HomeMy WebLinkAbout619 WILSON ST - Building Permits� ,
CITY OF COSTA MESA (� ,;.0, v V
� "'FS B!/ILDING DIVISION �`�� u
't�� �7 FAIR DRIVE. COSTA MESA. CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
t
° � FOR INSPECTIONS CALL: (714) 754-5626
�4"°�"°*� PERMIT NUMBER: E10-00214
PERMIT TYPE ELEC
APN: TPN007218
JOB ADDRESS: 619 W WILSON ST CM
V'�cinity:
STATUS:
DATE ISSUED:
ISSUED BY:
Suite/Unit:
FINALED
0 911 012 01 0
KJB
SCOPE OF WORK: 100 AMP METER PEDASTAL FOR AT&T. REF: ENCROACHMENT PERMIT PS�0.00377. ENC PERMIT IS AODRESSED
AT 2240 MEYER PL,
OWNER: CITY OF COSTA MESA
PHONE:
APPLICANT: HARPER, BENJAMIN
PHONE: 951.520-0434
CONTRACTOR: HARPER ELECTRICAL CONTRACTORS INC
Address: 704 DRY GULCH PLACEUnit:
Ciry/State: NORCO, CA ZipCode: 92860
ELECTRICAL PERMIT FEES
Electrical Plan Check Fee: $0.00
Electrical Permit Fee: $72.20
Reinspection Fee $0.00
TOTAL FEES $72.20
Address: Unit:
City/State/Zip:
Address: 704 DRY GULCH PLACE Unit:
City/State/zZip: NORCO, CA
License No. 779882
PHONE: 951 •520-0434
CELL:
NOTICE: The work authorized by this permit shall comply vnth all applicable handicap access requirements 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 oblain inspections and final approval will result in the expiration of this permit.
COOE�. INSPECTIONTYPE 0_�i� IN1111A1 � INSPECiIONTYPE 0� INT17Ul
1616 Fixetl System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing �
200 Final Re-Roo/ 210 Final Electrical �v �U ��� �
201 Final BlocklRe(aining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demoliti0n 250 Final Building/Occupancy
WORK� A D RATION:
I hereby rm un ry one of Ihe (ollowing declarations:
❑ I have and vnll maintain a certificate of consem to self-Insure for workers'
compensation, as pmvitletl (or by section 3700 of lhe Labor Cotle, for the
pertormance of the vrork tor which Ihis permit is issued.
❑ I have and will maintain workers' wmpensation insurance, as required by
section 3700 of Ihe Labor Code, for Ne peAortnance of the vrork tor which Ihis
permit is issued. My workers' compensation Insurance carrier and policy
number are:
Cavier:
(ihis secfqn neea nof Oe [omdetetl Alhe permrt k value0 ar one nundretl tlollars (5100) oNessJ
Policy Number:
❑ I certify ihat in the pertormance 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 o/ Califomia, and agree Ihat if I sh0uld
become subject to the workers' compensalion provisions o( Section 3700 0!
Ihe Labor Code. I shall forthwiM comply vrith Ihese provisions.
Applicam's SignaWre Dale
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINA�
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLL4RS
($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 affrm that I am licensed under provisions of Chapter 9(commencing
with Section 7000) o( Division 3 of the Business and Professions Code, and
my license is in full force and eftect.
Lic. # Class #
Conttacmr's SignaWre Oa�e
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a consiruction lending agency (or [he
peRortnance of [he �+ork (or wfiich this permit is issued. (Sec. 3097, Civil Code�.
Lender's Name:
Lender's Adtlress:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that untler penalty of perjury that I am EXEMP7 FROM THE
CONTRACTORS LICENSE LAW fOr the (ollowing rea50n (SeG. 7031.5.
