HomeMy WebLinkAbout1815 TANAGER DR - Building Permits Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
CITY OF COSTA MESA CONSTRUCTION PFR,MIT — PERMI O. TRACT NO. LOT NO. UNIT NO. 3531] 4/21/15 Ti
Project Address �� ///�({/�n(__o'y/y/�+ //A�i"r'' c23v t/
*Project
Mailing Addr ss (J ///l" Y.n TYPE OF CONSTRUCTION LI NEW Li ADD Li ALTERATION /Q REPAI R
P ❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P.yy. I Zone
Owner's Name �//�I7 L1.Pl� Phone DESCRIPTION OF WORK/USE OF BLDG.
Address •'V S Main Building: Accessory Building:
•Arch/Eng. License No. TYPE OF PERMIT Li GRADINGz I'`OUNDATION ❑ STRUCTURAL T Front ZO
•
Address �p(T]�/` (//J/]onM/�/�\/ ❑ TENANT ❑ ELECTRICAL 'U PLUMBING ❑ MECHANICAL B Rear N
,I� . A. ' / . .fi-� {M1• ! !X ❑ OTHER A 1
Contractor's.Nam �� .hone
. /• II'I• n1 fr ts./ • PROJECT DESCRIPTION SQ. FT. OCCUPANCY C Right N
Address(mailing)
nsN / :,, .9 arm/ CON ST RUCTION TYPE VALUATION$ R
K Left
•
City License No: - S
ZONE GRADING CU.YDS. ACRES Ping. Ref.4 Parking Req./Provided E
LICENSED CONTRACTOR DECLARATION - 0
I hereby affirm that I am licensed under provisions of Charter 9(commencing Remarks: Planning Notes: M
with section 7000 • Division 3 of the Business and Professions Code,and
my license is In f if • i nd effect. 1 I T
License . . _ . , , e I RECEIVED APR 1 6 1986 $
Date �•0. —I/4 Signature � AtArg i '_ L/'a; PLUMBING FEES
/
WORKERS'COMPENSATION DECLARATION
Bar Sink Showers
I hereby affirm that I nave a certificate of consent to self-insure or a certificate ELECTRICAL FEES
I of Workers' Com 'qiL Ins nee, or a certlfi d COPY thereof (Section
BackPreventerflowService kflSink
3800, Lab. C.) ____ , f /, O, Automatic Washer Transformer 0 15-50 KW
Policy No- Company C �,(�{(i(i(� Backflow Irrigation Sewer Cap Construction Pole Sub. 0 50+KW ••
�, I�y1 mortified py is hereby fu shed.
LWCerti e o filed with the city 1 iron. /.//� /�����`���` //,11' Bathtubs Sewer Connection Cooking Unit • Meter Duo to 100 amps
Date /J•' '( Applicant 0./.Q ail.
'
EXEMP IO FROM WORKERS'COMPENSATION DECLARATION Clarifiers Solar Collectors Dishwasher Meter-Dover 100 amps
(This section need not be completed if the permit is for one hundred($100) or
less). Dishwasher • Solar Piping Dryers OGas ❑Electric Sub Panel
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 Drinking Fountains Solar Tank Fan Motors 00-1 HP ❑1'/z-8
Workers' Compensation Laws of California.
Date Signature Floor Drains Swimming Pool w/Spa F.A.U.'NOTICE:If,after making this declaration, you should become subject to the Inc.Solar 09-15 HP 016-15+
Workers' Compensation provisions of the Labor Code, you must forthwith - Floor Sinks Urinal Fixtures Microwave
comply with such provisions or this permit•shall be deemed revoked.
CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet Device Boxes
I hereby affirm that there is a construction lending agency for the performance Pole Light
of the work for which this permit Is issued (Section 3097 Civ. C.)
Interceptors ] Water Heater �OU Outlets
Lender's Name Range
Lender's Address • Kitchen Sink Water Service - Switches Sign
OWNER BUILDER DECLARATION -
I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash Garbage Disposal
following reason (Section 7031.5 Business and Professional Code: Any city or • 9 sP ,Standing Sections
county which requires a permit to construct,alter,improve,demolish or-repair P—Trap Laundry Trays Generator ❑0.5 KW❑5-15 KW
any structure, prior to Its Issuance, also requires the applicant for such permit Trash Compactor
to file a signed statement that he/she is licensed pursuant to the provisions of Roof Drains -
the Contractor's 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 any applicant for a permit subjects the applicant to a civil
penalty of not more than five hundred dollars($500).
