL AAE($100,000),IN ADDRION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706OF THE LABOR CODE.INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby.effirtil'lliet 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 arideffect.Lk.a —t' )O 4 1 blasslr CS 3 Contractor's Signature: , Da e:e:.‘ '3 • ( 2 • al 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 end Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 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,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: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes ❑No (Section 25505 of the California Health end Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 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 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? U Yes (J No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes .0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signayure If Legal Owner(s) Date 3 ' X2 ' 0 24. • d/Or Added Applicant CODE t INSPECTIONTYPt PAISMAI& ;ODE. JNSPEORONTYPF. QAIE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 6-/4-01 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval _ 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy CITY OF COSTA MESA BUILDING DIVISION >9_tiara r___ DEVELOPMENT SERVICES DEPARTMENT P RMIT NUMBER I _.... PERMIT S. lira �E04-00239 6' l (714)754-5273 • Fax(714)754-4E356 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 222 LILLIAN PL Status: ISSUED Suite No Applied: 03/12/2004 Vicinity: Issued: 03/12/2004 Parcel Nunmber: 43921205 Applicant: SCHWAR,JIM ISSUED BY: Address: P 0 BOX 28437 Phone: 714-630-6100 , SANTA ANA,CA Zip: 92799 Owner:- 'MCCUSKER, MATHEW Address •222 LILLIAN PL Phone: 714-328-8500 COSTA MESA,CA Zip: 92627 " • Contractor: SCHWARZ CUSTOM POOL Address: P 0 BOX 28437 -Phone: 714-630-6100 SANTA ANA,CA Zip: 92799 License: 770413 SCOPE OF PERMIT INGROUND POOL AND SPA.REF B04-00527 - / - - - FEE SUMMARY Quantity - _ _ _ _ . Quantity ISSUE FEE $23.50 . -Temp Dist System/Lighting - $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers upto1 kva/kw $0.00 0 Pool/Spa $49.50 1 • - _ -- up to 10 kva/kw $0.00 0 / ' Lighting Fixts $0.00 0 - " up to 50 kva/kw $0.00 , 0 Recept Outlets $0.00 0 - - up to 100 kva/kw $0.00, 0 Switches •$0.00 0 over 100 kva/kw.' $0.00 ' 0 Non Res Appl $0.00 • -; 0 Low Voltage Equipment' - $0.00 0 Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 Ff Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a . $0.00 0 Circus(gen or ride) $0.00 0 ' Motors to 1hp $0.00 0 - Circus(mech ride or lights) " $0.00 0 , Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0- Fireworks Stand * $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 - Sub panel to 200a $0.00 ' 0 - Plan Check Fee , - - $0.00 ,t Pole Light Pkg $0.00 0 Reinspection Fee $0.00 f l�y/ 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 ( ) 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 carrier and policy number are: Carrier: Policy Number: (Thls action need not be completed it the permit is valued at one hundred dollars($100)or less.) 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' I4((("--"–Frimpensation laws of California,end agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith complywith these provisions Lt AppDcanl Signature: aD•�ate; • 12 - WARNING:FAILURE TO SECURE ORKERS'COMPENSATION COVERAGE IS LAWFUL AND SHALL SUBJECT AN EMPLOYERTOCRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECRON 3706 OF THE LABOR CODE,INTEREST.AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm thJ.amlicensed 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 Oct.Uc.a--" 7-7AS 4 13 Class a? r S 3 Contractors Signaatt Jrre: .......71; Dater)I 3 . 19 • 0 1 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.). • ❑ 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 drivers license. 0 Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,I.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,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 6,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 e 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 materiel? 