HomeMy WebLinkAbout291 23RD ST - Building Permits .�^ F • CITY OF COSTA MESA
4 9 BUILDING DIVISION
Y • ,,,r DEVELOPMENT SERVICES DEPARTMENT 4 19 s PERMIT NUMBER
t. 1 ....+dal I
PERMIT IDI
erase` P03-00280
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 291 23RD ST Status: ISSUED
Suite No Applied: 05/05/2003
Issued: 05/05/2003
Vicinity:
Parcel Nunmber: 42608411 ISSUED BY:
Applicant: BIGELOW, DAVID JOHN
Address: 291 23RD ST
Phone: 949-645-4701
COSTA MESA,CA Zip: 92627-1809
Owner: BIGELOW, DAVID JOHN
Address 291 23RD ST
Phone:
COSTA MESA,CA Zip: 92627-180949
if)
• "I
Contractor: OWNER-BUILDERQ
Address: ♦i S
Phone:
Zip:
License: 000000
Arch/ Eng:
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
CONSTRUCT NEW DETACHED 303 SF"POOL HOUSE"AT THE REAR OF AN EXISTING SFD.
INCLUDES A POWDER ROOM(TOILET AND SINK ONLY),SINK,AND REFRIGERATOR. SERVES
EXISTING SWIMMING POOL.
LAND USE RESTRICTION#2003000281227 RECORDED 3/14/2003 PROHIBITING USE OF THE POOL
HOUSE AS LIVING AREA AND/OR A DWELLING UNIT.
PLUMBING TO INCLUDE: 1 GAS REPIPE, 1 BAR SINK, 1 WASH BASIN, 1 WATER CLOSET, 1 WASTE
AND VENT,AND 1 EJECTION PUMP WITH TANK(50 GAL).REF.:803-00418
FEE SUMMARY
AMT QTY AMT QTY AMT QTY
ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 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 $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0
Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $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.
i
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
2446.48(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'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(Thissectionneed not be completed it the permit is valued at one hundred dollars($100)or less.)
1,0 I certify that in the performanc e w for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Car a, r t it Id become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these pr I s.
Applicant Signature: Date: f O
WARNING:FAILURE TO SECURE ()WEBS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI AL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100, ,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 lull
force and effect.Lic.# Class#
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
subjscis,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 properly 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.IL 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 properly,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does net apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to th- on .a ors License Laws.).
❑ I am exempt u .:r .�./� Business and Professions Code for this reason:
Signature: ' ` ®'• r i Date: �/,
Owner ID verified by• er's license.) -c LS Yes 0 No Driver's License No. • Expires: /.� 03
Verification of Ownership by(type of docu e 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,end that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and 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? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this_application apPermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 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? 0 Yes 0 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 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 CO. - •/NCE 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 t• 0••1tri .II state laws end city ordinances relating to building construction,and authorize representati es of the City of Costa Mesa to enter upon the
above-descr•-:pr••• r'•.'5-'- •• •• rposes,I agree not to occupy or allow occupancy of any building authorize y th' permit until final inspection.
s03
Signature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
CODE# INSPECTION TYPE PAW INTFAL$ 40PE♦ INSPECTION TYPE OATS INV11AL$
1616 Fixed System Final Fire Prevention _ 206 Final Mechanical }{'
1266 Pool Spa Final 208 Final Plumbing 7-Z/O"o[/I
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 Sign _ 222 Final Site
204 Final Demolition _ 250 Final Building/Occupancy
F CITY OF COSTA MESA
4 BUILDING DIVISION
). • rr„.; DEVELOPMENT SERVICES DEPARTMENT I I4 PERMIT NUMBER
r'* t PERMIT Y
J•
IPP
M03-00214
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
MECHANICAL PERMIT
Job Address: 291 23RD ST Status: ISSUED
Suite No Applied: 05/05/2003
Issued: 05/05/2003
Vicinity:
•
Parcel Number: 42608411 ISSUED BY:
Applicant: BIGELOW, DAVID JOHN
Address: 291 23RD ST
Phone: 949-645-4701
COSTA MESA,CA Zip: 92627-1809
Owner: BIGELOW, DAVID JOHN ' 101
Address: 291 23RD ST V
Phone: �\ 1)
COSTA MESA,CA Zip: 92627-1809 4$10
99
Contractor: OWNER-BUILDER 0
Address:
Phone:
Zip:
License:000000
SCOPE OF PERMIT
CONSTRUCT NEW DETACHED 303 SF TOOL HOUSE"AT THE REAR OF AN EXISTING SFD.
INCLUDES A POWDER ROOM(TOILET AND SINK ONLY),SINK,AND REFRIGERATOR.SERVES
EXISTING SWIMMING POOL.
LAND USE RESTRICTION#2003000281227 RECORDED 3/14/2003 PROHIBITING USE OF THE
POOL HOUSE AS LIVING AREA AND/OR A DWELLING UNIT.
MECHANICAL TO INCLUDE: 1 FACTORY FIREPLACE.REF.:B03-00418
FEE SUMMARY
Quantity Quantity
ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0
Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0
Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00 0
Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0
Inst/Rep.Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0
Refrig Sys<100 k BTU $0.00 0 Domestic 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 k BTU $0.00 0
Factory Fireplace $10.65 1 3 To 15 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 $0.00 0 Over 50 hp/Over 1,750 BTU $0.00 0
Appliance $0.00 0 Boilers
Fire Dampers $0.00 0 Up to 3 hp $0.00 0
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
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 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.)