LJ I, as owner of the property or my employees with wages as their sole Reinspection Fee I $15 Issue Fee $ 3
compensation, will do the work,and the structure Is not intended or offered - Reinspection Fee $15 Issue Fee $ 3
for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES
License Law does not apply to an owner of a property who builds or improves
thereon, and who does such work himself/herself or through his or her own DEVELOPMENT SERVICES REQUIREMENTS:
employees, provided that such improvements are not intended or offered for Boiler Hood or Type I D
sale. If, however,the building or Improvement Is sold within one year of com- - Canopy Type 11 ❑ ' Zoning Approved By Dare
pletion,the owner will have the burden Of proving he/she did not build or Im- Duct-Under Ground Building Approved By Date
prove for the purpose of sale). - v 2/ 60
❑ I,as owner of the property,am exclusively contracting with licensed con- Duct-Structural Refrigeration System - Application Issued By nate 1`~ -O
tractors to construct the project (Section 7044,Business and Professions Code: `
The Contractor's License Law does not apply to an owner of property who Duct-Ventilating • - 00-100,000 BTU ❑100,000 BTU SUMMARY OF FEES
builds or Improves thereon,and who contracts for such projects with a con- _
tractor(s) license pursuant to the Contractor's License Law). I am aware that Exhaust System ❑ Multiple❑ System Repair/Alteration _ BUILDING PERMIT $ SMIP $
proof of their Worker's Compensation insurance should be provided to me. �' PLAN CHECK $ �Y n �.} PERMIT
0 1 am exempt under Section B.& P.C.for this reason — Firepl/Fact.Blt. ICBO 4 Fire Dampers .. •
• PLUMBING $ vY(J ISSUANCE $
Date -. Owner Heating System& Ducting Registers PLAN CHECK 25% $ ENERGY P.C. $
I hereby certify that I have read this application and state that the above 00100,000 BTU ❑100,000BTL •
GRADING •$
information Is correct. I agree to comply with all city and county ordinances . ELECTRICAL $
and state laws relating to building construction, and hereby authorize repre- • MICROFILM $
sentatives of his ity to enter u•on the above-mentioned property for , PLAN CHECK 50% ,$
inspection p s•�1 / n Q/ MECHANICAL $ TOTAL FEE $ '6700 •
TOTAL�/ .
Pink -Accounting; Goldenrod -Assessor
CONSTRUCTION AND PLANNING POOL &SPA
APPROVALS Permit# Date Inspector APPROVALS Permit# Date Inspector
17 Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3..Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement •
56. Rough Plumbing & Pressure Test
6. Electrical OF ER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines,P-Trap, 0 Undrgrnd.
10.-Structural Floor System 61. APPROVAL TO DECK
•
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit - 66. Solar System-Final
16. Rough Electric Wiring - 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 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 ❑Oil
23. Gas Pipe-Rough & Test 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:9 87 °Gna .s 45
pee 203 U et item
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 f fl
^
40. Gas Service-Final
41. Solar Domestic-Final ,71
42. Backflow Preventer )
43. Backflow Irrigation v�
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations -O
47. FINAL STRUCTURE & BUILDING •
48. Special Requirements Completed
49. Electric Release to Edison - - •
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. • Date'
CITY OF COSTA MESA REQUEST FOR OCCUPANCY
TRACT NO. 0 66 a DATE 296 0 /97Z
LOT NO. ,/,/
ADDRESS /8.3' 77harnan .a e
The developer of the above entitled tract desires to sell 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-•S
(was or advised that this tract has
not been given final inspection nor has it been accepted by the City of Costa
Mesa as having complied with the conditions of approval which were imposed by
the city at the time the final tract map was approved.
The city assumes no liability for the enforcement of the conditions necessary
for approval other than those conditions protected by surety bond.
The undersigned agrees to indemnify and hold the city harmless from any claim
resulting in damage or personal injury to the undersigned by reason of the
aforementioned uncompleted condition.