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,ora 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 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)? ❑ o ❑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? ❑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 a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes 0 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (II"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 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Ignature Of gal Owner(s) 1, Date '3 ' ' z-a And/ r AuthodzedrApplicaft --- SDate LODE L INSPECTIONTYPE On JNTmALS CODES INSPECTIONTYPE ~ PATE INTmALS 1616 Fixed System Final Fire Prevention _ _ 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing -. )) � CJ ,�, 200 Final Re-Roof 210 Final Electrical 6�h- AA_ 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 O� A CITY OF COSTA MESA 4 BUILDING DIVISION o ). • (..a' i1 DEVELOPMENT SERVICES DEPARTMENT PE MIT NUMBER PERMIT "'Mammo B03-01704 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.camsPERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 222 LILLIAN PL BUILDINGStatus: ISSUED Suite: Applied: 10/02/2003 Vicinity: BATHROOM Issued: 10/02/2003 Parcel Number: 43921205 Zoning: Applicant CHRISTIANO, STEVEN R ISSUED BY: _ Address: 222 LILLIAN PL - Phone: (949)548-7172 COSTA MESA,CA - Zip: 92627 Owner: CHRISTIANO; STEVEN'R • Address 222 LILLIAN PL ' - Phone: (949)548-7172 COSTA MESA;CA- " - - Zip: 92627 • Contractor: OWNER-BUILDER Address: Phone: Zip: License:- 000000 Arch.: — -- Eng: . Address: Address: Phone: Phone: Zip: , License: License: • SCOPE OF PERMIT CREATE A NEW BATHROOM WITHIN THE EXISTING SPACE IN BEDROOM#3 IN AN ONE-STORY SFD. NO SQUARE FOOTAGE ADDED TO DWELLING. - • _ FEE SUMMARY_ Plan Check: $99.61 - • - - Calc Valuation: $8,000.00 Permit: $153.25 - Claim Valuation: $8,000.00 SMIP Res: ' $0.80 " SMIP Corn: $0.00 _ Other: .' $0.00 Inspection: ' $0.00 Total: ' $253.66; ' PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 " ,• Rear• -0 -0 • Left 0-0 Right 0-0 - ACCESSORY Front ... b-0 - Rear _"0-0 Left 0-0 Right 0-0 . PARKING Existing: `-0 Required: 0 ' Proposed: ' 0 - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 244646(6/00) e 0, DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This se ' n need not be completed if the permit is valued at one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree t at U I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. �7 Applicant Signature: 4' I A..-C -o Date: L4^ Z o 7 WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5106,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class# Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(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 subjects the a icant to a civil penalty of not more than five hundred dollars($500).): s owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the 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 pursl,Aant to the Contractors License Laws.). ❑ I am exeml){,iDerdse Business and Professions Code for this reason: Signature: .(i-4Date: 4/0'-Z-0 3 Owner ID verified by drivers license. ❑Yes 0 No Drivers License No. Expires: 1-1-2-oZ Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIll the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions.that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? DI 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 t0 be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes ❑No 8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. • Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for ins c'on pu s.I ree not to occupy or allow occupancy of any building authorized by this permit until final inspection. arL—oY ignature Of Legal Owner(s) Date And/Or Authorized Applicant Date CODE L 1BSPECDON TYPE PATE INTITIAL$ cQQE1 INSPECTIONTYPE PATE 1NT71IALJ 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 204 Final Demolition 250 Final Building/Occupancy 2 Sof 9 CITY OF COSTA