I certity that in the performance• •-e w or 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 • • , hat If I should become subject to the workers'compensation provisions of Section 37 of the Labor Code,I shalt forthwith
comply with these proms:•
Applicant Signature: / Date: i> /' 0
WARNING:FAILURE TO SECURE W KERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TOC INAL ENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),I 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#
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).
Lenders Name: Lenders Address:
Signature: r 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 end Professionspode)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
subje e applicant to a civil penalty of not more than five hundred dollars($500).):
I,as owner of the property,ror my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of properly who builds or improves thereon,and who does such work
himself or herself or 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 -ens= 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 -c•rs License Laws.).
❑ I am exempt •• -1// Business and Professions Code for this reason:
Iie
Signature: // Date: S S
Owner ID verified by d i•er's license. N Yes 0 No Drivers License No. /
' /3
Expires: /`/2261_5
Verification of Own- hip by(type of docu e i.e.-properly tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feel In depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the Califomia 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 end Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit 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 Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air 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? 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 COMP CE 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 p w ate Iiiii• - d city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-describe rop 71 a.I agree not to occupy or allow occupancy of any building authorized tit' permit until final inspection.
53
Signature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
coot 0 INSPECTION TYPE PAIL INTmAL$ POPES INSPECTION TYPE '
1616 Fixed System Final Fire Prevention 206 Final Mechanical 7-21-P
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 Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
51p CITY OF COSTA MESA
BUILDING DIVISION
r,, i DEVELOPMENT SERVICES DEPARTMENT /I if 0PERMIT NUMBER
PERMIT E03-00341
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 291 23RD ST Status: ISSUED
Suite No Applied: 05/05/2003
Vicinity: Issued: 05/05/2003
Parcel Nunmber: 42608411rir,,��//�/
Applicant: BIGELOW, DAVID JOHN ISSUED BY: "
Address: 291 23RD ST
Phone: 949-645-4701
COSTA MESA,CA Zip: 92627-1809
Owner: BIGELOW, DAVID JOHN
'Address 291 23RD ST .
Phone:
COSTA MESA,CA Zip: 92627-1809
Contractor: OWNER-BUILDER
Address:
9
SIS 0 ''I°
Phone: '
Zip: �,l.3 6;.•
License: 000000
SCOPE OF PERMIT
CONSTRUCT NEW DETACHED 303 SF"POOL HOUSE"AT THE REAR OF AN EXISTING SFD.
INCLUDES A POWDER ROOM(TOILET AND SINK ONLY),SINK,AND REFRIGERATOR.SERVES
EXISTING SWIMMING POOL.
LAND USE RESTRICTION#2003000281227 RECORDED 3/14/2003 PROHIBITING USE OF THE POOL
HOUSE AS LIVING AREA AND/OR A DWELLING UNIT.
ELECTRICAL TO INCLUDE:303 S.F. NEW STRUCTURE AND 1 MISC. CONDUIT.REF.: B03-00418
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 $0.00 Standing Section $0.00 0
New Res(1-2 units) $16.97 303 Misc Electrical Equipment $0.00 0
New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0
Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0
Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 0
Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0
Switches $0.00 0 over 100 kva/kw $0.00 0
Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0
Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0
Service to 200a $0.00 0 Misc.Conduit $18.20 1
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
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(Atha 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.)
certify that in the performance of or r 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 Calif t if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these pro s.
Applicant Signature: Date:- '.�/S 3
WARNING:FAILURE TO SECURE KERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL ENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE t$100.000 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.Lie.# Class#
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
subjec a applicant to a civil penalty of not more than five hundred dollars(5500).):
-.'l,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.).
❑ 1,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 tot o ors License Laws.).
❑ I am exempt r Business and Professions Code for this reason:
Signature: Date: SAA_.?
Owner ID verified b river's license. Yes 0 No Driver's License No. 410I- Expires: AS3'
Verification of Ownership by(type of doc ,en 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 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a,pormit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes ID 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? 0 Yes 0 No
(If ryes",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 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 y..-0'10:ZATION 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 ,t •. ordinances relating to building construction,and authorize representativ s of the City of Costa Mesa to enter upon the
above-described property for :.= o. of to occupy or allow occupancy of any building authorized this ermit until final inspection.
S:. ature Of Legal Owner(s) / / Date /
And/Or Authorized Applicant Date
CODE r INSPECTION TYPE PATE INTITIALS CODE. INSPECTIONTYPE • PAM INTmALS
1616 Fixed System Final Fire Prevention _ 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical l -2S 6}r,
201 Final Bleck/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
4 • CITY OF COSTA MESA
4 BUILDING DIVISION
:fet"4 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
Ft .
PERMIT
s B03-00418
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 291 23RD ST Status: ISSUED
Suite: Applied: 03/13/2003
Vicinity: POOL HOUSE AT REAR OF SFD Issued: 03/27/2003
Parcel Number: 42608411 Zoning:
Applicant: BIGELOW, DAVID ISSUED BY:•
Address:
Phone: 949-645-4701
Zip:
Owner BIGELOW, DAVID JOHN
Address 291 23RD ST
Phone: ` '
• 10 R I
1
COSTA MESA,CA Zip: 92627-1809
Contractor OWNER-BUILDER
Address:
Phone:
Zip: License: 000000
Arch : Eng:
Address: - Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
CONSTRUCT NEW DETACHED 303 SF'POOL HOUSE"AT THE REAR OF AN EXISTING SFD.
INCLUDES A POWDER ROOM(TOILET AND SINK ONLY),SINK,AND REFRIGERATOR.SERVES EXISTING SWIMMING POOL.