,, j 2
Purchaser
BY igfen04r9
RECEIVED Developer and/or authorized
CITY OF COSTA MESA representative
PLailPI!^:^ r
AUG 30 1972 BY L. A aaeed�k-
Airtf
PM Lender
V1619E1QItil 11121314!516
OWNER 1ST LOS Angeles Corporation DATE 3-13-72
JOB ADDRESS 1815 Tanager Drive BUILDING PERMIT NO. 34260
GENERAL CONTRACTOR The Buccola Co. DESCRIPTION of WORK Res.w/att.gar.
AP No. LOT 11 TRACT 6663 FIRE ZONE VALUE $ 31, 500.00
INSPECTIONS Signature Date GROUP J&J TYPE IZONE
SOIL /1/j ats ?,-41--7 PERMITS IS ED
GAS SUBCONTRACTOR
Date I Number Signature
WATER t/q iJcsJ1 .?L ��Plum•in•
ROUGH PLUMBING !L/ `ab2-. /, AM11�i� ��'��/�`S�
PROP. SWR. LINE ❑ HOUSE CON. 0 17_,,t) r�� PL , , • ?i--„21-72 4/7Z c, ''"-
SPRINKLING
SPRINKLING SYSTEM
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING A7c2, 4/-7,2t
TEMPORARY SERVICE OR POLE ((
UNDERGROUND ❑ POWER ET
ROUGH WIRING r _ 4i A
i eating and Vent.
TRENCHES n FORMS ❑ STEEL REINF. d Y //� o.. Cl�J��� 7_/0-7.o 9O.L •------
FLOOR SYSTEM f-' e "J.0 7,�'� 1,(x /� • 7_ -7g qr -"-
BOND
BOND BEAM n STEEL REINFORCE n ✓A / /
SHEATHING 41 . .97 if
FRAME AND FLASHING 2.11M/ST/ST
LATHING - IN OUT 1.' R 7V
PLASTER, BROWN COAT
STRUCTURAL, FINAL A _., _
HEATING, VENT., REFRIG. AND A.C., FINAL gr / f1/1/107 iv 77 -i• -.A ,, .6
PLUMBING, FINAL AND GAS TEST In S -7
ELECTRIC, FINAL .8,.14.7.2-
PLAN NO. 8AR 34260
LOT NO.COSTA MESA BUILDING-SAFETY DEPARTMENT AR � - 77Ems: 882* *** 161.96
P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626
For Applicant to Fill in Completely APPLICATION FOR BUILDING PERMIT
RECE Y DATE RWEIVED DATE ISED
BUILDINGADDRESS j4;19/5-- Tanager Drive �i�"��� ,j, ��
PERMI3QI}2 r
OWNER 1St LOS Angeles Corporation A.P.NO. v'tLOI.
MAIL BUILDING
ADDRESS#1 Wilshire @ Grand ADDRESS/1'5ZjV,ss C,e ,Ofl OE
z
CL L) CITY 1 Los Angeles NO. 625-7341 TRACT 6'4-3 f LOT/*/ BLOCK
d m NEWM
IADD ALTER REPAIR IMDVING DFDLLSH
Z H LENDER ‘./.7 1St Los Angeles Corporatiot
.J D BRANCH ��// //nJ'�
J N OWNER /C' - G., W�
m J ADDRESS# 1 Wilshire @ Grand yALUE
J Q OR ENGINEEREarl G• Kaltenbach TEL.547-8046 ""f}�'� 'G / $ '
NO
UN
FIRE
Or
W 0: ADDRES�I)23 E• 17thr Santa Ana ZONE T E /7 GROUP
d i., APPROVED
W Z CONTRACTOR The BuccOla Company BY DATE
JO
CO
J R ADDRESSI4SO1 Birth Street
W W TEL ZONE NO.OF USE OF NE 1WeET•G/�A17.
Z t CITY Newport Beach ND.54o-8833 ,-/ Pt-°•NSe2 BUILDING, , G.T.e
STATE CITY YARDS APPROVED YARDS APPROVED
LU O 21
LIC. NO. 146423 LIC. NO. 04 MAIN BUILDING ACCESSORY BUILDING
SIZE NO.OF BLDGS. (FROM Ch.STR STREET)
OF LOT 7O I X 1001 NOW ON LOT O FRONT Cot FT. FT.
USE OF r
EXISTING BLDG. R SIDE J FT. FT.
