HomeMy WebLinkAbout2955 HARBOR BLVD - Building Permits „, CITY OF COSTA MESA
4 ► BUILDING DIVISION
>2t ,,,•„ ,, DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
4. fl I FieRMIT
!'' SB02-00152
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
SIGN PERMIT
Job Address: 2955 HARBOR BL Status: ISSUED
Suite: Applied: 12/16/2002
Vicinity: Issued: 12/16/2002
Parcel Nunmber: 13920302 Zoning: CL CL
:{.(/ __
ISSUED BY:
Applicant: BURKE, LAURI
Address: 3128 E CHAPMAN , . -
/ -,i ' Phone: 949-975-8367.
ORANGE,CA v Zip: 92869 , . -/
yr /
Owner: /SAFFELL'&-MC ADAM/ - - - < `` :N
Address�, BOX 349 , - - ”
_ - �' A C,'yA-
COSTA MESA CA . Phone: -�' �N
' / 2973 HARBOR BLVD, Zip: 92626-3912 j - ,, /
Contractor: CAREY SIGN' RAPHICS Ylog/
`
Address: ) 2871.BLUESTAR r ��
Phoned 714-630-8414 � •` / V '.
ANAHEIM CA Zip:-: 92806 _
^License -376085 ^ ` -� a v
) N ,, ` "
,,Address
i .. Phone:
7., ,
- _ I �72-",,
/ � , Zip:
�` License: �\ C
1 •^' if77;:- 7 /� SCOPE-OF PERMIT rt/rs\ ! V) '
44 SQ.FT. WALL SIGN'FOR"BOOR-OFF MARUKAI :L ,u,
FEE SUMMARY / ..i -
Plan Check $41.05 - • p ` " j! . Calc Valuation $1,80000 'I
6 . ' ` i ,/
Permit ' ' $63.115 /j,;' Claimed Valuation $1 800 00
SMIP Com: $0.50 (-- : _. 'i:._ -_,
Other $0.00 t - -- t
\'‘‘ $0.00 . >„ / /, ';�
Inspection \: v$0.00 ., ; ,. %,� •.,/ / r
$0:00 i. 74'
$0.00>_ J r -9, e/-/ y
/ i " = wi /
Total;`,-, ',/,$104.70 - " - c-' ' `
\‘‘.i,-� N - -'PLANNING&ZONING ' <=,`N < /;
/, - i1/4
NOTES: / --
?
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(6100)
DECLARATIONS j
WORKERS'COMPENSATION DECLARATION: -
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit Is issued.
❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed If the permit is valued et one hundred dollars($100)or less.)
❑ I certify that in the perform:: ••i 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 Ca.0 la,and agree that If I should become subject to the workers'compensation provisions of Section 3 00 of t Labor Code,I shall forthwith
comply with these provi y, s,
Applicant Signature: �------ Date: it IU O C.!
WARNING:FAILURE TO S E •- ERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PE TIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARE(Sl.7..0.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 license der 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.It Class N
Contractors Signature: Date: n
_.•••CONSTRUCTION LE4ING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued.(Sec.3097,Civil Code).
Lenders Name: - Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a chnll penalty of not more than five hundred dollars($500).):
// r
❑ I,as owner of,the property;ar 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 thrblighhis 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 Drivers License No. Expires:
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 California Health and Safely 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 aggermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? D Yes D No
(Section 65850.2 of the California Government Code requires that the requested Information be fumished 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
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.
Signature Of Legal Owner(s) 1 .-, / I LO
/Date-3
n r Authorized Applicant '/—�! t W(/Date
v
CODE L INSPECTION TYPE BAIL mums CODE( INSPECTIONTYPt RAIL lEMALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
v
200 Final Re-Roof 210 Final Electrical al
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place ►� /�A�/ 220 Final Planning Approval
203 Final Sign A7q V 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
�, o.. /6 r& "
of , ifa
.. .
