HomeMy WebLinkAbout186 23RD ST - Building Permits t • Q
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"4 CITY OF COSTA MESA /
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yaP.O.BOX 1200 • 77 FAIR DRIVE • CALIFORNIA 92628-1200
.ft .-= : DEVELOPMENT SERVICES DEPARTMENT
January 10, 2005
To:
Building Safety Division Comcast Cable
Code Enforcement Newport-Mesa Unified School. Dist.(2)
Communications Pacific Bell
County Clerk Police Dept. - Planning & Research
County Planning and Dev. Services Sanitary District Engineer
County Registrar of Voters Sanitation Division Office
County Tax Assessor So California Edison Company
Engineering Division (2) Southern California Gas
ESRI State Board of Equalization
Fire Admin. - Training Officer U. S. Post Office - AIS
Fire Admin. - Mark Brown (Station 6) U. S. Post Office, Adams
Fire Prevention Thomas Brothers
Irvine Ranch Water District File (2)
Mesa Consolidated Water District
OLD ADDRESS NEW ADDRESSES A. P. NO
170 and 190 23rd Street 186 and 190 23rd Street 439-261-05
2337 Orange Avenue 2301, 2303, 2305, and 439-261-09
2337 Orange Avenue 439-261-31
2300-2321 Half Moon Lane*
Your cooperation in this matter is appreciated.
Sincerely,
L13-c-it--a- /_LLt_2.1
et
Willa Bouwens-Killeen
Principal Planner
c: Kimberly Brandt
Steve Castles
Shea Homes
603 S. Valencia Avenue
Brea, California 92823
' New street
Building Division(714)754-5273 • Code Enforcement(714)754-5623 • Planning Division(714)754-5245 /
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e INSULATION CERTIFICATE
This is to certify that insulation has been installed in conformance with the current energy Ii
regulation, California Administrative Code, Title 24, State of California, in the building located at e
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Jo HALF MOON LANEbHS-3-TRACT 16600-COSTA MESA 0
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•i TYPE: Fiberglass Batts MANUFACTURER: Owens/Corning THICKNESS: R-19 6-1/2" •
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0 SCHMID INSULATION CONTRACTORS, INC. LICENSE #221517 C-2 0
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47-k TITLE: PRODUCTION ASSISTANT DATE: 02/07/2006 •
ANNETTE PATTERSON i
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r INSULATION CERTIFICATE •
o This is to certify that insulation has been installed in conformance with the current energy e
4 regulation, California Administrative Code, Title 24, State of California, in the building located at e
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u HALF MOON LANE-PHS-3-TRACT 16600-COSTA MESA •
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TYPE: Fiberglass Batts MANUFACTURER: Owens/Corning THICKNESS: R-19 6 1/2"
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GENERAL CONTRACTOR: SHEA HOMES LICENSE # 0
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aBY: Gn, TITLE: PRODUCTION ASSISTANT DATE: 02/07/2006 e
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eS'Ill'AC Installation Certificate : Residential CF-6R
AIR CONOmONING INC.
Site Address PERMIT#
186 23RD STREET Bldg:-Unit: - to
1. BUILDER INFORMATION
Shea Homes SUBDIVISION: Half Moon Lane
603 S. Valencia Avenue CITY:COSTA MESA
Brea,CA 92823 COUNTY:ORANGE
INSTALLING CONTRACTOR: WESTPAC AIR CONDITIONING
2.PROJECT INFORMATION
DISTRIBUTION TYPE PUCT OR PIPING R-VALUE
Flexible Ductwork in Flexible Ductwork Will have a
Attic and Between Floors R-Value of 4.20 or Better
I,the undersigned,verify that the equipment listed in the category above my signature is the equipment installed and that the equipment
meets or exceeds the requirements of the Appliance Efficiency Standards. In addition,I have verified that the equipment is equivalent to or
more efficient than the equipment specified on the Certificate of Compliance submitted to demonstrate complience with the Energy Efficiency
Standards for residential buildings.