Z NEWBLOG?r165 sq .Lt ROOMS 10 STORIES 1 L,SIDE ' FT. FT.
Q EXTERIOR WALL ROOF
Cl COVERING COVERING Shake REAR ,a.7 FT. FT.
-i USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN&
O.
a / MAIN BLDGS. ACCESS.BLDGS.
Q / VAR.IIs DATE
0N40/ ✓ Ei�L�yc�/ ,, C.U.P.# APPROVED
N %/j APPrlyROV p /, /117 DATE al al V,7
o 'HOLD F9.SPECIAL REQUIREMENTS
UI hereby acknowledge that I have read this application and state STATE e?;t 9 /_/
D that the above information is correct and agree to comply with c F�
CCall laws regulating building construction, and I shall not employ a 2/ 1 / y
en any person in violation of the workman's compensation laws of
y //1¢� /
the State of California.Calliforniaw
qqY W
co
zI hereby certify that I am Properly licensed as a contractor under O.FT O
the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR
Chapter 9, and that such licenses are In full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: a
CC
am exempt from the provisions of the State of California Business
VALUATION
and Professions Code,Division 3, /Chapter 9. • PERMIT FEE $ /aO -679 Nm
Signaturermof �� �j�\\ /,t, ./1,�.�. /�Q� / ^� e
Permittee :i \/J Vs`^-15 - $ / PLAN CHECK $ ✓3. Q.S E
O
LL
Authorized Agent TOTAL FEE $
/ 7S
4
CITY OF COSTA MESA
BUILDING DIVISION - -
Y DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
F1
k *
PERMIT
' tter ✓B01-01738
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 1815 TANAGER DR Status: ISSUED
Suite: Applied: 10/30/2001
Vicinity: RESIDENCE AND ATTACHED GARAGE Issued: 10/30/2001
Parcel Number: 13963108 Zoning: R1 R1
Applicant: INDRIKAS, JANIS TR ISSUED BY: •
Address: 1815 TANAGER DR •
Phone: 714-424-0963
COSTA MESA, CA • Zip: 92626
Owner INDRIKAS, JAMS TR
Address 1815 TANAGER DR
Phone:
COSTA MESA,CA Zip: 92626
Contractor: OWNER-BUILDER •
Address:
Phone:
Zip: License: 0
•
Arch,: Eng:
Address: Address:
Phone: Phone:
•
Zip: License: License:
SCOPE OF PERMIT
REROOF:T/O EXISTING WOOD SHAKE ROOF, 1/2"OSB PLYWOOD SHTG OVER SPACED SHTG,40#BASE FELT,
INSTALL METAL DRIP EDGE,APPLY CLASS A 35-YEAR"ELK PRESTIQUE"DIMENSIONAL ASPHALT SHINGLES AND
DURA-RIDGE TYPE CAP.3700 SQ FT
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $6,000.00
Permit: $125.25 Claim Valuation: $6,000.00
SMIP Res: $0.60
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $125.85
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: •
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 end final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
•
DECLARATIONS
WORKERS'COMPENSATION DECLARATION: '
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑ 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'compeggation Insurance carder and policy number are:
Cartier: Policy Number:
(This section need not be completed If the permit Is valued at one hundred dollars($100)or less.)
❑ 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(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).
Lenders Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I em 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 fora perr.
sub] the applicant to a civil penalty of not more then five hundred dollars($500).):
I 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(Soc.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 a 11�under sec. Business and Professions Code for this reason:
Signature: G1... Date: 3 0 Lkto ber a 00 I
Owner ID vent*by drivers license. 0 Yes 0 No Driver's License No. Expires: I I– 03
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 ❑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 Masa 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 apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 0 No
(Section 65850.2 of the California Govemment 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? ❑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? ❑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 an ordinances relatin to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-descri d pro rty for inspection p oses.I ag e not to/occup r allow occupancy of any building authorized by this permit un 1 fine nspection.
Oti.. �`—ya[4 ' 30 UC i\O\b�'C 2.00Signature Of Legal Owner(s) . Date
And/Or Authorized Applicant Date
CODE I. JNSPECRONTYPE PAIS 11)IIDAL$ CODE* INSPECTION TYPE PALE JN1mAL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final �1 � 208 Final Plumbing
200 Final Re-Roof JI'27
o-2o11; 210 Final Electrical
201 Final Block/Retaining Well 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