HomeMy WebLinkAbout3412 LANTANA LN - Building PermitsPflOJECT PO�HESS: j 4 1 Z LANTANA LN
OWNEfl'SNAME: SMIETAN ROBERT TR �
aooaess: 3412 LA{1TANA LN
COSTA MESA,CA 92626
UNIT:
APCH/ENGMEEfl: NEC.NO.: �
p�OqESS: , � UNIT:
PEflMITTEE:BOB & GRAYCE SMIETAN (714)751-4555
aooness: 3412 LANTANA LN
COSTA MESA CA 92626
LICENSEO CONTXPCTUfl DECLABFTION: I hereby a�lirm Ihat I am licensetl under pmvisions o� Chapler 9(commencing wiih Seclion
7000) of �rv�sion 3 of Ihe Business antl Professions CoOe. and my license is in full �orce antl etlec�.
CITY LIC.: STATE LIC.: CLASS: "
Daie: SignaWre.
WOBRENS' COMPENSATION DECIABATION: I hereby afhrm �ha� I have a cerlilicate o� consenl �o sel6insure o� a cenificate ol Workers'
Camoensation Insurance, or a cenitie0 coDY �hereof (Section 3600. lab. C�-
POLICY,NO.: E%P. DPTE:
COMPRNY: � '
❑ Ceniliee copy is here�y �umishetl. ❑ Certi�ied coOY is �ileA with Ihe ciry Building �ivision.
Daiel ApDlicant:
E%EMPTION FflOM WORREBS'COMPENSRTION OECLABPTION: Qhiss an need natbecomDleteOi�lhe p rmiiisforone hurdretl�5f00�orless�.
I cetlity Ihal in �he petlo�mance o� ihe work br which ihis permii i 5 e0. I shall nol employ any D son in any manner o as to ecame
sublect� Ihe o ers C nsation Laws of Califomia. � �
�ate'. Slgnature: ce
. NOTICE: I. afte making Ihis Oeclaration. you should �ecome 5u�leci ta Ihe Worke ' Compensalion provisions of the �abor
Cotle. you mu5i fotlhwilA comply with such pmvisions or Ihis Dermi� s�all be tleemetl revoked.
CONSTPUCTION LENOING AGENCY: I here�y af�irm thai there is a con5imction IenOing a0ency tor Ihe per�ormance o� Ihe work �or
which �his permii is i=suetl (Seciion 3097. Civ. C).
LENOEH:
aooaess:
OWNEB BUILOEH DECIAFRTION: I hereby atlirm t�ai I am exempi �mm the ConUaciors' Sta�e License Law for [he following reason
�Sec�ion 7031.5 Business an0 Pmiessional Code: Nny �city of coun�y w�ich repuires a permit Io constmci, alter, improve, demolis�, o�
Bpair any StrucNre, prior to its issuance, also re0uires ��e applicant tor such Dermil to �ile a signetl slatemen� �hat he/she is licensetl
pursuam to Ihe pmvisions of Ihe Coniracmrs' Stale License Law �Chapler 9(commencing with Section 7000) af �ivision 3 of ihe Business
antl Pro�essions Coee) or thai he/she is e�empt Ihere�mm antl �he basis for Ihe allegeA exemption. Any viola�ion o� Section 7037.5 by
any appfican� br a permil 5ub�eci5 �he applicani �o a civil penalty ot no� more �han five hun0�e0 Oollars ($500).
I, as owner of ihe pmDeny or my employees with wages as their sole compensation, will Oo �he work, antl the
❑ SimcWre is not inten0e4 or ofiered for sale (Sec�ion 7044, Business antl Pw�essional Cotle: T�e Con�mctors' S[a�e License Law
Does nol apDly �o an owner ol a pmperty who buil�s or im0�ove5 ihereon, and who tloes such work �imsel�/hersel� or [hmugh
' his or her own employees, pmvitletl Nal suc� improvements are not in�endetl or otlere4 for sale. I�, however t�e �uiiding or
. improvemen� is sold wi�hin one year ol completion. ��e owner will have the burtlen o� pmving �e/she tlitl no� builtl or impmve
lor ine purpose of sale). .
7p, I. as awner ol Ihe property. am exclusively conVacting wi�h Iicense0 conlraciors Io constmc[ the proleci (Seclion 7044, Business
LJ antl Professions Code: T�e Contractors' State License Law Joes not apply to an owner oi praperty who builas or impmves thereon
and who con�racls lor such pmlec�s wiih a conVactar�s)license pursuant �o Ihe CONractofs' S�aie License Law),I am aware
tnat pmol oi tneir Warker's ComDensaiion insurance shoNA be pwvitletl m me.