MESA BUILDING DIVISION , , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F PERMIT JROTP03-00638 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 222 LILLIAN PL Status: ISSUED Suite No Applied: 10/02/2003 Issued: 10/02/2003 Vicinity: BATHROOM AND KITCHEN Parcel Nunmber: 43921205 ISSUED BY: Applicant: CHRISTIANO, STEVEN R Address: 222 LILLIAN PL Phone: (949)548-7172 COSTA MESA,CA . Zip: 92627 Owner: CHRISTIANO, STEVEN R Address 222 LILLIAN PL. ' Phone: (949)548-7172 ' COSTA/MESA,CA Zip: 92627 Contractor: OWNER-BUILDER Address: , • Phone: Zip: License: 000000 Arch / Eng: - - , Address: _ Phone: • Zip: License: . SCOPE OF PERMIT CREATE A NEW BATHROOM WITHIN THE EXISTING SPACE IN BEDROOM#3 IN AN ONE-STORY SFD. REPLACEMENT OF KITCHEN SINK;WASH BASIN AND SINK REPLACED IN EXISTING BATHROOM. NO SQUARE FOOTAGE ADDED TO DWELLING. 1 BATHTUB, 1 DISHWASHER, 1 SHOWER,1 KITCHEN SINK, 1 WASH BASIN, 1 WASH BASIN SET,2 WATER CLOSETS. , . REF: B03-01704 , 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 $9.80 1 "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 $9.80 1 Dishwasher $9.80 1 Sewer Cap for Demo $0.00' 0 Wash Basin Set $9.80 1 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(6(00) DECLARATIONS �) (Tht 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 se n need not be completed it the permit Is valued at one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. /� Applicant Signature: �r� .+�1� Date:. /O WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLI.ARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST.AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class# Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects th ' nt to a civil penalty of not more than five hundred dollars($500).): 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 properly who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt un rsec. Business and Professions Code for this reason: Signature: D te: /O —Z—O3 Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. ) Expires: 9-£ 0"? Verification of Ownership by(type of document,I.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 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)? ❑ o ❑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 apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes 0 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 8- Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 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 AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I be to complyewith all state city ree ordinancest relatingupy to building construction,any and autho by this representativesr it the City l Costa Mesa to enter upon the above-described property for inspection es.I Tee not to occupy or allow occupancy of any building authorized by this permit until final inspection. /0-2_-a 7 ignature Of Legal Owner(s) Date And/Or Authorized Applicant Date - ;ODE t IfISPECTIDNTYPE all MI INSPECTIONTYPE BAIL REIMS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing ZF(TDY r,{/s I S 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 / w9 CITY OF COSTA MESA < BUILDING DIVISION - .• (,,,'I �r . DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER ISI Oka /a 1 PERMIT J !" 1 -`"Peau ,s. )4103-00481 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 222 LILLIAN PL Status: ISSUED Suite No Applied: 10/02/2003 Issued: 10/02/2003 Vicinity: BATHROOM e Parcel Number 43921205 ISSUED BY: ..a Applicant: CHRISTIAN°,STEVEN R Address: 222 LILLIAN PL ' ' ' Phone: (949)548-7172 ' COSTA MESA,CA' . • : Zip: 92627 Owner: ' CRRISTIANO; STEVEN R Address: '222 LILLIAN PL',', Phone: (949)548-7172 ' COSTA MESA,CA Zip: 92627 Contractor: • OWNER-BUILDER - Address: Phone: - Zip: License:000000 - SCOPE OF PERMIT CREATE A NEW BATHROOM WITHIN THE EXISTING SPACE IN BEDROOM#3 IN AN ONE-STORY SFD. , -, • NO SQUARE FOOTAGE ADDED TO DWELLING. . r' 1 VENT FAN/SINGLE DUCT REF: B03-01704 • - -- FEESUMMARY Quantity - - Quantity ISSUE FEE . $23.50 Repair/Alt Absorbtion Unit $0.00 0 ' Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $0.00 0 _ Evaporative Cooler $0.00 0 Inst/Rep.Recess Wall Htr $0.00 0 , ', ' Commercial Incinerator $0.00 0 Refrig Sys<100 k BTU $0.00 0 t - Domestic Incinerator $0.00 0 Refrig Sys>100 k BTU $0.00 0 . Compressors/Absorption Systems Gas Piping - $0.00 : .0 - Up to 3 hp/100_k BTU $0.00 0 Factory Fireplace $0.00 0 : ' 3 To 15 hp/500 k BTU $0.00 0 Hood w/Mech Exhaust , ' " $0.00' . 