LAND USE RESTRICTION#2003000281227 RECORDED 3/14/2003 PROHIBITING USE OF THE POOL HOUSE AS LIVING AREA AND/OR A
DWELLING UNIT.
FEE SUMMARY
Plan Check: $274.33 Calc Valuation: $28,000.00
Permit: $422.05 Claim Valuation: $28,000.00
SMIP Res: $2.80
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $699.18
PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0
ACCESSORY Front 56-0 Rear 10-0 Left 24-0 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
2444348(WOO)
DECLARATIONS
WORKWAS'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,es required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carder and policy number are:
Carrier: Policy Number:
(This sect' need not be completed if the perml • valued at one hundred dollars($100)or less.)
I certify that in the performance of o •rf hich this permit Is Issued,I shall not employ any person In any manner so as to become subject to the workers'
compensation laws of Calor ,a :, I•:;v. • •=come subject to the workers'compensation provisions of Section 37 of the abor Code,I shall forthwith
comply with these provisi 0 �3
Applicant Signature: Date: 0
WARNING:FAILURE TO SECURE WOR '5'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI PENALTIES AND CIVIL RNES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN::.,TION 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.A 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).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
rr„'"-.
I hereby affirm that under penalty of perjury that 1 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 end Profession's Cbde),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 ppllcant to a civil penalty of,not more than five hundred dollars($500).):
11
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(Sec.7044,Business and Professions
Code:The contractors se 'w 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 ontr•-'rs License Laws.).
❑ I am exemp d e Business and Professions Code for this reason:
Signature: ate 3 Z7 Of
Owner ID verified by• er's license. I.t Yes 0 No Drivers License No. Expires? q,/3
Verification of Ownership by(type of docu ent,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? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required.has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application 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 El 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? 0 Yes 0 No
(If yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If'yes”,attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions,
Signature: Date:
CERTIFICATE OF P .AN D AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agre co•• .r:,„ stA' , and city ordinances relating to building construction,and authorize represe atives of a City of Costa Mesa to enter upon the
above-de d. ... •r!y .I agree not to occupy or allow occupancy of any building authorized b his pe • until final inspection.
3 z 453
Signature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
;ODE, INSPECTION TYPE PATE INI)DAL6 PORE If INSPECTIONTYPE PATE INIIRAL$
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 /�2�-.°°1
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attributes : Costa Mesa Parcels . Page 1 of 1
Map Layer Attributes for Parcels
Property Address
Address 1 291 E 23RD ST
Address 2 COSTA MESA CA 92627
Parcel Information
Assessor Parcel Number 42608411
Legal NEWPORT HEIGHTS LOT 324 S ELY 98 FT NELY 135 FT -INC POR ST AD)- -E X SEL Y 44 FT& POR ST ADJ-
Range
Township
Section
Quarter Section
Area 7306.4235200000003
Acres 0.17000000000000001
Owner Information
Owner BIGELOW DAVID JOHN
Owner Address 1 291 23RD ST
Owner Address 2 COSTA MESA CA 92627
Property Specs
Year Built 1952
Building Square Feet 831
Building Count 1
Stories Number 1
Parking Spaces 1
Number of Units 0
garage Square Feet 0
Front Footage 54
Depth Footgae 135
Bedrooms 2
Map Layer Attributes For Address Points
Address 291 23RD ST
Apt/Suite
City
State
Zip
Building ID
APT/Space
Phoen
SIC Code 0
Data Siurce parcels
Plan Type
tttp://mesagi s2x/website/costamesa/parcel/default.asp?opt=attributes&sessld={50924820-52 CC-427C-9... 02/27/2004
Property Profile - Page 1 of 2
DataQuick•*
Und and property data you can build al-
Property
rProperty Profile
Primary Owner: BIGELOW,DAVID J &SANDRA E
Secondary Owner:
Mail Address: 291 23RD ST
COSTA MESA, CA 92627
Site Address: 291 23RD ST
COSTA MESA, CA 92627
iv
.r,,,, Telephone Number:
\ : 426-084-11
ay,,11, u" a
s Reference APNAPN
:
u,',r:
�;.;,.,.;,,�.,,; Census Tract: 632.012
CA!IFOI1NtA t Housing Tract Number: 516
,fin_
Geo Betel:0 Lot Number: 324
Page Grid Old: 31-E1
Page Grid New: 889-B2
Legal Description: NEWPORT HEIGHTS LOT 324 S ELY 98 FT
NELY 135 FT -INC POR ST ADJ--E X SEL Y
44 FT & POR ST
Subdivision:
Property Characteristics
Bedrooms: 2 Year Built: 1952 Square Feet: 832
Bathrooms: 1.0 Garage: Lot Size: 7,290 sq ft/0.17 acres
Total Rooms: 4 Fireplace: Number of Units: 1 •
Zoning: PooUView: Use Code: Single Family Residence
1-Ieating/Cooling:
Sale & Loan Information
Transfer Date: 06-30-1998 Seller: Document: 0000416890
Transfer Value: $273,000 Cost/Sq Feet: $328.13 Title Co.: Guardian Title
First Loan Amt: $205,500 Lender: Chase Manhtn Mtg Last Trans W/O$:
Loan Type: Interest Rate Type: F Last Trans W/O$ Doc:
Assessed& Tax Information
Assessed Value: $326,441 Percent Improvement: 17.97 Homeowner Exemption: Y
Land Value: $267,780 Tax Amount: $3,501 Tax Rate Area: 15044
Improvement Value: $58,661 Tax Status: current
0 2004 DataQuick Information Systems.This information is compiled from public records and is not guaranteed.