Business and Professions Cotle: Any city or county vmich requires a permit to
cons[mct, alter, improve, demolish, or repair any struclure, prior to its
issuance, also requires the applicant for such permit to file a signed statement
Ihat he or she is licensed pursuant to Ihe provisions of �he Contractors
License Law (Chapter 9(commencing with Section 7000) o! Division 3 of the
Business and Pro(essions Cotle) or that he or she is exemp[ there(rom and
the basis for the alleged exemption. Any violalion of Section 7031.5 by any
applicanl for a permit subjecls the applicanl to a civil penalry of not more than
five hundred dollars ($500).):
❑ I, as ovmer of the property, or my employees with vlages as their sole
compensation, WILL DO THE WORK, and the slructure is not intentled or
oHered for sale (Sec. 7044. Business and Protessions Cotle: The Contrectors
License Law does not apply to an ovmer ot properry who builds or improves
thereon, antl who does such work himself or herself or lhrough his or her own
employees, provided that such improvements are not intendetl or ofteretl for
sale. If, however, the building or impmvement is sold within one year of
completion, the ovmervbuilder will have the burden o! proving Ihat he or she
did not build or improve for purpose of sale.).
❑ I, as owner of lhe property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to construct the pmject (Sec. 7044, Business and
Pro(essions Code: The contractors License Law tices not apply to an owner of
property who builds or improves Ihereon, and who contrac[5 for such pmject with
a contractor(s) license pursuant tothe Contractors License laws.).
❑ I am exempt under sec.
Business and Pro(essions Code for Ihis reason:
SgnaWre Da�e
305]A6 (3/O])
Owner ID verifed by tlriver's license. ❑ Yes ❑ No
Driver's License No. Expires:
Verifcation of Ownership by (type o( document, i.e. - property tax bill or tleetl):
DIVISION OF INDUSTRIAL SAFEN PERMIT CERTIFICATION:
❑ I hereby certify ihat no excavation (rve (5) or more feet in depth into which a
person is requiretl to descentl, will be matle in connection with work authonzed
by �his pertnit, and tha� no building strucWre, scaffolding, falsewurk, or demolition
or dismantling thereof, vrill be more Ihan thirty-six (36) leet high. (Chap. 32, Grp
2, Art 2, Sec. 347, Ttle 8, Cali/omia Administ2tive Code).
❑ As ovmer-builtler, I will not employ anyone to do vrork which woultl
require a permit from Ihe Division of Indusirial Safety, as noted above, unless
such person has a permit to do such work from lhe division.
Applicant's SgnaWre
Division of Intlustrial Safety Permit Number: _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant need to file antl
certify a Business Plan for emergency response to release or threatened
release of a hazardous matenal? ❑ Yes � No
(Section 25505 0! ihe Cali(omia Health antl Safety Code requires, with some
exceptions, that a Business Plan be filed vnth the Costa Mesa Fire
Department by every business which has at any one lime during a reported
year a quantiry of hazardous materials equal to or greater than a weight ot
500 pounds, or a volume of 55 gallons, or 200 cubic feet o( compre5sed gas
at stantlard temperature antl pressure�.
2. Does or will Ihe applicant or present or (uture builtling occupant neetl to fle
a regisiration form for acutely hazartlous matenals? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some
exceptions, requires registration with Ihe Costa Mesa Fire Depatlment by
each business which at any one lime has on han0 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 s[andard
tempereture and pressure).
3. Does or vnll Ihe applicant or present or (uture building occupant need to
prepare an RMPP (Risk Management and Prevention Program tor awtety
hazardous malerials)? ❑ Yes ❑ No
(Section 25534 of the Califomia Health and Safery Code provides tha[ the
Cosla Mesa Fire Depariment may require the preparation, certifcation and
filing with the Fire Department of an RMPP by businesses which are required
to regis�er acu�ely hazardous materials wilh Ihe Fire Depanment.