� I am e�empi under Sec'on:� B. 8 P. C.
lOr INS reasOn' . - l�
T Oale: ��� / ��— Owner �
I do hereby cenify Ihal 1 am aware ol ana untlersiand the requiremems oi Cali�omia Heal� antl Satery ode Sections 25505, 25533, antl
, 2553G an0 ��a� I or any future bmltling occupan� will/will not (circle one) nee0 io comply wi�� SaiU s�ate cotles antl Ihe requirement5lor a
permii lor con9mdion or mo0ilication Irom �he Air Oualiry Management DiSiric�. Fesidential con5�mciion applications are exemp� �mm
' these pmvisians. ,
Date: NOPlicani.
I hereby cerlilythall have read Ihis applicalion antl sla�e Iha���e abo in orma�ion is correct. I agree o comply wilh all ciry and coun�y
arainanceszntlsla�rela-globuildingconsimclionantlhereby �h zerepre5en�ative5ofihisci roenlerupon��eabove�menlione0
pio0er�y i�inspecti� pur 5 5.�� � /
9 //J � /
` oate: ��� �� Signamre: ��
� od�e�'s ucei e or otla� Securny a:
t64i-46 WM1ne—Builtlmg: Green—Cotle EnlorcemenC Canary—Applicam; Pmk—Revenue; Goldenrotl—Assessor
CITY OF COSTA MESA — BUILDING PERMIT ,
PERMIT NO: B 060138 PLAN CHECK NO; N , ,
CONSTRUCTION TYPE; 5—N PERMIT TYPE; STR PURPOSE; ALT
JOB DESCRIPTION ; REROOFASPHALT COMP OVER WOOD SHINGLES SQ FT: 2,300 .
CLAIM VALUE: 2,300.00 CALC—VALUE: 2,300.00 GROUP OCC.: R-3 /M-1
COMMENTS: SMOKE DETECTORS RE�UIRED PER THE 1991 EDITION OF THE U$C.
�r�r�r��t*�**��r�r**rt*�t�r**�r**�*�r** �t�t�t�t�r�rx�x*�r�r�trt����r�r�t�r�r�r��r****�*��*�**x�t�t�r*�r**�r*�e*�r�e
Z O N I N G R E Q U I R E M E N T S -
S E T�H A C K S
_ ' " '
------------ MAIN BUILD'ING.---------- --------- ACCESSORY BUILDING ---------
FRNT: FT IN REAR; FT IN FRNT; FT IN REAR; FT IN
LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT; FT IN
PARRING REQ• PROV; PARCEL; 41217404 ZNE; REF NO;
PLANNING NZ7T'ES>
_ �
1E k iF ik iF if iE 1E iF ik iklE iP 3k iF iEiF 3E iF iF iE if iElF IE If iE iE iF�1f� iF iE1E �E 1F iE iE �E if i! �k iF iF 3F ik iE iE 3liE iE iE aF iE iE iE IE iE iE 1E 3E iE iE iF if iE iE iE iE iE"iklF iE iE iE iE 3F iE iE 1E
D E V E L O P M E N T S E R V I C E 5 R E Q U S R E M E NrT 5
ZONING APPROVED BY DATE: �
BUILDING APPROVED HY : DATE:
APPLICATION ISSUED BY• � DATE•
lf1E1FklFki!lEiPiElFiE.iflElEiflEiffEifiFiE iEiEiElfiEiE�FiFlEiE � iF
iliFiliFiEiliEikikififiEikiFiFilifiElFlEiEifiEiFiEiEfFiFiEiFiEiEjFiEiFiFikififiE�filif�FiEiFiFik 3FIFif�fifififlFiFfEiE�Eif3FlEiFililjEitiFiF*iElfiFdFik
LEGALZZATION;N F E E S U M M A R STRUCTURAL SEGMENT;Y
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
PERMIT 54.00 50
' SMIP/NON—RES
PLAN
I5SUE FEE
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
TOTALS----> 54.50 0,00 0,00 54,50 54,50 .00
REVENUE DIVISION TOTALS--> COLLECTED; 54.50 OVER/SHORT: ,00
HLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHEC}t
59,00 .50
iF i! iE it 1ElE K iE if iF 1f iE iF iE iE �F iE iF ik iklE iE iEiElE iE iEiE iF iF iF 1E iE i! k iE iE 1E iE iE if iE iF iF 1E iklE kik iE iE �E ik iE iF iE iF ik �E �f iF iE �E i! iE iF ik 1k 1E 1k 3E iF if iE iF iE �f iF if
I N D I V I D U A L F E E B R E A K D O W N
'TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST
SFR 2300 REROOF BY VALUE RESIDENTIAL NOZONE 1.00 2,300,00
END OF FEES
r;� .��;' � �_ — ^;, , - -
N
�_� i � �
CONSTRUCTION AND PLANNING " .� - POOI & SPf! � �
APPROVALS Permit # Date Inspector APpROVALS Permit # Date Inspector
1. Temporary Electrical Service or Pole � 52. Pool & Equipment Location /� ti��-
i �.