3. HEATING INFORMATION
HEATING MANUFACT HEATING UNIT ACTUAL EFF. HEATING EQUIP HEATING
EQUIP. MAKE MODEL# AFUE CAPACITY LOAD
Furnace Lennox G4OUH-60C-110X 80%
4.COOLING INFORMATION
COOLING MANUFACT COMPRESSOR ACTUAL EFF. COOLING EQUIP HEATING
EQUIP. MAKE MODEL# SEER CAPACITY LOAD
A/C Lennox I3ACD048 10
The building design heat loss and design heat gain rate have been determined using a method specified in Section
150(h)of the Energy Efficiency Standards,and are two of the criteria used for equipment sizing and selection.
5.THERMOSTATIC EXPANSION VALVE(TXV):
Thermostatic Expansion Valve(or Commision approved equivalent)is installed and access is provided for inspection.
YES in NO Q N/A Q
6.SUBMITTED BY:
WESTPAC AIR CONDITIONING
Signature Installing HVAC Contractor Date
• r CITY OF COSTA MESA
BUILDING DIVISION
r
. DEVELOPMENT SERVICES DEPARTMENT P MIT NUMBER
o 2 PERMIT B05-00167
4)754-52733 • Fax(714)754-4856 • www.ci.costa-mesa. enLDING PERMIT FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 186 23RD ST Status: ISSUED
Suite: Applied: 01/31/2005
Vicinity: LOT 19 Issued: 04/18/2005
Primary Occ: R-3 Dwellings/Cong Res<10 Type of Construction: V-N
Parcel Number: TPN00555 Zoning:
Applicant: WILLIAMS, GARYAddress: 1450 N.TUSTIN AVE ISSUED BY: Yom ,c! —Phone: 714-245-9760 X24 ' `SANTA ANA,CA Zip: 92705
Owner: SHEA HOMES LTD
Address 603 SOUTH VALENCIA AVE
Phone: 714-985-1300
BREA,CA Zip: 92823
•
Contractor: OWNER-BUILDER
Address:
Phone:
Zip: License: 000000
Arch : WILLIAM HEZMALHALCH Eng:
Address: WILLIAM HEZMALHALCH ARCHITECTS INC Address:
SANTA ANA,CA Phone: 949-250-0607 Phone:
2850 REDHILL AV STE 200
Zip: 92705-5543 License: C12920 License:
SCOPE OF PERMIT
LOT 20
PLANS 2A
CONSTRUCT 2560 SF 2-STORY SFD WITH 449 SF ATTACHED GARAGE AND 72 SF PORCH. FIRST FLOOR WILL BE 1225 SF WITH 1335 SF
SECOND FLOOR.A FIREPLACE MODEL#4236(ANSI UL127)WILL BE INSTALLED IN THE FAMILY ROOM;THERE WILL BE A 2ND FLOOR
LAUNDRY ROOM.
REF: G04-00010,PA-03-47,T-03-06
SEE PA-03-471T-16600
FEE SUMMARY
Plan Check: $305.27 Calc Valuation: $257,575.34
Permit: $1,878.55 Claim Valuation: $0.00
SMIP Res: $25.76
SMIP Corn: $0.00
Other: $0.00
Inspection: $0.00
Total: $2,209.58
PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front 20-0 Rear 10-0 Left 5-0 Right 5-0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord. No.92-28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
DECLARATIONS `
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 lar 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 at one hundred dollars($100)or less.)
c5ertify 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 C:Ilfomia,and ag that If I should become subject to the workers'compensation provisions o1 Section 3700 of the Labor Code,I shall forthwith
comply with these pr.ia'ns.