http://www.gotitle.com/cgi-bin/profi le.asp?rmt=TOPS&graphic=%2Faccounts%2FT07378%2Fcompan... 02/27/2004
I/ 50 9 CITY OF COSTA MESA , I
4 BUILDING DIVISION
> r�.'n ..4 DEVELOPMENT SERVICES DEPARTMENT !Ica NUMBER
PERMIT -00141
Sabi,man
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 291 23RD ST Status: ISSUED
Suite No Applied: 03/03/2003
Vicinity: Issued: 03/03/2003
Parcel Nunmber: 42608411
Applicant: HOPE, JEFF ISSUED BY: (5:::: [�
Address: 8 CARLSBAD LANE
Phone: 949-510-9565
ALISO VIEJO,CA Zip: 92656
Owner: BIGELOW, DAVID JOHN
Address 291 23RD ST
Phone:
COSTA MESA,CA Zip: 92627-1809
Contractor: OWNER-BUILDER
Address: •
Phone:
Zip:
License: 000000
SCOPE OF PERMIT
UPGRADE ELECTRICAL SERVICE TO 200 AMPS.
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 $0.00 Standing Section $0.00 0
New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0
New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0
Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0
Lighting Fixts S0.00 0 up to 50 kva/kw $0.00 0
Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0
Switches $0.00 0 over 100 kva/kw $0.00 0
Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0
Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0
Service to 200a $30.50 1 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(mach 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
Motors to 100hp $0.00 0 Other Electrical Fee $0.00
Motors over 100hp $0.00 0
Communication drops $0.00 0 Investigation Fee $0.00
Sub panel to 200a $0.00 0 Plan Check Fee $0.00
Pole Light Pkg $0.00 0 Reinspection Fee $0.00
Sign Circuits $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 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)
DECLA ATIONS 'a 1
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and win 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.)
gI 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 shout. .: .me subject to the workers'compensation provisions of Section 37000ppp of the Labor Code,I shall forthwith
comply with these provisions. 3/ 0 3
3 /
Applicant Signature: / /44 at . Date: !Jn(
WARNING:FAILURE TO SECURE W,"4� , r•. -ENSATION �, RAGE IS UNLAWFUL AND SHAH SUBJECT AN EMPLOYER TO CRIMINAL PENAL ES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100.00),I y•/MON T•THE COST 0r•• PENSA11ON,DAMAGES AS PROVIDED FOR IN SECTION 37060F 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.Uc.If Class 4
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
O 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).):
yI,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 appty to an owner of property who builds or improves thereon,end 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 exempt under s. Business and Professions Code for this reason: /
Signature: Y. .411,="1...4.157 J l l T Date: 4o / 0
Owner ID verified by•/.r• Ice ' Expires: 7/9/07
Verification of Owner/ip by(type of docu :fit.i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
O 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,An 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and 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,ore 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
has ono the hand CaliforniaHeaal Band Saf t Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one
quantity ly wi to equal to or greeter 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 acutoly hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP Is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5,-....Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification
from the South Coast Air(Duality Management District or from any other air pollution control district or agency? ID 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 pert of the facility to Pe constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If yes",attach certificate of Compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Si/br/f bigot!r J 2/�O Date
j/AP• ,y,. •�I ariz.•Ap.TIc•nt Cate
CODE A INSPECRON TYPE / I PATE num CODE I INSPECTIONTYPg PATE imine
1616 FixedoolSystem : nal Fire Prevention 206 Final Mechanicalmbi
1288 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical 4-25.03
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
DECLARATION OF AUTHORITY Bldg. Permit#
FOR AGENTS OF PROPERTY OWNER This Permit# G Tn U3-OD f 4
TO APPLY FOR PERMITS
Street Address/( 02Q / 2.1a' ccs • AP Number:
1. I (we/ b ��/A\\\v/L # N/OLsi /6Z-'lo ,) , declare that I am the Owner of Title of the above
referenced realTproperty,and that I (we)hereby authorize: /J p C`
•
Name: v z fre e�( I e) l `oy� Telephone Number: L / ✓(aS�Ol
� S
Street Address: /) (a i (T o ciQ MK)
City: Al j s 0 V 'Q j 0 State: C� Zip: 926 c6
to obtain permits in my behalf,as owner/builder,for C I eco 1 CICS cApqrad.-Q_
at the above referenced property.
2. Should any person become an employee engaged in the improvement of the property, I (we) shall immediately provide Worker's
Compensation Insurance coverage and cause a certificate of that coverage to be filed with the Building Division of the City of Costa
Mesa,as required by State of California laws.
3. As owner/builder in fact, I understand and accept that my responsibilities do not transfer to any other person, company or
corporation.
4. I agree to indemnify and hold the City of Costa Mesa and its employees or officers harmless from any claim resulting in damage or
personal injury to myself or any other parties as a result of work authorized by the permits from the City of Costa Mesa.
5. I declare under thepenaltyof i perjury
ythat the foregoing is true and correct. ("ask /,�///
Executed this . J day of / //4 rc I l 20 a 3 ,at es c.„ ,California.
Print Name: /\ ace* ` ,•l6L�-
Signature: %/7mat.ti ?_ l4?Co
Date: >< 3 - 3 - 03
Note: This authorization does not grant authorization to perform the work as owner,
it solely provides for limited power of attorney to secure this permit in any behalf.