2. Soil Pipe-Und{�qrnd.. . i� 53. Steel Reinforcement � � � �'�
:,�:�
i�3.�.ElectricalCondvitUtility�Undrgrnd. � :y • � 54. Forms- � � �
�^�4._E(ectrical Condurt-llndrgrnd. % � 55. Electrical Bonding � . � �='
r
;y�5� ieel Reinforceingrt$ -_ . 56. Rough Plumbing & Pressuve Test 'f � ;.
�Lr:..'�Electrical UFE$ md. 57. APPROVAI TO COVER�GUNITE � �
�'-�r�?�ootings Y'� _ 58. Eiectrical Conduit-Undrgmd. -
��
"[B�:Foundation S^] .7 59. �Gas Pipe, O Undrgrnd., Test �
- i •.,
�;9. Water Pipe-Undrgrnd. � � 60. Backwash Lines, P-Trap, O Undrgrnd. . �` ,�
10. Structurel Floor Svstem , 67. APPROVAL TO DECK _� � ?
11. Pioperty Sewer Li� & House Connection ' -
; 62. Backwash & Receptor-Final -
12. $ewer Cap _ , ^,% 63. Heater'& Vent-Final �'�i� .
n -'
13. Roof Drains '� %�,: - 64. Plumbing System - Final �� �� �
i � '-t /
14. Rough Plumbi'ng ` ' .,., 65. Electrical-Final ;; �� •- �
15. Rough Electrieel-Conduit �r 66. Solar System-Final ,.�"�/
i6. Rough Electri,FWiring 'i ' 67. Fencing & Access ApProval I ���
L L
17. Rough WiringSign � 68. APPROVED FOR PLASTERIf�}Q":, � �
18. Rough Electri�l-T Bar Ceiling � 69. POOUSPA SYSTEMS FINAL � �'
19. Rough Heating & Air Conditioning '� � � FIRE DEPT. FiEQUIREMENT '-
,� � �.
J'r�c':-. �. < nJ
20'� R dgh�Factqry �ifiPlace ' r'n S' "- ^� :� � 'S-` " APPF�OV`/��'S�>> Pe{mit # 'r
-i � �. x t S:�" +. � x 3' _r x.: C n r r
21�.'Oucts,in Stsuctu�ec •• •• _S = J� = -� x ' 70. �Hnderye�iin� H�dro � �
„
22._ D Gts, �yeni� ati. x � r S " -¢' f:. � �
��. � `,n,�;. t'� x 7 � � �.x x< 71. Produc��p�nq ���as 40i1
�� '= .- . . .� c �-,-: K -� � �� . , .
2..Ga:,Pipe-Roy9h &rTest i r S * m !' S O+� t' �� 72, Undergrc2rind FiusO v x F=
� - _ - '
24°Roaf Framirrt� c� � F-�-- V'� r== y y* % 7� Undergrn�.Stor.�g�eT�nI�OGas ❑0'il
.<. - '. �Y . ri ,� :..: r . �.. V
25. Roof Slfeathing �.- " v v x �' > C�Jx x 74:. Overhead Hydr� � :, �
26� T�Bar Ceilin9 (S[ci;Cturap &�Mbnocoat % :y � �V x x 7�; pry Cher�ical . " �'-" e :� '
27y Frame and Flashine � x � > -n.� .� 76 �Dry Starislpipe =- � �A ,' '� G
� 28. Uthing�& Siding r y �C� s '� �_ ..� �Y 7F. FIXED SY,.S�TE�M�INAf� � r
Y rJ .i S:i �. .� . � R .. �[ '� -1 y 1 R ._[.
29. Insulat�on ..t.a �" S .. x r Y 7&: FIRE PREV. FNNAL :., >
"' 30. Drywall�NaiNng�r _ " � " " ��' -H�EALTKDEPF!REQi11R MENT
� 31. Plaster��royap Co'a,{ ,- ; ,T , � 1�.'� „ � ; � 79.' FINAL 4j_y�'�,f'ECTION �X f' ' -
. v . - - -
-� 32' Electrical Powei-MEt'er�Final �^= � x: 80n FOOD CERTIF�CATE 15S� ED
S r .. '{ rt' ,T Fr,. i % # M -' �> x � [Y
,- 33, Final �Iect,i� k �r y: > �����' Notes: y -y n ' (�. r��r,
�: 34' Final Heatirte &J��ir Coaditio[17pg C+. x� � x* ,s; S ('.x x, y' �p
: �/ � ^.1 Y > � 1 X 'T
' 35:� Final Gas Pipe�Tes� : �r ' � �` �� '� =`_? � � =`' S -�
� � ,�. .. � K �_ i'G x �r
_ 361 Hned oL CanoPV'. � � * C� x. Z i'.o �.. �,,':r
� r - �
� 37;,Fiq�a,l F2'ctory F�i7eplac� � := �`� L,� ; ' � g. w �� ��;
`. . , . ..;
J 38. Fin31 Plumbing �z � �? • � - . � � rS -
- r['
'.39. Water SLrvice-FiOai � r -' % s �'.=/r�;. �' .ti�y � z �
r 40. Gas Ser.pice-Final a : .,,: ;�- � . _ > '� � -.� i� . � �
.r
41. Solar pomes"tic-EinaP �� � • '< �5 , K x = -- �
�+ f lY'X T' �:� X.