0 . - ' ' 15 To 30 hp/1,000 k BTU $0.00 0 VAV Box . . $0.00' -\o . , 30 To 50 hp/1,750 k BTU $0.00 0 Vent Fan/Single Duct $7.25 1 ' . Over 50 hp/Over 1,750 BTU $0.00 0 Appliance - " , $0.00 ' 0 - . Boilers Fire Dampers $0.00, , 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00, 0 3 To 15 hp • $0.00 0 Inst or Relocate Appl Vent .$0.00 0 ' 15 to 30 hp ' - $0.00 0 Air Handlers c 10000cfm ' $0.00 0 ' 30 to 50 hp $0.00 0 Air Handlers> 10000cfm $0.00 0 • Over 50 hp $0.00 0 Floor Furnace $0.00 .0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Imestigatioh Fee $0.00 Plan Check Fee $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 I 2446-46(6/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This se ' need not be completed if the permit is valued at one hundred dollars($100)or less.) ‘I certify that In the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. , � Applicant Signature: .r L�.s�'r.'—� Date: /O -z-o '7 WARMNG:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class# 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: 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 d Professions Code)or that he or she Is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subje a applicant to a civil penalty of not more than five hundred dollars($500).): I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not 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 u r sec. — Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑Yes 0 No Drivers License No. Expires: ' Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. 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 ❑No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3—Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LI No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). e Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If'yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all to 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 ins on pu s .I gree not to occupy or allow occupancy of any building authorized by this permit until final inspection. /O-2-03 ignature Of Legal Owner(s) Date t And/Or Authorized Applicant Date CODE/ INSPECTION TYPE PATE R/TRIALS CODEI INSPECTION TYPE OAS I ALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 2-5"-Octth(j 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy M CITY OF COSTA MESA 0 4e'° BUILDING DIVISION o•, ,� DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 1 �w'°�-'oz's., 1 k IPIM • PERMIT E01-00185 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT - Job Address: 222 LILLIAN PL Status: ISSUED Suite No Applied: 03/14/2001 Vicinity: REAR OF HOUSE Issued: 03/14/2001 Parcel Nunmber: 43921205 Applicant: CHRISTIANO, STEVEN R ISSUED BY: Address: 222 LILLIAN PL Phone: (949)548-7172 COSTA MESA,CA Zip: 92627 Owner:• CHRISTIANO, STEVEN R Address', 222 LILLIAN PL ,, . Phone: (949)548-7172 COSTA MESA,CA Zip: 92627 E'Zt! Z Z DATE 5 • Contractor: OWNER-BUILDER A- - Address: - Phone: Zip: License: 0 ` SCOPE OF PERMIT - .. CHANGEOUT EXISTING ELECTRICAL SERVICE. - ' FEE SUMMARY Quantity - - - - Quantity - ISSUE FEE $23.50Temp Dist System/Lighting $0.00 0 , ' - Temp'service test $0.00 Busway/100 ft $0.00 0 . Res. a/c package $0.00 Standing Section $0.00 0',. - New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 New Res(3+units) $0.00 0 Transformers up,to 1 kva/kw $0.00 ,-0'. .. Pool/Spa $0.00 0 up to 10 kva/kw $0.00 - 0' Lighting.Fixts $0.00 0 -,'Lip to 50 kva/kw $0.00,; ',0 Recept Outlets $0.00 0 'up to 100 kva/kw $0.00 ' 0 Switches $0.00 _ 0 - • over 100 kva/_kw - -$0.00 0 . Non Res Appl • $0.00 0 Low Voltage Equipment - ' "_ $0:00 0 ---... Res Appl $0.00 . 0 Low Volt Wiring System/Ckt• . 