• • • •
•
-- a
_ .(
M • • OO . • o E . M .
DIVISIO . BUILDING SAFETYM A R .0 K A 1
•
CITY OF COSTA MESA N
• APP,OVED 1tt \C\ ' 'cxt% re- wo•J
SIGN LAYOUT SCALE: 'r4' —�iJ`-0� \ " '7 (" �:t•�� -
• MUST bB kept co this job at al Urines and it�' ' az ALIYa,IfP KMIE)TO Qp Awu.MCR
This 681 of plans and SPBL7TM8110os • • .m,AtrICaAmax Na
wl MI-CAI
from the r.• - OAmxNait I-CAIWAND.
am a2Aerffiioflof153nIo w9lgrlvtilenP +�^ 1449/1.140ArtA 1 SC ELb As RE01l1tf0
' make -a M0wT AS UMW
AS
INTERNALLY ILLUMINATED CH d4NE€ RS q�ptp7beheldtop�ltulato = '1 NE .�VOUS=GTO .Napa..0
AND LOGO.' The stamping oftt�Planandspe otcosTtehakordmato:� "'""`m• °°""° e.000T.
OVERALL HEIGHT: 34" of the violation atany provisions ofany Cm % ANCHOR "2y,' r WflftD WU, t
OVERALL LENGTH: 16,-C" • These Plans and permit shell Ore by foliation end become !' 'A I w,. UMW n ro" *ASR
SEE ATTACHED DRAWINGS FOPQ and maintained active per L)� t� nA,e.mu D Ea SCUM w u[2u EKiCAUQ
1/2"FLEX TUBING Ram%%aND00A SD..ny
UM 04101R ea r MAEY 1 SCa1oA[Y
u.M DM r,.MYC
c�n _�-y�(/' UL LISTED 24 GA CLOWTo se,„leaf 'T°"s.pi �rtAAsrwAMEi sa
Ralf/(,'W I✓� t TRANSFORMER BOX
I
. APPROVED
I �
CITY OF COSTA MESA
PLANNING DIVISION
SUBJECT TO BLDG. DEPT. REG. 'SM t5mm NEON 1U3tNG
NOTE: ADDITIONS, DELETIONS, WM
ALUM.LETTER
OR CORRECTIONS SHALL BE
APPROVED BY THE PLANNING� DIV.• SIDE NEW CONSTRUCTION DETAIL - NTS
Illi
BY: A/ /� ;,. DATE: 121/441----
/�l441- �; 1i �.g Ootc- c>,•' rviA'cutc,►
I
/� ry x APPROVED ares®R.
• San
■ C.., OMj274/O'L M'® l
/� -kat NMIasCsus SA� s/w FM,�tt3In. ® ✓3A Kett aE...ow.w
26 ' SEs Se=.oOM FAX Mg=om C TA Ol ESA, CA-
6T11TE uc[A[[1(0. f . •
1' 1(
L0 '
•Harbor Boulevard 1 „ .
toe' ui'
s,
Q0 Q
loonroys JJ M v.., ,'.r sum/
Mv+vwnsar sicyJ II v
2947
SE Fern n y Space Available 1,210 s/f
12
Baker St r-, . a
z
0
10
In
N
'Q' -13�uaiwG-
C A n G -
-suitow& $VlLD,PJC— .
9
7 8
• Market 2 3 4 5 6.