4. It an RMPP is presently required, has Seclion 25534 of Ihe Calilornia
Health and Safety Code been fully complietl with? ❑ Yes ❑ No
5. Does or will the applicant or presenl orluWre building occupani require for
the Work Which is the subject of this appliwlion a permit for sucn cons[ruction
or motlification from Ihe South Coast Air Ouality Management Dislnct or (rom
any other air polWtion control di5tnct or agency? ❑ Yes ❑ No
(Section 65850.2 of the Califomia Govemmem Cotle requires that the requestetl
in(ormation be (umished on applications for rron-resitlential building pertnits).
6. Will any part of the facilily to be constructetl under this permit be vnthin
1000 teet from Ihe ouler boundaries of a school? ❑ Yes ❑ No
Qf "yes", the facili�y mus� meet the requirement o( Sections 25534 and 42303
of the California Health antl Safety Code).
7. If a permit from lhe South Coast Air �ualiry Management District or other
air polWtion contml dishict or agency is required for the work which is the
subject of this application, have all of the disclosures prescribed by Califomia
Health and Sa(ery Cotle Section 42303 been made7 ❑ Yes ❑ No
8. (If yes", attach cenificale of compliance from the appropriate air pollution
control oKcer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
information given above is correct. I agree to wmply with all state laws antl
city ordinances regarding Hazardous Materials and Emissions.
SignaWre Dale
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalty of perjury that I have read this application and s[ate that
the information given is correct. I agree to comply vnth all state lavrs and ciry
ordinances relating to builtling construction, and authorize representatives of
the Ciry o� Cos[a Mesa [o enter upon the above-described property (or
inspection purposes. I agree not ro occupy or allow occupancy of any building
authorized by this permit until Mal inspection.
SignaWreofLegalOvmer(s) Dale
Ana/or AulM1onre4 AonLranl
CITY OF COSTA MESA
� � pMFsq BUILDING D/VISION
i�� 77 FAIR DRNE. COSTA MESA. CA 92626 •(774) 754-5273 • Fax (714) 754-4856 • www.ci.wsta-mesa.ca.us
f
° � FOR INSPECTIONS CALL: (714) 754-5626
�"°"°�fi PERMIT NUMBER: E10-00214
PERMITTYPE ELEC STATUS: ISSUED
APN: TPN007218 DATE ISSUED: 0 911 012 01 0
ISSUED BY: KJB
JOB ADDRESS: 629 W WILSON ST CM
Vicinity:
Suite/Unit:
SCOPE OF WORK: 100 AMP METER PEDASTAL FOR AT&T. REF: ENCROACHMENT PERMIT PS10-00377. ENC PERMIT IS ADDRESSED
AT 2240 MEYER PL.
OWNER: CITY qF COSTA MESA
PHONE:
APPLICANT: HARPER, BENJAMIN
PHONE: 951-520-0434
CONTRACTOR: HARPER ELECTRICAL CONTRACTORS INC
Address: 704 ORY GULCH PLACEUnit:
City/State: NORCO, CA ZipCode: 92860
ELECTRICAL pERMIT FEES
Electrical Plan Check Fee: $0.00
Electrical Permit Fee: $72.20
Reinspection Fee $0.00
TOTAL FEES $72.20
Address: Unit:
Ciry/SWte/Zip:
Address: 704 DRY GULCH PLACE Unit:
City/State/zZip: NORCO, CA
License No. 779882
PHONE: 951-520-0434
CELL:
NO710E: The work authorized by this permit shall comply with all applicable handicap access requirements under Calitornia statutes and related
regulations. (Ord. No. 92-28, § 1, 12-27-g2)
EXPIRATION: PERMI7 EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPEC710NS: In order for the vrork authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final appraval must be obtained. Failure to obtain inspections and fnal approval will result in the expiration of this permit.