11ppIicant'SIgHAtule: � � ��MIr..1Datte:: if/
oior
kWARNINGrFAILURE • E W.-KERS'C[ PENS I VERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TOCRIML PENALTIES AND CIVIL FlNES UP TO ONE HUNDRED
THOUSAND OOLARE($100,000),IN ADDITION TO THE OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS 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.a Class it
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she Is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
sub'ects the applicant to a civil penalty of not more than five hundred dollars($500).):
Pas owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such Improvements are not intended or offered for sale,If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I.as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
I am exemp nder se i Business and Professions Code for this reason: ������ �y�
ign0t e: SS_�.., 4 Aar eV—a'� •
L Expi�j;. Obi/Vag
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? ❑Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Depanment 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).
will
the applicant
o present
—3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑No
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a_aermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ NO
(Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑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-des ed property for ins purpr:lipI agree not to occupy or allow occupancy of any building authorized by this permit ntil final inspection.
4' 8 6 J_
ggalu :Of .al'Owner(s) -Data
And/Or Authorized Applicant Date
CODE 6 INSPECTION TYPE DATE INIIDALS CODE I INSPECTION TYPE PAIS NIHAU
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 Well 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign222 Final Site
204 Final Demolition 250 Final BuildinglOccupency
,/
,
CITY OF COSTA MESA �/
4 •�' n BUILDING DIVISION
F:J ,,r„ c..4 DEVELOPMENT SERVICES DEPARTMENT P AMIT
NUMBER
t J. 1 4 / PERMIT
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 186 23RD ST Status: ISSUED
Suite No Applied: 04/29/2005
Issued: 04/29/2005
Vicinity: LOT 20
-
Parcel Nunmber: TPN00555 -
ISSUED BY:
Applicant: WILLIAMS, GARY
Address: 1450 N.TUSTIN AVE
` Phone: -
SANTA ANA,CA Zip: 92705 -
Owner: SHEAHOMES22,
Address 603 SOUTH VALENCIA AVENUE
Phone: 714.985.1300
BREA,CA Zip: 92823 •
Contractor: OWNER-BUILDER
Address: ,
. Phone:
Zip:
License: 000000
,
SCOPE OF-PERMIT' '
LOT 20/PLAN 2A _
. PLUMBING PERMIT FOR NEW 2560 SF.SINGLE FAMILYRESIDENCE FOR"SHEA HOMES". INSTALL 3
' BATHTUBS, 1 DISHWASHER,7 GAS OUTLETS, 1WASHER;°1PRESSURE REGULATOR, 1 SEWER
CONNECTIKONS,3 SHOWERS, 1 KITCHEN SINK;1 SERVICE SINK, UP TO 4 VACUUM BREAKERS,3
WASH BASINS, 1 WASH BASIN SET, 1 WASTE&VENT SYSTEM,4 WATER CLOSETS, 1 WATER
HEATER, 1 WATER PIPING,& 1 WATER SERVICE.
REF:B05-00167
FEE SUMMARY' - --.'. ,
AMT QTY • AMT , QTY . AMT QTY
ISSUE FEE $23.50 Laundry Tub/Washer $9.80 1 ' 'Sump Pump $0.00 0
Backflow irrigation ,,, $0.00 0 " Landscape Irrigation "$0.00 0 Swimming Pool $0.00 0
Backflow Preventer $0.00 0 : ' -P-Trap $0.00' 0 Trap Primer ' $0.00 0
Bathtub $29.40 3 • Pressure Regulator $9.80, _ 1 - - Urinal $0.00 0
Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00. - 0 Vacuum Brkr Bkflow(1-4) $12.30 1
Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 - 0 Vacuum Brkr Bkflow(5+) $0.00 0
Dental Units $0.00 0 Septic Tank $0.00.., - 0 Wash Basin $29.40 3
Dishwasher $9.80 1 Sewer Cap for Demo . 5 '$0.00 ---a Wash Basin Set $9.80 1
Drain, Floor $0.00 0 Sewer Connect $24.65 -- 1. -' Waste and Vent System $9.80 1
Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $39.20 4
Drain, Roof $0.00 0 Shower $29.40 3 ' - Water Heater/vent $12.30 1
Drinking Fountain $0.00 0 Sink,bar $0.00- 0. Water Piping(Inst or Rep.) $9.80 1
Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§ 1,12-21-92)
EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codesrand all
required Inspections end final approval must be obtained.Failure to obtain inspections and final approval will result In the expirationthis permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
DECLARATIONS11 (---,)
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 Cade,for the performance of the work for which this,Hermit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
certify that in the performance•f the work for which this permit is issued,I shell not employ any person in any manner so as to become subject to the workers'
cat
ompensation laws of Califo and agree that I Id be ome subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provisi
rA een Ignature: GliDele f ii7a jC
WARNING:FAILURE SECURE W E COMPENSATION GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAL IT ES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLAR (SIOOCCO),I D ON TO THE COST OF PENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3708 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.p Class k
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 am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors IJcense 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
old 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 t• the Contractors Lice•se Laws.).