1. MARUKAI MARKET 7. Supercuts
2. Mail Boxes Etc. 8. Sewing Machines
1 3. 3-Day Blinds 9. BOOK-OFF MARKAI
: 4. Dentist 10 Tanning Salon
5. Little Ceasars Pizza 11. Cleaners
• 6. Taller-Alterations 12. Mag's Donuts
Costa Mesa Ca. 92626 & Bakery
t1019
dlt tie-
usei9 ti• #74XS CM Pia*Co) ®f81@<4i>
80 1000 T 1025 2586 151 �:1
7 PAM.1 Loo e/tl 1 11u l d/o l t.'
1 Lai/al 1
C '_ C
r
1:-
41i 'KO
n--gi
---- / �
�JResy�s t� l ° I- d
IMO 11E9 M1 ` J 191 EOM ''pp ¢,t�, �rtPr,f
331019 °� ' N- . wit
IE�f�@<qq> 130 33101 it �4° 4j'1 6o. .. �Q�
—FLRu*711., low-13/4,2-1s' A Y• 4- °� Q. 9A0 4
I if
%/'may ` 4, Ac$(9r'�'G'
M1 , .[�, N
II (%a' f S=1/so 11019 `�' FS P
lima -ekts
vs,
8820 6700 %e, 'lib
4%1kt T�
ruby pie 1 aribs a/o 1 - ,4‘411-1,1t
la f 1 ,
5 5 5 asoo 5 J' 13 5 5 age 5 tl Si
444
1 HUI bin Ltt ,-01 1 0845/8'1 1 / ty
EE e I le %' t .+ Ns/ _
= -.......„.............................
GCI`], 0_ : n . . .. . . . . . . . . . ....... . . . .;.._ .•O�� 4-
(P. --N) .riri., tl tl!UMW
tl t�YgG g I I i lA 5 g tl• '�9
—.. I_ � �t— I1 Trin!S'u��t�l� Lr 1 I I H Wt > 4is.t—s S1PEllCUTS
jr
4 4
' nl u, '.
• _ r i
in®s=t/loo LST®s=t/t00
1 1392®s- FJ19-i?3 881812E43/12 F
X t101: SF.1LH O± Wit•hai0$. :R 4Clt/ie. Ritt!tht$(:11140SROJttI
0 L71•+I4 i4(.tek 'cN'4f>7=a 711.a8UTh-a* BOOK OFF FC MARUKAI COSTA MESA g
x SIEMS*zM Cf416*U1.1't Id. t-a(,dbft itRica tl(i ffitC'*. 'J i fljLgg mm T TRIP �' D-PLAN
A 3:19 @u8>1L1Jr3ZI&')i- Ff*$@LSOttEFl@O.t O5 g IYTF4 0?/l63Nt
_
2002332.06 1/100,60 7
X ti- Fit2B*D"3112• fit:t )fhI t(mffitmo �oS inch 3 T •. " '' D85GN DRAW
I.... . Shioaawe
t61(0!/
ii
.
• • • • • •
en a BOOK• OFF M
I. MARUKAI
Slcsry LAymrT 7/8"= I `-oil SII til
/ 4974, .461 yip?
- 22' o�� / a �. aa'- o" / 004 8/4' '4
/ �r(���'✓ °" �I 0 .f S (pry b '/ • -° Q, r c�`/k
• i. ti
til ifil
f 4� 5 �
a
. ••
* BOOC.O .
4247 toffil1
BOOKKA1 aS_____MARUKAI .. II
F$ ■ MOM
3 ._ i ...: rr� e:.y :;M m ;. a„ ..
.. .. arta MlI• # dfrit i1!1 ___
�re� l r�ran o
sE
- - ___ _ - - -.. . ._. -
-AST eL_E. 17C9N1 N(ACTH E E-v '1oN •
/a" = i'-o" Ya" _ ( L-°`"
L11i1 1`'' `-SIC• OFT— .
SCALE• DRAWN BY: APPROVED BY:
r NoTSD
DATSE
un � �� E:
REVD:
J4 pZ
2871 BLUE STAR STREET DRAWING NUMBER
ANAHEIM,CA.92806 ' 1 (+A rZ i on 7-MAKE ✓<._ .
(714)630-8414 FAX(714)630-8801 s� ,9
s A c .
E-MAIL csg@careysigns.com \
STATE LICENSE Number 376085
CITY OF COSTA MESA _
4/ ► BUILDING DIVISION
..4' DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
iIE ar
PERMIT E02-01104
SbotooRana 6.