L00� INSPECTONTYPE ORi IN RL 40oEt INSPELTIONTYPE pATE INTRULS
i616 Fized System Findl Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Finai Plumbing
200 Final Re-Roof 270 Final Electrical
201 Final BlocklRe�aininq Wall 212 Final Fire Prevention
202 Final Factory Fire place 220 Pinal Planning Approval
203 FinalSign 222 FinalSite
204 Final Demolition 250 Final Building/Occupancy
WORKERS' COMPENSA710N DECLARATION:
I hereby aHirm under penalry of perjury one of Ihe following declarations:
❑ 1 have and will maintain a cenifcate of consent to sel(-Insure for workers'
compensalion, as providetl for by section 3700 of the Labor Code, for the
Aorma ce of Ihe work for which this permit is issued.
ave and will maintain Horkers' compensation insurance, as requiretl by
an 3700 of [he Labor Code, for Ihe peAortnance of the work for which this
pertnil is issued. My workers' compensalion Insurance carrier and policy
number are:
Carner:
(This sedqn neetl ra( be mnpetetl athe perm9 is ✓dlued at one nuiWrcd tl�tlars (5100) a ieu f
Policy Number:
❑ I certify thal in the pedortnance of Ihe work for which this permit is
issuetl, I shall not employ any person in any manner so as to become subject
to Ihe vrorkers' compensation laws o! Calilomia, and agree that if I shoultl
become subjecl to the workers' compensation provisions of Section 3700 of
ihe Lab otle, I shall forthwith comply with these provisions.
O�h 2'.�i iYd1l _ �' (� (�
. ppli nls ignaNre ate
WARNING: FAIIURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SU&IECT 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, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aKrm Ihat I am licensed under provisions of Chapter 9(commencing
with Section 7000) of Division 3 of Ihe Business and Professions Code, antl
my license is in full force and eRect.
Lic. # � Class #
� �
Contractor's 'igna ure Da e
CONSTRUCTION LENDING AGENCV:
❑ I hereby affum that there is a constructbn lending agency for the
per(ormance of [he work fa wfiich ihis pertnit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lentler's Address:
Signature Da�e
OWNER-BUILDER DECLARATIONS:
I hereby affirm that untler penalry of perjury that I am EXEMPT FROM THE
CON7RAC70RS LICENSE LAW for the following reason (Sec. 7031.5,
Bu5ine55 antl Professions Code: Any city or county which requires a permit to
construcl, alter, improve, demolish, or repair any stmcWre, prior to its
issuance. also requires the applicant for such permit to file a signed statement
Ihat he or she is licensetl pursuant to the provisions of Ihe Contrectore
License Law (ChaDter 9(commencing with Section 7000) o( Division 3 of Ihe
Business and Professions Code) or thal he or she is exempt therefmm antl
Ihe basis for the allegetl exemption. Any violation of Section 7031.5 by any
applicanl (or a permit subjecls the applicant to a civil penalty of not more lhan
five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as their sole
compensation, WILL DO THE WORK, antl Ihe stnicWre is not intended or
oHered lor sale (Sec. 7044, Business and Professions Cotle: The Contractors
License Law does not apply to an owner of property who builds or improves
thereon, and who does such work himsel( or herself or through his or her own
employees, provided that such improvements are not inrendetl or oftered for
sale. If, however. Ihe building or improvement is sold within one year of
completion, the owner-builder will have the burden of proving thal he or she
tlid not build or improve for purpose of sale.).
❑ I, as ovmer o� the property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and
Pmfessbns Code: The cont2ctors License Law tices not apply to an wmer of
property who builds or improves Ihereon, and who contrac[s for such proleCt with
a cmiractor(s) license pursuant to the Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for this reason�
Owner ID verified by tlriver s license. ❑ Yes ❑ No
Driver's License No. Expires:
Venfication of Ownership by (rype of document, i.e. - property [ax bill or deed):
DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION:
❑ I hereby certify Ihat no excavation fine (5) or more feet in depth into which a
person is required to descend, will be made in connection with v.ork authorized
by Ihis permit, and ihat no building s[ructure, scaHdding, falsework, a demolition
or dismantling thereo(, will be more than thirty-six (36) feet high. (Chap. 32, Gry
2. Art 2, Sec. 341, Ttle 8, Califomia Administ2 We Code).
❑ As ovmer-builder, I will not employ anyone lo do vrork which vrould
require a permit from �he Division of Intlustrial Safery, as notetl above, unless
such person has a permi� �o do such work from the division.