❑ I am exem•t u sec. 1 ./ Business and Professions Code for this reason:
Signator:. ralr• Date: 4//0
Expires: 61/v/O 9
Verifica'•• , • nership 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? ❑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 then a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 if an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑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 Duality Management District or from any other air pollution control district or agency? LJ Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑No
(If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air(Duality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No
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 inspectionpure• e�s. :gree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
t----- / ate
And7O ••ut "fir.-App icer( Date
CODE I INSPECTIONTYPE ' ' PATE Mal CODER INSPECTION TYPE ' ' PAX m. .
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"
CITY'OF COSTA MESA
4 9 BUILDINGiDIVISION
>:�,,,,,, c,4r :DEVELOPMENT.SERVICES'DEPARTMENT RMIT NUMBER
PERMIT M05-00238
(7141754:5273••'Fax'(714)'754-4856 • www.ci:costa-mesa.ca.us -7TFAIR'DRIVE,.COSTA MESA,CA 92626
•
MECHANICAL PERMIT
Job Address: 186 23RD ST Status: ISSUED
Suite No Applied: 04/29/2005
Issued: 04/29/2005
Vicinity: LOT 20 n li /I
Parcel Number: TPN00555 - ISSUED.BY: f-^[ &-
Applicant: WILLIAMS,-GARY'- . 1
Address: 1450 N:TUSTIN AVE -
Phone: - '
SANTA ANA, CA _ - Zip: 92705 -.- - - - • , .
- ,
Owner: :.SHEA HOMES -
•Address: '603 SOUTH VALENCIA AVENUE
Phone: 714.985.1300 • . -
BREA,CA's Zip: :92823
•
Contractor: OWNER_BUILDER
Address: _
y .Phone: .
Zip:
•
5
License:000000 •
• SCOPE OF PERMIT
LOT 20/PLAN 2A - - _ '
•
MECHANICALPERMIT FOR NEW 2560'SF SINGLE FAMILY RESIDENCE FOR"SHEA HOMES". •
INSTALL 2 FAU'S;1 DUCTWORK,2 FACTORY FIREPLACES,6 VENT FANS,2 FIRE DAMPERS,
• ' &2 A/C CONDENSORS. - '
•
REF:B05-00167 - - -- - .