40.00 0 Service to 200a -' $30.50 1 Misc.Conduit "$0.00 0 Service to 1000a ' , $0.00 0 Misc.Conductor Service over 1000a - $0.00 0 Circus(gen or ride) - ' $0.00'- , 0- Motors to 1 hp $0.00 ' 0 Circus(mech ride or lights) $0.00 0 ' Motors to 10hp $0.00 0 Christmas Tree Stand -$0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 _ - 0 Other Electrical Fee .' ' $0.00 Motors over 100hp $0.00- ' , 0 ' ' Communication drops $0.00 0 Investigation Fee $0.00 • Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $54.00 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all 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(&00) WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: o I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. o I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3106 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class 4 Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097.Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that l 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 fore permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): yrs 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`ownerbuilder will have the burden of proving that he or she did not build or improve for purpose of sale.). O I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Caws.). ❑ I am exempt un r sec. Business and Professions Code for this reason: Signatures- i CDate:—_ 2ly !9 Owner ID verified by drivers license. 0 Yes 0 No Driver's.License.No.�- /L---Expires:—T-(/3-Joy Verification of Ownership by(type of document,i.e.-properly tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the 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 ❑No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑yes ❑No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a2ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No (If yes',the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7 II a permit from the South Coast Air Duality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 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 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 insp• tion purpo -s.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature O Legal Owner(s).�- L bate • And/Or Authorized Applicant Date COPE 1 IIISPECTION TYPE PAIL IKir1At$ CODE r INSPECTION TYPE PATE MAU 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 204 Final Demolition 250 Final Building/Occupancy I PROJECT ADDRESS: 422 LILLIAN PL UNIT: CITY OF COSTA MESA — BUILDING PERMIT PERM NO; B 05751S OWNER'S NAME: SMITH, BRETT ADDRESS: SMITH SANDRA PERMIT NO: B 057519 PLAN CHECK NO: N GOVT; N SUFP; N I • 222 LILLIAN PL COSTA MESA,CA 92627 CONSTRUCTION TYPE; V—N PERMIT TYPE: STR PURPOSE: ALT 548-4011 ARCH/ENGINEER: REG.NO.: JOB DESCRIPTION ; T/ OFF REROOF W/ COMP SQ FT; 1 , 500 .a ADDRESS: UNIT: CLAIM VALUE: 1 , 500 , 00 CALC—VALUE; 1 , 500 .00 GROUP OCC; R-3 / PERMITTEE: BRETT SMITH ( 714 ) 548-4011 ADDRESS: 222 LILLIAN PL COMMENTS; T/OFF REROOF W/ COMP tl CM CA 9262.6-4616 *"*******-*******-*******%*****xx******* $•x**X**x***'x>E*** 9c.* • ,:0, '. �+t" T '7eGT 'V'R LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section ZONING R EQUIREMENTS 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. SETBACKS REQUIRED • CITY LIC.: STATE LIC.: CUSS: Dale: Signature' MAIN BUILDIING -- ACCESSORY BUILDING WORKERS'COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell-insure or a certificate of Workers' FRNT: FT IN REAR: FT IN FRNT: FT IN REAR ; FT IN Compensation Insurance.or a certified copy thereof(Section 3800.Lab.C). LEFT: FT IN RGHT; FT IN LEFT: FT IN RGHT: FT IN POLICY NO.: EXP.DATE: COMPANY: PARKING REQ. PROV; PARCEL: 43921205 ZNE: REF NO: ❑ Unified copy is hereby furnished. ❑ Certified copy is filed with the city Building Division. PLANNING NOtES> 1,1 Date: Applicant: **************!6**************x******x*******3(**;e******************x-ii.