AOP�icanfs SignaWre Date
Division o! Industrial Safety Permit Number.
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will �he applicant or present or future building occupant need lo file and
certify a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Ves ❑ No
(Sec�ion 25505 of �he California Health and Sa(ety Cotle requires, vnth 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 lo or greater than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feet o( compressed gas
at s�andard temperature and pressure).
2. Does or will the applicant or present or fuNre building occupant need to file
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of Ihe Califomia Health and Safety Code, with some
exceplions, requires registration with ihe Costa Mesa Fire Department by
each business which at any one time has on hand a quantiiy of acutely
hazardous materials equal to or greater than a weight o( 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
temperature and pressure).
3. Does or vnll the applicant or presen[ or future building occupant need to
prepare an RMPP (Risk Management and Prevention Program (or acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 0( the Calitornia Health and Safery Code provides that Ne
Costa Mesa Fire Department may require the preparation, certification and
filing with the Fire Deparimen[ of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
4. I( an RMPP is presently required, has Section 25534 of the Califomia
Health and Safery Code 6een fully complietl wi[h1 ❑ Ves ❑ No
5. Does or will Ihe applicant or present or (uture building occupant require for
Ihe work which is the subjec[ of this application a permit for such construction
or motlification /rom the South Coast Air Quality Management DiStrict or from
any other air polWtion control diStriCt or agency? ❑ Yes ❑ No
(Section 658502 of the Califomia Govemment Cotle requires that the requested
in(ortnation be fumishetl on applications fa rwn-resitlential building permits).
6. Will any paA of the facility to be consWcted under this permit be within
1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
Qf "yes", the facility musl meet the requirement of Sections 25534 and 42303
of the California Health antl Safety Code).
7. I! a pertnit lrom the South Coast Air Quality Manaqement Distnct or other
air pollution control tlistrict or agency is required for Ihe work which is the
subject of this application, have all of the disclosures prescrihed by Calilomia
Health antl Safety Cotle Section 42303 been made? ❑ Yes ❑ No
8. (It'yes", attach cenifcate of compliance trom the appropnate air pollution
coMrol oKcer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
information given above is correcL I agree to comply with all state laws antl
city ortlinances regarding Hazardous Materials and Emissions.
CERTIFICATE OF COMPLIANCE AND AUTHORIIATION OF ENTRY: I
certify under penalty o( perjury Ihat I have read this application and state that
the information given is correcL I agree to comply with all state laws and city
ordinances relating to builtling constmction, and authonze representatives o(
the Ciry of Costa Mesa [o enter upon the abovetJescnbed property (or
inspection purposes. I agree not ro occupy or allow occupancy of any building
aulhorized by Ihis permit until fnal inspection.
A_ SlgnaWreofLe al wner(s) D �e
$ignawre Dale �� �� _ g a a
305)-46 (3I0]) ��p� quth ri etl Appl¢ar�Y � Dale
CITY OF COSTA MESA
BlIILDING DIVISION
DEVELOPMENT SERVICES DEPARTMENT
PERMIT
(774) 754-5273 • Fa�c (714) 754-4856
Job Address:
Suite No
Vicinity:
619 W WILSON ST
MEDIA ONE CABLE N BOX
Parcel Nunmber: TPN990155
npp�icant: MEDIA ONE
Address:
owner: CITY OF COSTA MESA
Address , �
ELECTRICAL PERMIT
Phone:
Zip:
Phone:
Zip:
Contractor: EVANSJE ENETERPRISES DBA: WEST COAST CABLE
Address: 5425 BERRYHILL DR
CA Phone: Q14) 985-0411
YORBA LINDA � . Zip: 92886
" �License: 734530 �
ISSUE FEE
Temp service test
Res. a/c package
New Res (1-2 units)
New Res (3+units)
Pool / Spa
Lighting Fixts
Recept Outlets
Switches
Non Res Appl
Res Appl
Service to 200a
Service to 1000a
Service over 7000a
Motors to thp
Motors to 10hp
Motors to SOhp
Motors to 100hp
Motors over 700hp
Communication drops
Sub panel to 200a
Pole Light Pkg
Sign Circuits
Temp Pwr Pole
Intermed Pole
PERMIT NUMBER
E99-01146
77 FAIR DRIVE, COSTA MESA, CA 92626
ISSUED BY:
SCOPE OF PERMIT
INSTALL ELECTRICAL METER FOR NEW CABLE N POWER SUPPLY FOR -MEDIA ONE-.