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 2955 HARBOR BL Status: ISSUED
Suite No Applied: 12/16/2002
Vicinity: Issued: 12/16/2002
Parcel Nunmber: 13920302
Applicant: BURKE, LAURI - - - - ISSUED BY:
Address: 2871 BLUE STAR - -
X71 '- - Phone: 714-630=8414
ANAHEIM CAS'' - - Zip: 92806 % � 'N
i
Owner/ SAFFELL'& MC ADAM- , "N- , ��,
Address'/'BOX 349 V - -
7i V
' COSTA MESA;CA.' Phone: ' % 1(1,
4
/ X2973 HARBOR BLVD Zip: 92626-3912 N 7 /-
°� .
Contractor: CAREY SIGN GRAPHICS - #' `,
Address: 2871 BLUE STAR-
_Phone: 714-630-8414
- ANAHEIM CA , ''/ ' ' Zip: 92806 , :y '
z .
- License: 376085 -,�
_ - \ ,\
r. - SCOPE OF PERMIT - _. ,
- REF:SB02-00152.ILLUMINATED WALL SIGN FOR"BOOK-OFF".2 SIGN CIRCUITS.
FEE SUMMARY
Quantity /� :A / Quantity ' i - - 5 ,
'ISSUE FEE . - $23.50 .., ' -Temp Dist System/Lighting-- $0.00 0 '- , .,
l 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 A $0.00 0 ' /-1-- up to 10 kva/kw $0.00 .0�
Ligh5ng Fitts ' ' `\ �
\; $0.00 , 0 -; - �', ;up to 5o 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 App/, - - 50.00 1 0" R - Low Voltage Equipment '- $0.00' 0 / ,
' Res Appl - ' $0.00 0 - Low Volt Wiring System/Ckt -$0:00 0 , ,/
Service to 200a (///./ 50.00` �,0 Misc.`-Conduit �. -$0.00,7' 0 "/
Service to 1000a y �/� $0:00. -0 N;/ Misc:Conductor --- $0.00 y<0 /%
Service over 10006N .-,, , ,$0-00` �0`- "r ' Circus(gen or ride) - " - ",$0.00, �0
Motors to lhp 'V ,- $0.00 0 ' - Circus(mech ride or lights) ',v $0.00- /-0 /
Motors to 10hp N '- $0.00' / '' 0 _ Christmas Tree Stand. " `''- $0.00 - /0
Motors to 50hp ' _$0.00`' /," 0' ,, Fireworks Stand%, I v' `. '$0.00%% j0
Motors to 100hp `x$0.00 -' '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
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord.No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or If work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754.5626
2446-46(Woo)
DECLARATIONS.
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
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
' aork 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:
mar: 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 performan ,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 Car •r a,and agree that If I should become subject to the workers'compensation provisions o Section 700 of the Labor Code,I shall forthwith
comply with these• dvi),.. / ca
/7
Applicant Signature: Date: /� I UN 0
WARNING:FAILURE TO SE .RE W. E.. •• PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PE TIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOUARE(S1• 000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under visions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Llc.ft Class It
Contractor's Signature: Date: VS1116 ft
CONSTRUCTION LENDIN GENCY:
❑ 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 Ucense Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professioas,Cade)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).):
v , ,
❑ I,as owner of the'properdrrry,'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 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 Contracto' Ucense Laws.).
❑ I am exempt under sec. Business and Professions Coda 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 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 a_aermit for such construction or modification
from the South Coast Air Duality 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).
6 Will any part aihe 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 11 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 Safely 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.
Signature Of Legall
Owner(s) 12'l r ,f(ye Date
OILSorized Applicant ,{,(/ Date
CODE r INSPECTION TYPE PETE MALI CODE( INSPECTIONTYPE PAIS 1NT1EAka
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