.L
~42.' 0ackflow PreveMer :,a ' � r .. ' - . � �
43. Backflow I�S�9atio(� � r'' � � ` ` � - " �� J .
•-x - x n
� � a 1 .. .. . . .�
-44. Landscgpe�rigaiion SYstem.7„ �.r, �: -�n J - =x * �: �? - �;;; . V ,�
'' ` . -lc ! r �: S .-:;c :. - � _ .,� 4 T, j .t
= 45: Sound Attenuatiari � '
f < J 'ti}:'n J S ' ..
i ti., r ..
� 48 . HandiCap Regul'ati0ns � � '' ., �z S � rN . `:� .,
4Z> FINAL STRUCTURE & Bl71LDING� p!Z � � - �- ?- � ^ ^ '"
. � �,
48;-'FINAL PLANNING ��. ..,�; I I�; �; i i 't
� 49: Electric Release to Edison . - �> ��J� �- i • .
' � /1i�>. v
' 50; Ga� Reiease.to Southern California Gas Co a I �� F�; =.' � -. j_T� r' ?- `;
�.51. CERTIFICATE OF OCCUPAN v ;_ „ •n � _ t r�. ;:�
No. Date
� z� zs
!� 2�,�`�"� �F�o2 Twiniaq Laboratories �,f =��t�E�z.,, e�t��f�=,t«t, ��,t�.
�' � P.O. BO% 4] . 3710 AIRPO.Ri WAY . LOIJG BEACH. CALIR 90fl01 . �7i7� <2eJ355 . �217� 6364386 . �1N� 828-6<3P
2iANf.= O�'�IGES:
- TESTING . isn.o,�,...�,.o..s..... ^� vo�c�...,,c..arer�„s
Sanre/ma.Gli�vnieGDW f!d ` ��.Sw=m�m�ve.,G.O.Aoi�1
�n� Slb1P: �4i, ��
� � i� �, La�q 4ern. Ce1.0 G06p1 �1U� G10-D2o
' �+� �_��� .
September 28, 1973
COMPRESSION TESTS ON GUNITE
Mr. Jack Hubbard
3�06 Ostrom AVenue �
Long Beach, California 9080&
'- ��PROJECT Swimming Pool for L. BlYSTONE
ADDRESS 3412 Lantana Lana. GoSta NeSa
Examination: $C73-(�52(�
,. .., SAMPIE fROM Shallay.end, Deep end, donJ beam
ARCMiIEQ CONiRAC10R
Mthony Poois
fNGINFEa SV9CONiR4C10R
R. J. Kolodr�ej - Sama -
SPECIFIED
MIX �l�IIY CO I STRENGTH
DATE CAST
DATE TESTED
CYLINDER NO
COMPRESSION
TOTAI LOAD, L85.
POUNDS PFR SO. IN
CYLINDER SIZE:
COMPIIANCE
CYLINDERS
9-20-73 CYLINDER 512E:
9-27-73 9-27-73
I 2
7-Day 7-Day
65,000 100,500
2,505 3,555
S-3/4" x 12-1/2" 6" x 12-1/z"
7-Day test compitas with spectflcatlons.
MpDE !Y DEIIVENED BY
D. McBee Oave
Permlt #3}3(sk ,�11c%%�
2,000 p5I
9-27-73
4"HOLD"
3 5"HOLD"
6"HOLD"
7-Day
72.000
2,655
5-7/8" x 12-1/2"
4KFIVFD ON
9-21-73
oinuieuiroN:
Jack Hubbard - 2 �
Costa Mesa Build(ng Dept. BUILDING SAFETY DEPT.
0 C T 1 1973 /,-
f,�
, _, �
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� �',�%ti� • ,, '
.., r.� �o�.s ..� s. n� �., .< , r cz,..� o� �i. .. �o.�� u. r� , i �. ,. ,n4 r�.on ro� � �auc.- o+ n� o..= oc�•o�rs covc��s�ovs ov �.
.=.e�s ivco n F�r..�,� ..a ..eu` s =rs��:eo �� �... .. _ ..- • �. .�.� .,. .. . .. .,,.�. ovr��r_�.o� .o n.�Fa-s -..e ooe��e .�.o o��sr,��s
330 15
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• . . ' _ 'Y . - i ' • � ; . . i • • ,- .. -
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_ ' . . • , .. . . Juae '12� 1973-`. _ .. . ..
i. . - ' - . .. - - - . ' : . - - - r,
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' . .. : . . . � — - - � - . . . . ' _ . � - � . .
_ . . , .� i . � . . . . ' . .
C o.
. . - � . . � � . . . .