077946(rev.11)00)
401 it
L" v44 CITY OF COSTA MESA
NSala !=` BUILDING DIVISION
,i •^• I ;iRMIT
NUMBER DEVELOPMENT SERVICES DEPARTMENT 00-0047100471
+ .,.. PERMIT
�0epoomco,
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 291 23RD ST Status: ISSUED
Suite No Applied: 05/25/2000
Vicinity: REAR OF PROPERTY Issued: 05/25/2000
Parcel Nunmber: 42608411
Applicant: DONNA ISSUED BY:
Address: 24512 BRIDGER RD
Phone: 714 859-8466
EL TORO,CA Zip: 92630
Owner BROWN, GLEN D
Address 291 E 23RD ST
Phone:
COSTA MESA,CA Zip: 92627
Contractor: SWAN POOLS
Address: 24512 BRIDGER RD
Phone: 714 859-8466
EL TORO,CA Zip: 92630
License: 440333
SCOPE OF PERMIT
ELECTRICAL FOR THE CONSTRUCTION OF NEW 450 SF POOL/SPA IN REAR YARD OF EXISTING SFD.
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 $0.00 Standing Section $0.00 0
New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0
New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0
Pool/Spa $49.50 1 up to 10 kva/kw $0.00 0
Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 0
Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0
Switches $0.00 0 over 100 kva/kw $0.00 0
Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0
Res Appl $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 1 hp $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
Motors to 100hp $0.00 0 Other Electrical Fee $0.00
Motors over 100hp $0.00 0
Communication drops $0.00 0 Investigation Fee $0.00
Sub panel to 200a $0.00 0 Plan Check Fee $0.00
Pole Light Pkg $0.00 0 Reinspection Fee $0.00
Sign Circuits $0.00 0
Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $73.00
Intermed Pole $0.00 0
COMMENTS/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
Jnr a period of 180 days.
1
ISPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
quired Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
R INSPECTIONS CALL: (714)754-5626
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'compensation Insurance carrier and policy number are:
Carrier: /1C /DN • Policy Number: We �(.9d.5"-i7G,7
(This section need not be tompleted 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 shell 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: 6:+Ms) /' 1 /.t 2 Date: 5;2 —orf
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($100,000),IN ADOPTION 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 provisionsio 'of Chapter 9(commencing with Section 7000)of Division 3 of the Business and professions Code,and my license is in full
force and effect.Llc.4 '9"9 3.3 r Class a
Contractor's Signature: , �,,.i� / U/4,+.n-zc.i Date: .6"-"„2-S-06
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
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the properly,or my employees with wages as their sole compensation,WILL DO THE WORK,end 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 exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. 0 Yes 0 No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e..property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet In depth Into which a person Is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder.I will not employ anyone to do work which would require a permit from the Division of industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,ora volume of 55 gallons.
or 200 cubic feet of compressed gas at standard temperature and pressure).
__..... .....foracuey.. azar. ous.. .___.—_
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes 0N
(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 compiled with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification
from the South Coast Air Duality Management District or from any other air pollution control district or agency? Ii Yes IJ 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 slate that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature Of ner(s) Date
1,4 s--24,97-4 -;,2--ea
And/Or Authorized Applicant Date
CODE I INSPECTION TYPE - PATE 1NRTIAL8 CODES INSPECTION TYPE PAIL Lump
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical 3- L7"3
201 Final Block/Retalning 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
2446.46
411
L9. MSSq CITY OF COSTA MESA
!'` BUILDING DIVISION
"ret NUMBER
i DEVELOPMENT SERVICES DEPARTMENT
.. a
PERMIT
y
400-00216
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
MECHANICAL PERMIT
Job Address: 291 23RD ST Status: ISSUED
Suite No Applied: 05/25/2000
Issued: 05/25/2000
Vicinity: REAR OF PROPERTY
Parcel Number: 42608411
ISSUED BY: 219
Applicant: DONNA
Address: 24512 BRIDGER RD
Phone: 714 859-8466
EL TORO,CA Zip: 92630
Owner: BROWN, GLEN D
Address: 291 E 23RD ST
Phone:
COSTA MESA,CA Zip: 92627
Contractor: SWAN POOLS
Address: 24512 BRIDGER RD
Phone: 714 859-8466
EL TORO,CA Zip: 92630
License: 440333
Arch/Eng:
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
MECHANICAL HEATER FOR THE CONSTRUCTION OF A NEW 450 SF POOL/SPA IN REAR YARD OF
EXISTING SFD.