•
. FEE SUMMARY •
Quantity - Quantity
ISSUE FEE ' $23.50 _ Repair/Alt Absorbtion Unit $0.00 0
Inst FAU<100 k BTU $29.60 2 'Repair/Alt Refrigeration Unit - $0.00 0
Inst FAU>100 k BTU $0.00 0 Ventillation,System $0.00 0
Repair/Alt Cooling/Heat $13.70 1 . EvaporatR'eCooler $0.00 ' 0
Inst/Rep. Recess Wall-kik $0.00•.- 0 - Commerciaflncinerator r':.. - - $0.00 0
Refrig Sys<100'k BTU $0.00, 0Domestic Incinerator' ' - . $0.00 0
Refrig Sys>100 k BTU - $0.00'• .0, - Compressors/Absorption Systems '•
Gas Piping ' ,- $0.00- '•0 Up to 3 hp/100 -BTU';: ' ' , " $0.00 0
Factory Fireplace '$21.30 '"2 ', '3 To 15 k
hp,/500 k BTU ' $0.00 0
Hood w/Mech Exhaust • $0.00 ' 0 • 15 To 30 hp"/1,000 k BTU • - . $0.00 0
VAV Box • $0.00, 0 30 To 50 hp/1,750 k BTU _ $0.00 0
Vent Fan/Single Duct ' $43.50. '6 Over 50 hp/'Over 1,750 BTU ' ' $0.00 '0
Appliance $0.00 0 Boilers _
Fire Dampers - $14.50 . 2 Up to 3 hp $29.40 2
Smoke Dampers $0.00' -0 - 3 TO 15 hp - - $0.00 0
Inst or Relocate Appl Vent $0.00 0 15 to 30 hp " , $0.00 0
Air Handlers< 10000cfm $0.00 0 ' - . 30 to 50'hp ' $0.00 0
Air Handlers> 10000cfm $0.00 0 - Over 50 hp $0.00 0
NOTICE: 'The..workauthorized:by this-permit'shall:comply with_all:applicable handicap access-requirements undertalitomia statutes and related
regulations. (Ord.No:92-28,- '1,-12.2P92)
':'EXPIRATION:'This-pennihshall!automatically.expire and.become void:if work-is-not commenced.within 180:days;.or if work is suspended or abandoned
fora-penod:of 180.days.
•% 'INSPECTIONS: '.In'order for_the:workauthorized.underahis:permit to:be•considered-legal, such•work-musfeomply.wkh.all applicable codes, and all
required Inspections:and final:approvafmust.be.obtainedFFailure.to obtain inspections and'final,approval-will result-inthe.expiratlonoper`mit.
'FOR'INSP.ECTIONS:CALL:-(714)'75445626
I
.2446-46(6/00)
DECLARATIONS i'~1 n
•
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations: - ' • - • • -
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number: `
(Thisy(Tsection.. need not be completed if the permit is valued at one hundred dollars($100)or less.) •
E/�ms'"I certify that in the performance of the work for which mit this peris issued,I shall not employ any person in any manner so as to become subject to the workers'
1 compensation laws of Califo ':,and agree that i I s.gild become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provisio
Appticant57gna ire: / t•r are '. • mil ti S--
WARNING:FAILURE TO ' ' 'COMP • ATION CO RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE Is fAr TION TO 'E COST•- • PENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3705 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.LIG.# Class x
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions 01 the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such Improvements are not Intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
yr 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 pursuan to the Contractors License Laws.).
❑ I am exempt er sec./ Business and Professions Code for this reason:
Signature: Cicense.
Expires: rp4949
Verificafio • •wnership by(type of do m nt,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? ❑Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 9 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑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? 9 Yes 9 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 roperty for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Appr fr;
9ft .. [ /"` ata
411,
I INSPECTION TYPE prig JNTRIALS CODE r INSPECRON nit , 0-
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 '
CITY OF COSTA MESA
4 BUILDING DIVISION
>7. -�isi , DEVELOPMENT SERVICES DEPARTMENT P MIT NUMBER
I
s4 ' t't PERMIT
• �, � os# E05-00403
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa€LtuTRICAL PERMIT 77 FAIR'DRIVE,COSTA MESA,CA 92626
Job Address: 186 23RD ST Status: ISSUED
Suite No Applied: 04/29/2005
Vicinity: LOT 20 Issued: 04/29/2005
Parcel Nunmber: TPN00555
Applicant: WILLIAMS, GARY
y
. ISSUED BY: 1/4-
`
Address: 1450 N.TUSTIN AVE I
Phone:
SANTA ANA,CA- - • Zip 92705 -
‘ ( �-
Owner: ' SHEA HOMES ) -- .
Address " ,603,SOUTH VALENCIA AVENUE . . ,
Phone: 714.985.1300
BREA,CA Zip: 92823
Contractor: 'OWNER-BUILDER '
Address:
.,
. • s .