Mr: Lillerd�Blystone .• _ � - , . , .' y�",
. _ ' 2412`Laritana.'Lane �• • , . - . ; ° . �
Costa Hesa,, C81'ifornia . 92626, �� • :
i ,
Dear Sirs . � - , M1 . . " ` .
' A buil`ding.permit has.been'�issued io AnEhony'Pbols to conatruct a � ' '
private .swimming pool' on y property. :, � � , . ' �-��?�
- _ �_In;ordei that youz pool'will be ,safe.one and'for [he�.purpose.of , , ,
- . . advising�:you.of,y,our•iesponsibility`regardirig':the requirements of..�
" . - the`.Costa Mesa Munici'pal=Code,� we refer'you to"Section 8107, a copy ; ' r''
( �' of which ie attech�� _ , � _ . "`
""' ` This'.letter Ls�direct to you in order,tha[ you will be aware of
- �• our ordinances"and caa'make a_comple.te safety'check of your:pool' �•
- area. ' ' ,.. , . ... . • . .
; �. Sincerely y.ours, : . . . . �. .
* - ..
, . - . , - � - : • . ' . _ _ . _
.. , . . . , . �;
_. . • , :; , _. _
- . - . , ' , ` . . RICHARD HANHART•_ - � '
, : �' r � o' '; Building Safety;Director- '- • _ ��
., , rRHscb , . � .� . _ .
. - _ . ` . .s. • f ; _ . ; . . � . • . - ; . ,
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.�tr ���y.
CITY OF COSTA MESA REQUEST FOR OCCUPAA'CY .
TRACT N0. % %/ �G ` DATE S '
LOT N0. I % H�
aDDxEss 3 412 ��.,���__a;c�e
The developer of the above entitled tract desires to se11 the above set
forth lot prior to the time that the tract has been completed and its streets
accepted by the City of Costa Mesa.
The undersigned, by executing this agreement, acknowledges that
(he-she-they) (was or were) advised that this tract has
not been given final inspection nor has it been accepted by the City of Coata Mesa
as having complied with the conditions of approval which were imposed by the City
at the time the final tract map was approved.
P
The City assumes no liability for the enforcement of the conditions
necessary for approval other [han those conditions protected by surety bond.
The undersigned agrees to indemnify and hold the City harmless from
any claim resulting in dar�age or personal injury to the undersigned by reason
of the aforementioned uncompleted condition. -
RECEIVED
CiTY OF C�Si;I ia'[,A
„ . .. -,-.
F�'.I.J .('.] �. U � J I J
AM PM1�
�igiQ;?a�i1��.2�3�`�;��4�5�6
�
a
�
9
BY � � '� .
Purchaser
i >
/ �/—
BY �7r �9,/�� J-�1��l-i C�'77� i'��/
Developer and/or auchorized
representacive
BY �J /'�
�)' _t��•./'C'� ��! r.��i
�Lender
p5�p M6
a �
o.
Y .
F �
J
.q`W>�o � .
CITY OF COSTA MESA
BUILDING D/VIS/ON
77 FAIR DRIVE, COSTA MESA, CA 92626 • Q14) 754-5273 • Fax p14) 754-4856 • www.ci.wsta-mesa.ca.us
FOR INSPECTIONS CALL: (714) 754-5626
PERMIT NUMBER: M10-00068
PERMIT TYPE MECH
APN: 41297404
JOB ADDRESS: 3412 LANTANA LN CM .
vicinity: � �
SQ. FT: 0
STATUS:
DATE ISSUED:
ISSUED BY:
Suite/Unit: ..
ISSUED
07114/2070
RMD
SCOPE OF WORK: MECHANICAL PERMIT TO CHANGE OUT FAU < 100 K BTU LOCATED IN CLOSET, AN EXISTING A/C UNIT
< 100 K BTU. COMPLAINCE FORMS ATTACHED TO JOB CARD AND CITY PERMIT. '
OWNER: SMIETAN, ROBERT TR �
PHONE: 714-751-0555 � �
APPLICANT: JACOBY, ERIC � �
PHONE: � 714-777-7777
CONTRACTOR: SERVICE CHAMPIONS
Address: 22911 SAVI RANCH PKWYUnit �-��
City/State: YORBA LINDA, CA ZipCode: 92887
Address: - 3412 LANTANA LN Unit:
City/StatelZip: COSTA MESA, CA -
Address: Unit: � -
City/State/zZip: � - , - -
MECHANICAL PERMI7 FEE SUMMARY
MECH ITEM FEE: � $53.10
PLAN CHECK FEE: � - $0.00
INVESTIGATION FEE: ' $0.00 �
REINSPECTION FEE: $0.00 �� .