REF:B00-00747
FEE SUMMARY
Quantity Quantity
ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0
Inst FAU <100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0
Inst FAU>100 k BTU $18.20 1 Ventillation System $0.00 0
Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0
Inst/Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0
Refrig Sys<100 k BTU $0.00 0 Domestic 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 k BTU $0.00 0
Factory Fireplace $0.00 0 3 To 15 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 $0.00 0 Over 50 hp/Over 1,750 BTU $0.00 0
Appliance $0.00 0 Boilers
Fire Dampers $0.00 0 Up to 3 hp $0.00 0
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
Floor Furnace $0.00 0 Other Mechanical Fee
Floor or Suspend Heater $0.00 0 Investigation Fee $0.00
Plan Check Fee $0.00
Reinspection Fee $0.00
TOTAL CALCULATED FEES $41.70
COMMENTS/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 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 /�
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 wilt 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: / �n
Carrier: /. IPA Policy Number: we
(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: 6-4 S n n
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML RNES 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 WOE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under rovisions 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 402 33 3 C-53 Class a e -S3
Contractors Signature: ,
Date: 4—-O d
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: 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 sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors Ucense Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors Ucense Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date: •
Owner ID verified by drivers license. 0 Yes 0 No Drivers Ucense No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
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 Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
—5.—Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 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 Califomia 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 COMPUANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
A/ Signature tegalOwner(s) Dai
off
And/Or Authorized Applicant Dat0
CODE# INSPECTION TYPE PAIL INTiALS CODE I INSPECTION TYPE p RAIE u1
J *-
1616 Fixed System Final Fire Prevention 206 Final Mechanical `5-3 I
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
2446.48
.``6g1e M�'r9; - CITY OF COSTA MESA
>i BUILDING DIVISION
i E' PERMIT NUMBER
:.- DEVELOPMENT SERVICES DEPARTMENT
a PERMIT •
#ii- - .p7•.1 JP00-00278
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 291 23RD ST Status: ISSUED
Suite No Applied: 05/25/2000
Issued: 05/25/2000
Vicinity: REAR OF PROPERTY
Parcel Nunmber: 42608411 ISSUED BY: g m
Applicant: DONNA
Address: 24512 BRIDGER RD
Phone: 714 859-8466
EL TORO,CA Zip: 92630
Owner: BROWN, GLEN D '
Address 291 E 23RD ST
Phone:
COSTA MESA,CA Zip: 92627
Contractor: SWAN POOLS
Address: 24512 BRIDGER RD
Phone: 714 859-8466
EL TORO,CA Zip: 92630
License: 440333 ,
Arch/Eng:
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
PLUMBING FOR THE CONSTRUCTION OF A NEW 450 SF POOL/SPA IN REAR YARD OF EXISTING
SFD.
REF:B00-00747
FEE SUMMARY
AMT QTY AMT QTY AMT QTY
ISSUE FEE $23.50 Laundry Tub I Washer $0.00 0 Sump Pump $0.00 0
Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $60.75 1
Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0
Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0
Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0
Connect(Ice,Soda,etc) 50.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0
Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0
Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0
Drain,Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0
Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $0.00 0
Drain, Roof $0.00 0 Shower $0.00 0 Water Heater/vent $0.00 0
Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0
Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 0
Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0
Gas(1-4 outlets) $6.15 1 Sink,kitchen $0.00 0 Water Softener $0.00 0
Gas(Over 4 outlets) $0.00 0 Sink,service/mop $0.00 0 OTHER $0.00
Gas Repipe $0.00 0 Spa(private) $30.25 1 VIOLATION $0.00
Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00
Interceptors(Grease, Oil) $0.00 0 REINSPECTION $0.00 0
Interceptors(Sand Auto) $0.00 0
TOTAL CALCULATED FEES: $120.65
COMMENTS/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 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
v
•
DECLARATIONS'-
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations: -
❑ I have and will maintain a cenlficate 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: 14/6.49043-43424
./C�D�S dad
Carrier: LE4/n/"J • Policy Number: W
(This section need not be completed it the permit is valued at one hundred dollars($700)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 proyisions. //// '/
Applicant Signature: Oit..r7•.f/ !`A.f Lx Azv�/ Date: 4 dI/
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL EWES UP TO ONE HUNDRED
THOUSAND COLLARS($100,000),IN ADDtON 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.a �y 3 33 a7 -}3 Class a -5 3
Contractors Signature: ,�Uhvn,- Date: 5,2 S-oro
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction tending agency for the performance of the work for which this permit Is Issued.(Sec.3097,Civil Cale).
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
subjects the applicant to a civil penalty of not more than five hundred dollars(5500).):
❑ 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(Sec. 7044, Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth Into which a person Is required to descend,will be made In connection with work authorized by this
permit,and that no building structure,scaffolding.falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2.Art 2.Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑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 hes 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 et 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 a plication apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? IIU Yes 0 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? ❑Yes D No -
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certity that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature,Df Legal Owner(s) Date
Ar--pi.-4.." /' t 1,4A-4.-A-91-7•e
5.-.2.$---0�
And/ r Authorized Applicant Date
CODE r INSPECTION TYPE PAIL PMT141.$ SOPS• INSPECTION TYPE PAIS A
1818 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing 3-53
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
2446.46
405777 MFS. • CITY OF COSTA MESA
>j BUILDING DIVISION
PERMIT_NUMBER;
DEVELOPMENT SERVICES DEPARTMENT
PERMIT B00-00747
eoht eetre,e
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 291 23RD ST Status: ISSUED
Suite: Applied: 05/25/2000
0 Vicinity: REAR OF PRPERTY Issued: 05/25/2000
Parcel Number: 42608411 Zoning:
Applicant: DONNA ISSUED BY:
Address: 24512 BRIDGER RD
Phone: 714 859-8466
EL TORO,CA Zip: 92630
Owner: BROWN, GLEN D
Address 291 E 23RD ST
Phone:
COSTA MESA,CA Zip: 92627
Contractor: SWAN POOLS
Address: 24512 BRIDGER RD
Phone: 714 859-8466
EL TORO,CA
Zip: 92630 License: 440333
Arch : Eng: RON LACHER
Address: Address: 1201 N TUSTIN AVE
Phone: Phone: (714)630-6114
ANAHEIM,CA
Zip: License: 92807 License:
SCOPE OF PERMIT
CONSTRUCT NEW 450 SF POOL/SPA IN REAR YARD OF EXISTING SFD.