$23.50
$0.00
$o.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$30.50
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Quantity
FEE SUMMARY
Temp Dist�System / Lighting
8usway /100 ft � .
- ��Standing Section
Misc Electrical Equipment
Transformers up to 1 kva/kw
........_......up to 10 kva/kw
.................up to 50 kva/kw
� .................up to 100 kva/kw
..................over 100 kva/kw
Low Voltage Equipment
Low Volt Wiring System / Ckt
Misa Conduit
Misc. Conductor
Circus ( gen or ride)
Circus (mech ride or lights)
Christmas Tree Stand
Fireworks Stand
Other Electrical Fee
Investigation Fee
Plan Check Fee
Reinspection Fee
Status: ISSUED
Applied: 12/1/1999
Issued: 12/1 /1999
Quantity
$0.00 0
$0.00 0
$o.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00
$0.00
$0.00
$0.00
TOTAL CALCULATED FEES $54.00
COMMENTS I 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 Ihe work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspecHons and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CAL�: (714) 7545626
WORKERS' COMPENSATION DECLAqpTION:
I hereby attirm under penalry oi perjury one ot the following tleclarations:
❑ I have antl will maintain e certificate ot consent to selFlnsure for workers' compensation, as providetl for by section 3700 of Ihe Labor Code, for iha pertormance of the
work tor which t�is pertnit is issued. -
❑ I have antl will maintain workers' cpmpensation insurance, as required by section 3700 W the Labor Code, tor the performance of ihe work for which Ihis pertnit is issuetl.
My workers' compensation Insurance carrier antl policy number ara:
Carrier: Policy Number:
(This section neetl not be crompleted ll fhe permit is valued et one huntlretl dollars ($100) o� less.)
❑ I certify ihal in �he pertortnence of �he wOrk tor which ihis pertnit is issuetl, I shall not employ any person in any manner so as to becoma subject to Ihe workers'
compansation laws ot Califomia. and agree that if I should become subject to Ihe workers' compensation provisions ot Section 3700 of the Lebor Cotle, I shall forthwith
comply with these provisions. �
Applicam5ignaWre: ��^-�� ✓�...^ Date: '� Z-9 `
WARNING: FAILURE TO SECURE WORKERS' �pMPENSATION CAVEfiAGE IS UNLAW FUL AND SW1LL SUBIECT AN EMPLOVER TO CflIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSPND DOLLARE �5100,000), IN FDDITION TO THE COST OF CQNPENSATIIXJ, DAht4GE5 AS PROVIDED FOfl IN SECTION 3/W OF THE L480R CODE, IMEREST, AND FTTORNEY'S FEES.
LICENSED CONTRACTORS DECLARqTION:
I hereby aHirm that I am licensed under provisions of Chapter 9(commencing wiih Section 7000) of Division 3 of the Business and Professions Code, antl my license is in full
force antl eHect. Lic. p Class #
ContrectofsSignature: ��`� ._Y..r��. Date: /�L-i-"Qy
CONSTRUCTION LENDING AGENCV:
❑ I hereby ettirm thet ihere is a cons�mction lending egenCy for the pedormance of the work for which t�is permit is issued. (Sec. 3097, Civil Code).