TOTAL FEES: $53.10
License No. 799170
� PHONE: 714-777-1777
CELL:
NOTICE: The work authonzed by this permit shall comply with all applicable handicap access requiremenls under California statutes and related
regulations. (Ord. No. 92-28, § 1. 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
C UE;1. INSiECiIONflPE DATE INIOIALS CODEp INSPECTIONTYPE Or1Tg INTIP
1616 Fixed System Final Fire Prevention 206 Final Mechanical 1 � a 7 � I b
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 2W Final Electrical
201 Final Block/Relaining Wall 212 Final Fire Prevention
202 Final Facfory Fire Place 220 Final Planning Approval
203 FinalSign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
r . ,.
WORKERS' COMPENSA710N DECLARATION:
I hereby aKrm under penalry 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 seclion 3700 of Ihe Labor Code. for the
p�ance o( Ihe work for which this permit is issuetl.
I have antl will mainlain wurkers' compensation insurance, as required by
section 3700 of Ihe Labor Code, for lhe perfortnance of Ihe work (or which this
pertnit is issued. My vrorkers' compensation Insurance carrier and policy
number are:
Carner �fk.J �� %/J S C D D F itl �/
�is'seaimnee�0�rroI10ecompetednmepermrtavaWedal enund�e0tldlars(5f0o)orless)
Pol cry�Ph mber: W�ig �/d i�� �� V
❑ I certify that in the pedormance o( the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject
to Ihe workers' compensation laws of California, and agree that if I should
become subject to the workers' compensation provisions ot Section 3700 of
Ihe Labor od sh forthwiih comply with lhese provisions.
2�/y�/ v
Applica i namre Da1e
h_ J '�
WARNING: FAILURE O SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($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 licensetl under provisions ot Chapter 9(commencing
wilh Section 7000) ot Division 3 of ihe Business antl Professions Code, and
my license is in full force and eflect. l
,N`��'" '—'�t– - % c ass # i�i Z C/
�Conua.�q�. ' ure �Dat�
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CONSTRUCTION LEN G AGENCY.
❑ I hereby affirm that there is constructbn lending agency for the
pedortnance of �he work for wfiich lhis permit is issued. (Sec. 3097, Civil Cotle).
Lender's Name:
lender's Address:
OWNER-BUILDER DECLARATIONS:
I hereby affirm tha[ untler penalry of perjury thal I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5,
Business and Protessions Code: Any city or coun�y which requires a permit [o
consWct, alter, improve, demolish, or repair any structure, pdor lo its
issuance, also requires the applicant (or such permit to Poe a signed statement
Ihat he or she is licensed pursuant to the provisions of the CoMrectors
License Law (Chapter 9(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or ihat he or she is exempt theretrom antl
the basis for the alleged exemption. Any violalion of Section 7031.5 by any
applicant for a permit subjects the applicant ro a civil penalty of not more than
fve hunared dollars (8500).):
❑ I, as owner o( lhe property, or my employees with wages as their sole
compensation, WILL DO THE WORK, antl the struclure is not intended or
oRered for sale (Sec. 7044, Business and Professions Code: The Contractors
License Law does not apply to an owner of property who builds or improves
Ihereon, and who does such work himself or herself or through his or her ovm
employees, provitled that such improvements are not intended or oifered for
sale. If, however, the building or improvement is sold within one year of
completioq the ovmer-builder vnll have the burden of proving that he or she
did not build or improve for purpose of sale.).
❑ I, as ovmer of Ihe property, am EXCLUSIVELY CON7RACTING WITH
LICENSED CONTRACTORS to construc[ the pmject (Sec. 7044, Business and
Professbns Code: The contractas License Law dces not apply to an owner of
property who build5 or improves [hereon, and who contraCls fof SUCh proj0ct wi[h
a cont2cta(s) license pursuanl to the Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for this reason:
SignaWre Da�e
309�G6 (3/W �
r
Ovmef ID verifietl by driver S liCenSe. ❑ Ye5 ❑ NO
Dnver's License No. Expires:
Verification of Ovmership Dy (type of documeni, i.e. - property lax bill or deetl):
DIVISION OF INOUSTRIAL SAFETV PERMIT CERTIFICATION:
❑ I hereby certHy Ihat no excavation frve (5) or more feet in depth into wfiich a
person is required to descend. vnll be made in connection with vrork authonzed
by this permit, and ihat no building structure, Scaffdding, falsework, or demolition
or dismanlling thereof, will be more than thirty-six (36) feet high. (Chap. 32, Grp
2, Art 2, Sec. 347, TiHe 8, Califomia Administ2tive Code).
❑ As owner-builder, I wiil not employ anyone to do work which would
require a pertnit from the Division of Indusirial Safety, as notetl above, unless
such person has a permit to do such work from the division.
Applic3nfs Signalure
Division o( Industnal Safety Permit Number _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant need ro file and
certity a Business Plan for emergency response to release or threatened
release of a hazardous matenal? ❑ Yes ❑ No
(Section 25505 of the Califomia Health and Safery Code requires, wilh some
exceplions, lhat a Business Plan be filetl with ihe Costa Mesa Fire
Department by every business which has at any one time dunng a reported
year a quantity of hazartlous materials equal to or greater than a weight of
500 pounds. or a volume ot 55 gallons, or 200 cubic feet of compressed gas
at standard temperature and pressure).