****** **363E EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need not be completed if the permit is or one hundred($100)or less). DEVELOPMENT SERVICES R E Q U I R E M E N S I certify that in the performance of the work for which this permit is issued.I shall not e oy any perso in any manner so as to become subject to thhee,Workers'Compensationomp� Lawssy'California, I ZONING APPROVED BY DATE: '�• Date: /!I cE Lit /9V Signature: r NOTICE:If,ager making this declaration,you should become subject to e r ers'Comp motion provisions of the Labor BUILDING APPROVED BY ; ///777 •;�� DATE: , Code,you I forthwith comply with such provisions or this permit shall be deemed revoked. C / CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED B Y; p� !'At DATE• r 2 L� which this permit is issued(Section 3097,Civ.C). **********************VWWWWW .IF*********WR-************************* n ** LENDER: *********************************************************************A********* ADDRESS: LEGALIZATION;N F E E SUMMARY STRUCTURAL{ SEGMENT:Y OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES, GRADING (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish,or PERMIT 35 . 00 50,/ repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed SMIP/NON—RES pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business ! and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by PLAN ,( any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). ISSUE FEE u I. as owner of the property or my em loyees with wages as their sole compensation, will do the work, and the BUILDING—DIV— PERMIT ISSUE PLAN—CHECK TOTAL PAID %' DUE ❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'State License Law TOTALS > 35 . 50 0 , 00 0 . 00 35, 50 3 5 • 5 0 • 0 0 does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through his or her own employees,provided that such improvements are not intended or offered for sate.d,however the building or REVENUE DIVISION TOTALS--> COLLECTED: 35 . 50 OVER/SHORT • 0 0 improvement is sold within one year of Completion,the owner will have the burden of proving he/she did not build or improve for the purpose of sale). BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business 3 5 • 00 50 'n' ❑ and Professions Code: The Contractors'State License Law does not apply man owner of property who builds or improves thereon JJ� and who contracts for such projects with a contractor(s)license pursuant to the Contractors'State License Law).I am aware ***********************************************************3E*********1** ******* that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL F E E BREAKDOWN © I am exempt under Section: B P 7 0 4 4 B.S P.C. for this reason: �j�A/LL WORK BY OLWNER / - TYPE QTY DESCRIPTION UNIT COST 4.DTAL COST Dale: 4Q�.T 2 `9F2— / Owner: 7 T ! �7 / R 1500 REROOF BY VALUE RESIDENTIAL N07.ONE 1 . 00 1 , 500 . 00 I do hereby certiVhhat I am aware of and understand the requirements of California Health.. Code Sect ons 25505,25533,and END OF FEES 25534 and that I or any future building occupant will/will not(circle one)need to comply with said state codes and the requirements for a permit for construction or modification from the Air Ouality Management District.Residential construction applications are exempt from JI these provisions. n Date: Applicant: 41 I hereby certify that I have read this application and stale that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building const lion and hereby authorize representative.•I •5city to rupon the above-mentioned property for inspection purposes. J� /q� Dale:/X4.1 2fr Mt Signature: /_I�/' Medi nt 0011600T_0,t.tn561 "i-C)..! Driver's Lice or Social Security x: DATE: 051.2c1/92 I i''l : :`:2i - 1641-46 White—Building:Green—Code Enforcement:Canary—Applicant:Pink—Revenue:Goldenrod—Assessor . CONSTRUCTION AND PLANNING - POOL ,PA • APPROVALS Permit# Date Inspector APPROVALS Permit# Date Inspector • 1:Temporary Electrical Service or Pole i - 52..Pool & Equipment Location _ 2. Soil Pipe-Undrgrnd. - 53. Steel Reinforcement - 3. Electrical Conduit Utility-Undrgrnd. 54. Forms . - 4. Electrical Conduit-Undrgrod. 