FEE SUMMARY
Plan Check: $199.71 Calc Valuation: $18,900.00
Permit: $307.25 Claim Valuation: $18,900.00
SMIP Res: $1.89
SMIP Corn: $0.00
Other: $0.00
Inspection: $0.00
Total: $508.85
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 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 )
DECLARATIONS c
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: 1,41/d--
(This
/ 'nG
Carrier: tl /02) • Policy Number: [-7/'
(This section need not be completed tithe permit Is valued of one hundred dollars($100)or less.)
❑ 1 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 agreer agreeI should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provis*.j.,se Applicant Signature: .S'—>rl,.,,ii /._(/j 4 -4.--,�B-
- st-f2I Date: —e-2-
WARNING:
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($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am 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.x PA0,3 4 Class k
Contractor's Signature: �N-n,_, J �A �.7,.est7 i/ Date: S�,2 —z0
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: 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 toe 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.).
❑ 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 en owner of property who builds or improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date: •
Owner ID verified by drivers license. ❑Yes 0 No Drivers License No, Expires:
Verification of Ownership by(type of document,i.e..property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,Califomia Administrative Code).
❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and 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 owi._the a-._ or future occupant need _ iYes..-_---_- No 2 or will applicant present or building occupant need to file a registration form for acutely hazardous materials? ❑Ves 0 No
(Section 25533 of the Califomia 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 0 No
(Section 25534 of the Califomia 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 It an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ppermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes u 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 It
-Er permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature OfL wner(s) Date
nd /
And/Or Authorized Applicant Date
CODE♦ INSPECTION TYPE DATE INTRIAL$ CODE x INSPECTION TYPE IE INTITIALS
1616 Fixed System Final Fire Prevention n ) 206 Final Mechanical
1266 ' Pool Spa Final r x 1 Cita {�D0 r ) 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
2446-46
05/24/00 13:58 FAX 713 708 1919 CDFA/RIFA e 001/001
mXY-22-00 MON 11 :53' M SWAN POOLS 590253 P• 01
('n•k4 7(4 • 701817/9
Cooperative Red Imported Fire Ant Project
Notification of Intent to Move Soil from or within Quarantined
Areas of Orange, Riverside, and Los Angeles Counties
riit]rACompliance Agreement#.90SOfD/O'S79 Permit 11
Issuing City/County Agency
Name of Company Requesting Approval: 52a/till AfiS
Contact Person: ECIC7�5[-�7Z^
Address: 24 S�/ 2- ?/OOSC-J ea%)City/derzip:_ 47c76.70
telephone:1J 997J h',sYA'4O6 Fax _( 9579) r2c7dc?s.�'
!:.xcavation Location: 131i el ow TB": S89 lel
2.6?I East" 23x-`i ACRES:
0.--0- --a Mesa C' QjLeri
Destination Location: it:
• ACRES:
Estimated Quantity of Soil (e.g. Ii Cubic Yards):
Anticipated Date of Movement:
Urgency Le'cl for Immediate Inspection and Release: [Circle One] inch Mt'U m r,v..
/G.. .Movement of Soil is Permitted.
ElHold Movement Until Site Checked -WE WILL CALL AS SOON AS POSSIBLE TO
SCHEDULE INSPECTION DATE AND TIME.
Date flapped: #of Traps: Trapped by:_ Acres:
Date Picked Up: Comments: PDR#:
Soil Movement is Strictly Prohibited for the Following Reason(s):
Name ofI 'APro'eet�8egulatoryOErcial: kAREA/ C��i//< Date: .l/e4//9r,
Rett_t_ tarnr• ttoCave Arcot/13/19
OWNER BANKHEAD, Loretta MAR j . 1958 DATE 10-30-57
JOB ADDRESS 291 — 23rd St. JUL 8 l838 BUILDING PERMIT NO. 5924
11 ELVERAL3CONTRACTOR Owner-Builder OCT 2 81958 VALUE § 160.00
P. No. 4 LOT TRACT FIRE ZONE DESCRIPTION OF WORK Tool shed add to pvt.gar.
GROUP J TYPE 0 ZONE R14 PLAN NO. 962
PERMITS ISSUED
I •ECTIONS DATE SUBCONTRACTOR
DATE NUMBER
Trenches Forms Steel
Floor System . —iW
Steel Reinforce Chimney Re-Rod 111.1.17
Bond Beam r7 i
Frame and Flashing % 1.11.1MEIMMIllaillEIMEMI
Lathing, In Out 1.11111==.1111Ma
Plaster, brown coat AlarrrT
Underground soil W/G Pipe est 411Miray ' n - .,
Top Out / 1 1(.Y1
Furnace arj�� .,1s \ f. 1
Gas Vents � �
, � '� - T 1
Rough PlumbinglinlINIZIMISMInat
Cesspool Septic Tank iffillannernir /
Prop. Swr. Line House Con. St. Swr. limant a
Sprinkling System EMENNigarnagrar,
Heating Final rf_ V /
Plumbin. Fixtures, FinalIMMISIIMMIIIII
F' ' Gas Test
C ruction 'ole
Underground Power
Rough Wiring '
Fixtures, Final
OCCUPANCY
Farm 210-5M-1-57 592k
J �-- 5962 FEE RECEIVED
10 -30 - \.? c _
COSTA MESA BUILDING DEPARTMENT
P.O.BOX 317 FINANCE DEPT.
COSTA MESA. CALIFORNIA CITY OF COSTA MESA
FOR APPLICANT TO FILL IN APPLICATION FOR PERMIT
BUILDING �ti - 'L-3 �^ 6�. af BUILDING
ADDRESS `I .
COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY•
_.�j
• I/ RECEIPT NO. PERMIT NO. //�I
OWNER 59 /
MAIL O+ (+ RECEIVED BY DATE RECEIVED GATE ISSUED ' 'Q
ADDRESS J / ,. -30 ; /O- jU�� /
CITY NO Z RECEIVED
ARCHITECT LIC
OR TICTER u1A COSTA MESA. CALIFORNIA
N C.
FIRE
ADD1, ZONE
FICITY LIC ZON � NO.OF "'-
PLANS
TYPE �/ GROUP
CONTRACTOR(-.,(a�J-f,.,�y,�,Q l_VfNO.
TEL. APPROV D
ADDRESS NO. BY DATE
LEGAL LOT CORRECTIONS
DESCRIPTION NO. BLOCK TRACT
A.P. NO. he - i 6 0 [/1�l�/1 _ eaOF f it/ I/ NO.OF BLOCS. /
/�I _OF LOT ,,]I Y /� Now oN LOT , j
1
USE OF A MESA 1
EXISTING BLDG. - ' CITY OF • TEP
SETBACK LINE FROM ^J� !! y L,�IINIL D 1.
CENTER OF STREET (� {/ ' REAR YARD O P _ .EPY. REG.
- `} SUB! 1 A 1
SIDE YARD ' RIGHT J / LEFT A A
DESCRIPTION OF WORK V DAT k"
uY PIAN T
NEW ALTERATION ADDITIONX.
•
REPAIR MOVING DEMOLISH
BUILDINO.OF
SIZNGE )l t�O: ROOMS �q1�STORIES
EXTERIOR ROOF INGab 4T'��
COVERINGy'j/�/ ,O OVER N G COfJfL/_
USE OF NEW //t._ 1/
BUILDING �.TJ`/__l A'-�J'f."'l'Z"w1\
£.L.1-LG4 .. A J d_M.l..,,LA
CII--YC—
I H REBY AC OABOVEI THAT I NAVE READ THIS APPLICATION AND
STATE THAT BOVE IS CORRECT AND AGREE TO COMPLY WITH ALL
CITY ORDINAN EB ND STATE LAWS REGULATING BUILDING CONSTRUC-
TION. f VALUATION —_
SIGNATURE OF .L a PERMIT FEE $
PERMITTEE y.- �.A -.4e $ 1//� -,-
-
/
JJJ ��l 9 i PLAN CHECK $
•
,
AUTHORIZED AGENT TOTAL FEE Si YeMr
" -COSTA MESA BUILDING-SAFETY DEPARTMENT
P. O. BOX 1200 " 2907 6/06/81 15,00 II
Costa Mesa, California
�",, PERMIT NO.
PLUMBING PERMIT APPLICATION TRACT NO. RECD. BY 11L3 /'5/3
CONTRACTOR C. C. Cole Plumbing LOT NO. DATE ISSUED
BUILDING USE v-/_ 'D/
Address 2280 Newport Bl. Resident ial O fG o /
' City Costa Mesa, Ca. Tel. No.645-1161 ADD ESS 291 E. 23rd Street •
State License No, 275585 Class. SC36 COSTA MESA. CALIFORNIA
NEAREST
OCROSS Sr. Santa Ana Ave. 4
w City License No. -/-4.....8 n e
OWNER Glen Brown_- il. ��5
< NUMBER ,TYPE OF FIXTURE OR ITEM FEE MAIL +'-
0_ Wifer Closet(Toilet) ADDRESS 291 E. 23r� Street p
J a'L `f�Bath Tub CITY Costa Me e
L . � TEL. NO. 548..2183
Shower I hereby acknowledgethat I have read this application
Lavatory(Wash Basin) and state,that thelabove is correct and agree to comply
> Kitchen Sink with.alli_City Ordinances and State Laws regulating
1 Laundry Tub or Tray — plumbing.,
•
w service Sink :''+ I ceitify that I possess the above valid state of Cali-
a \
forma classification or aIt the legal owner of the resi-
O Floor Sink -' ri Jdential property to • b•s above
(r Floor Drain -,') IN a4. �-
Cl. Dishwasher -:cct Vf yY Signature of n
Permittee 11 -01L
2 Drinking Fountain s` i CI' f
w Urinal kt. / INSPECTION RECORD
Garbage Disposal .«llika Zwr r� �
1 Automatic Washing Macri. � VM
. .. _-{a,,,. II....., ink iLlQ t ��.e/9 I pt el
F Water Softener_\ IG V. .I' (f $ .spf, .2
1 Water Heutci&�VenC �.
i /o f
CC Receptor\_."
w
Cl- •
SwimlPool Filter System )
CC 1 Gas System . 1.4, Outlets D -
D Lawn Sprinklers
O Installation or Alteration
1 Water Pining 2 — APPROVALS
Back Flow Prevcnter
ca Prop. Se Wei' ft. INSPECTOR DATE
= House Sewer Cannection U/G Soil
F Cesspool, Septic.Tank U/G Water
Services-Water ❑ Gas ❑
Miscellaneous Rough Plumbing
• Sprinkler System
• Gas
Property Sewer
_ Pool Receptor
Filter System . \
Pool Heater et
Miscellaneous Q
Issuing Permit , 00
Final Gas I(� '� �/ Cr
TOTAL I'FEE, . 11. 0 C Plumbing Final iJ . -i) o �� t
Utility Co. Notified Q,
FORM eu-a. BLDG. PERMIT NO. N/e