%, . . Zip: -
i License:000000
- - SCOPE OF PERMIT
LOT 20/PLAN 2A _ . - -
ELECTRICAL PERMIT FOR NEW 2560 SF SINGLE FAMILY RESIDENCE FOR"SHEA HOMES". INSTALL
2 LIGHT FIXTURES,3 RECEPTACLE OUTLETS,&1 SWITCH IN GARAGE,AND 1 RES NC
PACKAGE. ,
REF: B05-00167 - .. - a
FEE SUMMARY -
Quantity Quantity ,
ISSUE FEE . $23.50 Temp.Dist System/Lighting $0.00 - -0
Temp service test $0.00 Busway/100, ft $0.00 . 0
Res.a/c package $54.50 Standing Section.. $0.00 0
New Res(1-2 units) $143.36 ,.2560 , Misc Electrical Equipment..--.Th+ $0:00". 0
New Res(3+units) - $0.00 .y . 0-- . Transformers up to 1'kvarl& ' `,. $0.00 0 -
Pool/Spa $0.00 ,` 0 - up to 10 kva/kw --"$0.00 0 -
Lighting Fixts - $2.20 : 2 - ' � up to 50 kva/kw�,= $0.00 -0
Recept Outlets $3.30 ' 3 up-to 100 kva/kw--' $0.00 . . 0 '
Switches $1.10 1 over 100 kva/kw ' $0.00 ' 0
Non Res AppI $0.00 0 _. Low Voltage Equipment $0.00 7 70
Res AppI $0.00 ' - ' 0 ' - Low Volt Wiring System/Ckt - $0.00 0 '
Service to 200a ' $0.00 0 Misc.Conduit . $0.00 - 0
Service to 1000a $0.00 - 0 . Misc.Conductor. . '$0.00 0
Service over 1000a $0.00 ' : 0 , Circus(gen or ride) , -'$0.00 0
Motors to 1hp $0.00 0 Circus(mech ride or:lights)" $0.00 0
Motors to 10hp $0.00 0 .. - Christmas Tree Stand - $0.00 0
Motors to 50hp $0.00 0 - - Fireworks Stand $0.00 0
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.shallautomatically expire:and become void ifwork isnotcommenced within180days,or if work is suspended or abandoned
for a period-of 180 days.
INSPECTIONS: In order for the workauthorized under this:permitto.be considered legal, such work must comply with,all applicable codes, and all. '
requiredinspectlonsand.final:approval:mustbe.obtained.Failure to obtain-inspections and final approval will result in-the expirationofthis permit:"...
FORIINSPECTIONS'CALL: (714)75445626,
•
2446-46(6/00)
•
DECLARATIONS /1 (^',
•
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 at one hundred dollars($100)or less.)
v3 'certily that in the performance of the work for w is . his permit is issued,I shall not employ any persen in any manner so as to become subject to the workers'
r21C1) compensation laws of Cali•mia,and agree th.-/ .hould become subject to the workers'compensation provisions of Section 3780 of the Labor Code,I shall forthwith
comply with these prove J�/ r��� (�
At
A'ppltraMrbT lure �� !/lam a a'�Dr �/ LC
WARNING:FAILURE 0 SECUR 'OR('•S'OOMPENS• '• GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI PEN TIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND•• ($100.•••,IN ••ITION TOTHE• • NSATION,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.Lie.# 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: 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 civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sate(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.). •
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 pursu t to the Contracto Li ense Law .).
❑ I am exam der se . Business and Professions Code for this reason: f
Signa -/ Date: -S////6C �• /
Own r ID verifie y ver's license. ❑No Driver's License No. � Expires: kG//t{`O`I
Verifi tion of nership by(type of document,i.e.-property tax bill or deed):
1\
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 end certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
. compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification
from the South Coast Air Quality Mahegement District or from any other air pollution control district or agency? LJ Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑No
(If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes ❑No
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I a•ree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
a- :mat - ef/e
d Ort
��1/�fiate
`NOi Au int
• _pjr[•r•E� - . gm' . .. .'(NTRIALS CODE INSPECTION TYPE ME 1NTRUL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical • •
ir
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 '