55. Electrical Bonding �' 5. Steel Reinforcement I 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation i 59. Gas Pipe, 0 Undrgrnd., Test -4 9. Water Pipe-Undrgrnd. � 60. Backwash Lines, P-Trap, 0 Undrgrnd. (SI__I__ 10. Structural Floor 6'/stem ; : 61. APPROVAL TO DECK li!r' 11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final _ • ~ 12. Sewer CaP 63. Heater & Vent-Final V' . -,(~ 13. Roof Drains t 64. Plumbing System - Final /r ' _ • 14. Rough Plumbing . . 65. Electrical-Final . r- i 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 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. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil 23. Gas Pipe-Rough & Test r 72. Underground Flush 24. Roof Framing 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 76. Dry Standpipe 28. Lathing & 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: J 34. Final Heating& Air Conditioning 35. Final Gas Pipe-Test 36. Hood or Canopy .- - 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service-Final 40. Gas Service-Final 41. Solar Domestic-Final 42. Backflow Preventer 43. Backf low Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations `47. FINAL STRUCTURE & BUILDING ies,_m_rit. de„* _ 5 c.,`4 e/ m!_ oda- 48. i48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date OWNER M471-DIS, AT,PFPT 14 DATE 7-5-56 JOB ADDRESS 222 Lillian Place BUILDING PERMIT NO. j286 GENERAL CONTRACTOR Bair's Remodeling Service VALUE $ 950,00 AP -- LOT 19 _ BLOCK TRACT 1163 Craraea V. ,UP J TYPE IT ZONE FIRE DISTRICT 3317 PERMITS ISSUED INSPECTIONS DATE SUBCONTRACTOR DATE NUMBER Footing Trench /� ._ 7-7-_1 Foundation Forms and Grade to Garage Rough Framing _ $-$ (C 7 -/g S Plumbing, Rough to Slab Plumbing,Rough Complete Temporary Pole Wiring, Rough Heating,Rough Heating, Final Sewer, House Sewer,St. Septic Tank or Cesspool Lathing, In Out ,�}}��/ P' `^ring &Li Yr' ' s75fr I sing,Final,Fixtures Complete (J Plumbing,Final Gas Test Occupancy • _p�,/ / Occupancy (,/�JX�/�j_ 3�//TS�h FORM 210 3M 10.95 v / 3286 Costa Mesa Building Department APPLICATION FOR PERMIT P. O. Box 317 BUILDING 1 COSTA MESA, CALIFORNIA 3317 FOR OFFICE USE ONLY FOR APPLICANT TO FILL IN Receipt No. Permit No. Building Address ? 9( - .• .- %t4? .� �. "16 Costa Mesa, California Received by Date R(ec'd.(r 7 SDate Issued Nearest 7 — " J' -cc Cross St. • c'.,L,,'v1 at Buildin � 'V-MaC1 ,co .� Address Owner Costa Mesa, California Mail $,Q2 2V/ �aM Addres ©ieta Nearest Tel. • Cross St. City (� tY{u¢� Noy(I it-10% ZoneI No.of Type, / Group / Architect or Lic. /'�} Plans I [/ Engineer_ No. Approv • l by Date ddress 97 1 y LIT c.(, 1. Id; MiLi1'l., ntracto• ,n No. T Address/t0),,° r seg, _ PLANNING DEPT Legal SUBJECT TO BLDG. DEPT. REG. Lot _ Description / �) I No. 7 1 Block I Tract/(43 -'/ (Attach Metes and Bounds) BY ; DATE !! -� No.of Bldgs. / FLAN I.,CH. / � Size of Lot 7. )( 1 p 0 Now on Lot _ 0 Use of .V I No. I Roof - a Usisof Bldg. No.of R .o t °a 4 7l 2, Setback Line from /� Rear Vard ( — ! a i ik k�'- 3/4 11 Center of Street 76 Side Yarn { 1�� '�' �.Y•r-'ti;,') D DESCRIPTION OF WORK t W i s--- r New I ;/\ ( Alteration I I Addition %: Repair I I Moving I I Demolish I � r• Building /� No.of n^T(�, tAt " _Size J% >( on Rooms / StorieIs n1TV I* ‘J1/4-;‘'" nor Wall .-f— I Roof d -- 'APPROVALS wring Covering ( APPROVALS UseNew Building yid - Foundation Location _ Inspector Date r Forms,Materials, Under-Pinning Frame: Fire Stops, Bracing,Bolts I hereby acknowledge that I have read this Application and state that the above is correct and agree to comply Lath. Int. with all City Ordinances and State Laws restllating building const ction. Lath.Ext. Signature of Permittee �OH ./ L .lll.rn . .ts.:/,�u' - Plaster,Int. • Authorized Agt. �/ 4 j, / .0 ' Plaster, Ext. Valuation Permit Fee $ ,& Masonry Reinforced (� 0-U Plan Check$ Bond Beam $ Total / Fee $ 6 FINAL FORM 204 10.55 D,P,8 5. .• c--' • • COSTA . a S S. ‘' ,Th-Ti`,5-7,5101,11-sitt309'.E.,**"'*6.00 a. . a. • •:'\ • -• •. • • • • •,, • ,•, \,, .-•••• • • 2. -•-•• • -, • • • • Street ; PLOT PLAN Show location and distances from 1. Property line and between buildings. • ;Si!