2. Does or will the applicant or present or future builtling occupant need to fle
a registra[ion torm (or acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of �he Califomia Health antl Safety Code, with some
exceptions, requires registration with the Costa Mesa Fire Departmenl by
each business which at any one time has on hand a quantily o( acutely
hazardous materials equal to or greater than a weight ot 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 (uWre building occupant need [o
prepare an RMPP (Risk Management and Preven[ion Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 ot the Califomia Health and Safety Code provides tha[ the
Costa Mesa Fire Department may require ihe prepara[ion, certifiwlion and
�ling with the Fire Department of an RMPP by businesses which are required
lo regisler acutely hazardous materials with the Fire Departmen[.
4. I( an RMPP is presently required, has Section 25534 0( �he California
Heal[h and Safety Code been fully complied with? ❑ Ves ❑ No
5. Does or will the appliwnt or present or (uWre building wcupam require for
the work which is ihe subject of this application a permil for such construction
or modification from the South Coast Air Quality Management Districl or from
any o[her air polWtion control disMct or agency? ❑ Yes ❑ No
(Secibn 658502 of the Califomia Govemmen[ Code requires that the requested
in(ormation be fumishetl on applications for non-residential building pertnits).
6. Will any pah of the tacility to be constructed untler this permit be vrithin
7000 feet from lhe outer boundanes of a school? ❑ Ves ❑ No
Qf'yes", the faciliry must meet the requirement of Seclions 25534 and 42303
of Ihe California Health and Sa(ety Code�.
7. It a permit from the South Coast Air �uality Management Dislrict or other
air pollution control district or agency is requiretl for the work which is the
subject of ihis application, have all of the disclosures prescnbetl by Califomia
Health antl Safety Code Section 42303 been made? ❑ Yes ❑ No
8. (If'yes", attach certificate of compliance from ihe appropriate air pollution
conVol oKcer).
CERTIFlCATE 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.
Signalure
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalry of perjury [ha[ I have reatl this applica[ion and state that
the infortnation given is correct I agree to comply wim all state laws and city
ordinances relating to building construction, antl authonze 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 fnal inspec�ion.
- S aWreolLegal eqs) Oate �
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Simplified Prescriptive Certifica-'
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100d' 2esidenticd CompZiu�tee Fornrs March 207 U
OWNER LARWIN
JOB ADDRESS ana ve.
GENERAL CON7RACTOR Owner Bldr.
AP No. LOT 178 TR!
INSPECTIONS Si .
SOIL
GAS
W ATER
ROUGH PLUMBING A
PROP. SWR. LINE OIJSE CON.
SPRINKLING SVSTEM
MISCELLANEOUS
ROUGH HEATING AN� AIR CON�ITIONING
TEMPORARV SERVICE OR POLE
UN�ERGROUND n POWER I-I
FLOOR SYSTEM
BOND BEAM ❑ STEEL REINFORCE
SHEATHING
FRAME AND FLASHING
LATNING - IN OUi
PLASTER,BROWN COAT �
STRUCTURAL, FINAL
HEATING, VENT., REFRIG. AND A.C., F
PLIIMBING. FINAL AN� GAS TEST
Cl
LO
DATE
Rllll f
SUBCONTRACTOR
Plumbin
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COSTA�MESA BUILDING-SAFETV DEPARTMENT
�Q� B P.O. BOX '1200 COSTA MESA, CALIFORNIA 92626
For qpplicant to Fill in Completely
BUILDING
ADDRESS 3412�Lantana Avenue
OWNER Larwin So. Calif. �
MAIL 16255 Ventura Blvd.
ADDRESS
cirv No �986-88
Encino CA
CONSiRUCTION _ _ _ _ .__
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BRANCH 16LJ� Ventura 151vd,
ADDRESS Encino, Calif,
ARCHITECT � . ' TE
ADDFESS 9j00 Wilshire Blvd_� Bev. h
CONTRACTOR Larwin $o. Calif.
ADDFtESS 16255 Ventura Bllvd.
TEL.
arv Encino� CA N�� 986-
LIC. No. 191311 LICVNO. B��
SIZE NO.OF BLDCS.
OF LOT 7'3 X � Q'3 I NOW ON LOT
USE OF
EXISiING BLOG, -
N'EWB DG. �70`h FOOM$ STO(ilES
COVERING ALL StUCCO COVOERING WWu Shl
USE OF BUILOING AND WORK TO BE PERFOFMED
P��o ,•r����ti�.88
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APPLICATION POR BUILDING PERMIT
RECEIV � � TEfi�CEIV�� DA�TE I�S�E?�
I ���f � � �
-PERMIT NO.
A.P. NO.
6UILDING /� .
ADDRESS
T(iACT %7�H
OWNER .G
S
FIRE �
ZONE TVPE
APPROVED
BV
ZON NO.OF l
� PLAKS Z E
VARDS APPROVED
DISTANCE BET
MAIN BLDGS.