Lenders Name: Lender's Address:
Signature: Date:
OWNEfl-BUILDER DECLARATIONS:
I hereby affirm that under penalry of perj�ry that I am EXEMPT PROM THE CON7RAC70RS LICENSE LAW for Ihe following reason (SecJ031.5, Business end Protessions
Code: Any city or county which requires a permit to coretmct, alter, improve, demolish, or repair any simcNre, pnor to its issuance, also requires the epplicant tor such permit
to file a signetl statement ihat he or she is licensetl pursuant to the provisions of ihe Contrecrors License Law (Chapter 9(commancing with Section 7000) ot Division 3 of ihe
Business antl Professions Code) or that he or she is exempt therefrom and the basis for the allegetl exemption. Any violation ot Section 7031.5 by any applicam for e permit
subleds the applicant to e civil penelry of not more than five hundred dollars ($500).):
❑ I, as owner of ihe property, or my employees with wages as their sole compensation, WILI DO THE WORK, and the stmcture is not intended or ottered for sale (Sec.
7044, Business antl Protessions Code: The Contrectors License Law does nol appiy to an owner of property who builds or improves ihereon, end who does such work
himself or herself or ihrough his or her own employees, provitled ihat such improvemenis are not intended or oNered tor sale. If, however, ihe building or improvement is
sold within one year of completion, Ihe owner-builtler will have ihe burden of proving that he or she tlid not build or improve tor purpose of sale.).
❑ I, as owner ot ihe propetly, am E%CWSIVELV CONTRACTING WITH LICENSED CONTRACTORS to constmd the project (Sec. 7044, Business and Professions
Cotle: The contractors License Lew does not epply to an owner of property wha huilds or improves thereon, antl who contrects for suc� project with a contrector(s)
license pursuant to the Coniractors License Laws.).
❑ I am exempt untler sec. Business and Professions Cotle tor this reason:
Signa�ure: � Data:
Owner ID veritied 6y tlriver's license. ❑ Yes ❑ No Oriver's License No. Expires:
Verifica�ion of Ownership by (type of document, i.e. - pmperty Iax hiil or deed):
DIVISION OF INDUSTRIAL SAFETY P�RMIT CERTIFICATION:
❑ I hereby certi(y Ihat no excavetion tive (5) or more feet in depth into which a person is required to descend, will be made in connec�ipn with work authorized by Ihis
pertnit, and Ihat no builtling strucWra, scatfolding, falsework, or tlemolition or dismantling thereof, will be more than ihirry-six (36) feet high. (Chap. 32, Gry 2, Ar12, Sec.
341, Ttle B, Califomia Administretive Code).
❑ As owner-builder, I will not employ enyone to tlo work which would require a permit irom the Division of Industnal Safery, as notea abova, unless such person �as a
permit ro do such work from the division.
SignaNre: Date:
Division of Industrial Safety Permit Numqer:
CER7IPICATE OF COMPLIANCE AND AU7HORIZATION OF EMAY: I certify under penalty of periury that I have read this application and stata �hat Ihe information given is
correct. I agree to comply with all state laws and ciry ordinances relating to building construction, and authonze represantatives of Ihe City ot Costa Mesa to enter upon �he
above-descnbed property for inspection puryoses. I agree not to occupy or allow occupancy of any building authorized by this permit until linal inspedion.
SignaWre Of Legal Owner(s) Date
-�...,..,� __,�..�.� i t. z- S4
And/Or Auihorized Applicant ate
CO�E 11. INSPECTIONTYGE
1616 Fixed System Final Fire Preveqtion
1266 Pool Spa Final
200 Final Re-Roof
201 Final BIocWRetaining Wall
202 Final Factory Fire Place
203 Final Sign
204 Final Demolition
2ad6-46
o� i�
COUEt INSPECTIONTYPE
206 Final Mechanical
208 Final Plumbing
210 Final Elecirical
212 Final Fire Prevention
220 Final Planning Approval
222 Final Site
250 Finai Building/Occupancy
iarmn�s