VAR.,$
t ilOLD FOR
��
OF
VARDSAPPROVED
.CCESSORY BUILDING
BET. MAIN &
I hereby acknowledBe that I have reatl ffiis application antl state ,
that the above ��formation is correct antl agree to comply with
all laws re8ulating builtling construction, entl I shall not amploy
any person in violation of the workman's compensstion laws of
the.5tate ot Ce�itornia. . _ / . ' �� / W
I hereby certify Mat I am properly licensetl as a contractor under SQ. FT. � (LD o
[he State of Ce�ifornie Business and Professions Code, Divisicn 3, HE AMOUNT SHOWN UNDER VALUATION IS FOR �
Chapter 9, antl iha[ such licenses are in full forca and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: m
am exempt frorn the provisions ot�the Scate of California Business ¢
antl Professions Cotle, Di on 3, Chapter 9. . VALUATION m
PERMIT FEE $ ]
Signatura of m
Permittee ���� D. Downs s��/�./,(/f � PLAN CHECK 8 47.00 LL
Authorizetl ABent � u(/ � TOTAL FEE $ � / G"C./ o
� OWN E R
�� JOB ADDRES:
\�\ GENERAL CO
�� AP No. ],]
�INSPECTIONS
Pool Location
Forms
Main Drain _
Steel Reinforce
Elec. Bond _
AppYoval to Cover
Und�rground Electric _
Gas Piping Test
Filtering System Lines —
Backwash Lines and Recep.
ElecTrical Final
Heater and Vent Final
Filtef System Final
Backwash and Recep. Final
- - V� .
Lillard DATE (-11-
Lantana Lane BUILDING PERMIT N0.
nthon,v Pools DESCRlPTION of wORK Private poa
3 TRACT 18 FIRE ZONE VALUE $ 2500.00
Si nature Dote GROUP J TYPE 7
'L' -1j SUBCONTRACTOR PER
Dote
E ectric
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0•2- .p �6-1-73
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COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For Applicant to Fill in Coinpletely
ADDRESS — 4�'''�'w�
O W N E R' LILIdiRD BLYSTONE°
MAIL � y
ADDflESS (/
TEL.
CITV L � � NO. �y
CANSTRUCTION �`.�$h ,
LENDER
BRANCH
ADDRESS
AflCHITECT� �„' �{olodziej -����� Sp
CONTRACTOR �thonv Pool�
AD�RE55 J87� Firestone �ZVC1�•
CITV
South Gate No�'Sp32210
L C NO. 1JO17`3 LICVNO.
SIZE NO.OF BLDGS.
OF LOT I NOW ON LOT
USEOF residence 3RC1
EXI5TING BLDG. gai'�ugB
SIZE OF � NO. OF
NEWBLDG. ROOMS STORIES
EXTERIOR WALL ROOF
COVERING COVERING '
USE OF BUILDING AND WORK TO BE PERFORMED
private swim pool in rear of single
f2111j.1j� C�W@11171�
PAIO
JUN 11•73cns;�� 759� ***�35.00
' APPLICATION FOR BUILDING PERMIT
FiECEIV BV DATERECEIVED DAjpE�15 �J/
�'� ` �� %
A.P. NO. �S _�� 1� � PE M� .
BUILDING
ADDRESS 3ii12 LANTANA
`
TRACT 777 R LOT i 7R BLOCK
}S7C
OWNER �
usE .St41• COOZ
�
FIRE
20NE
APPROVE . _ _
NE ' P�O�nF� USE OF NEW
eUILDING �� P�L
VARDS�APPFOVED ' VAFDSAPPROVED
MAIN BUILDING ACCESSORV BUILDING
iOM C/L STREET) �p
]NT FT � Fl���_
DISTANCE BET.
MAIN BLDf3S.
VAR. #
C.U.P. #
BET. MAIN &
ACCESS. BLDGS.
DATE
APPROVED
„oTF G—�/-7
I hereby acknowletlge that I have reatl ffiis application and state
that the above information is correct antl agree m romply with
all laws regulating builtling construction, antl I shall not employ
any person in violation of the workman's compensation laws of '
ffie Sta2e of Califomia. '
I hereby ceriify thet I am properly licensetl as a contrac[ocunder SQ. FT.
the State ot California Business antl Professions Cotle, Divisicn 3, THE AMOUNT SHOWN UNDER V
Chapter 9, antl Ch licanses are in full forca antl effect, or I THE PURP�E OF ESTABLISHING A
am exempt m ffie provisions of Me ate of Califomia Business VALUATION
antl Profa ons Cotle, Division 3, Cb prer . ,
ZJ�OO�OO ' PERMIT FEE
Signa[u of _ �/ °
Permitte �LG�� i $ ' PLAN CHECK
Authorizad Agent �. G�/7c:.«�-l�i�/
TOTAL FEE
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