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HomeMy WebLinkAbout259 22ND ST - Building Permits c -- _ F 4`0111 9 CITY OF COSTA MESA - _ BUILDING DIVISION F . DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER -• PERMIT P05-00666 41`b4Pop.370 se (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.M213MBING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 259 22ND ST Status: ISSUED Suite No Applied: 08/30/2005 Issued: 08/30/2005 Vicinity: Parcel Nunmber: 42615304 Applicant: BOB SCHALOW Address: ISSUED BY: Phone: 949-515-9563 Zip: Owner GANNON, LAURIE . Address 259 E 22ND ST Phone: 949-637-1153 - . • COSTA MESA,CA Zip: 92627 Contractor:' Address: • Phone: - Zip: License: SCOPE OF PERMIT REINSTATE EXPIRED PERMIT P03-00163 TO INSTALL KITCHEN SINK AND WATER HEATER , CHANGE-OUT RE;B03-00412,B05-01449 " r FEE SUMMARY AMT °QTY .: AMT '(3_TY_- - .V.^ 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 Prevent& ', $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) $0.00 0 • 'Receptors - $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $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 $12.30 1 Drinking Fountain $0.00 0 Sink,bar •- $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank f $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) " $0.00 0 ' . Sink,kitchen $9.80 1 - 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) • $0.00 •0 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) • moo " 0 . - . TOTAL CALCULATED FEES: $45.60 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. • INSPECTIONS: In order for 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 2448-48(8/00) .C, 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 sell-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 lass.) ❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVEMGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect.Lic.# Class# 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(commenting 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 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 un.:. ec. / - lusiness and Professions Code for this reason: • Signature: ' tee' Expires: /ETA/ ✓' 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,Califomla 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 materiel? 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? ❑Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this Application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U 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). 8 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application,have at of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under�penalty of perjury that I have read this application and state that the Information given is correct. I agrer to comply/ th all state law :nd city ordinances rola 6'building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-.:- rib:•pro.; ; or inspection• •oses.I agree not upy or allow occupant any building authorized by this ermit u I final inspection. 30 45 gnature Of Legal Owner(s) Date And/Or Authorized Applicant Date CODE L INSPECTION TYPE PATE VfTI1AU ONE. INSPECTIONTYPE PATE IMITIALI 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing T I'OS � 67:141 ...CYC 200 Final Re-Roof 210 Final Electrical PP o 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 5011 CITY OF COSTA MESA • frD BUILDING DIVISION >N' .4. DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER ler.erifr al PERMIT 110111.4'wr ows°d`' P03-00163 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 259 22ND ST Status: ISSUED Suite No Applied: 03/13/2003 Issued: 03/13/2003 Vicinity: Parcel Nunmber: 42615304 ISSUED BY: Scior / Applicant: GANNON, LAURIE Address: 259 E 22ND ST Phone: 949-637-1153 COSTA MESA,CA Zip: 92627 Owner: GANNON, LAURIE Address 259 E 22ND ST ,1) Phone: 949-637-1153 p -�[l�O COSTA MESA,CA Zip: 92627 ��^/�c^1��:��...IIIL( (1 04 Contractor: OWNER-BUILDER I `/J Address: 5Z. Phone: Zip: License: 000000 Arch / Eng: Address: Phone: • Zip: • License: SCOPE OF PERMIT CHANGE OUT SINK IN KITCHEN.CHANGE OUT WATER HEATER. 6/24/03:SUPPLEMENTAL PERMIT TO ADD 1 GAS OUTLET(1-4) 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 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $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 $12.30 1 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $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(&00) r . DECLARATIONS • WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have end 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. O 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.) U'/(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 III should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these proisions. Applicant Signature: CLJJ'tA--1 C'Qdin, \(XDate: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE(S100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37080F THE LABOR CODE,INTEREST.AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect.tic.0 Class 0 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: 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(5500).): O 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 havethe burden of proving that he or she did not build or improve for purpose of sale.). VI,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business end 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: AXA-J\ PZaiEFFF=T1-- Expires: La—lh—°L-I 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 Cede). O 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 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Flre 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 Califomia Health end Safely 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 _ ..__,_ . ._.. ..__.. .._...____....__ _ ._ _ __ _i... 5 Does or will the applicant or present.Or emen butling o at any other for the work which is the subject age of this application agermit for such construction or modification from the South Coast Air Quality Management District or from other air pollution control district or agency? Yes ❑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 (It'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 prescnbed by California Health and Safety Code Section 42303 been made? 0 Yes ❑No 8 (If'yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the a ove-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. uus_ (0 n (9-lk --03 Signature Of Legal Owner(s) Date And/Or Authorized Applicant Date CODE t INSPECTION TYPE DATE gjIfALfl DOOR INSPECTIONTYPE PACE It711T1AL§ 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 `,STS CITY OF COSTA MESA t4 BUILDING DIVISION > ..,,.. ..fiI r DEVELOPMENT SERVICES DEPARTMENT PERM NUMBER Jt ' PERMIT "�; 04-01316 Sabo fie sass (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 259 22ND ST Status: ISSUED Suite No Applied: 12/20/2004 Vicinity: Issued: 12/20/2004 Parcel Nunmber: 42615304 Applicant: SCHALOW, ROBERT ISSUED BY: A. Address: Phone: Zip: Owner: GANNON, LAURIE Address 259 E 22ND ST Phone: 949-637-1153 COSTA MESA,CA Zip: 92627 Contractor: Address: Phone: Zip: License: SCOPE OF PERMIT REF:804-01282-346 S.F. EXPANSION TO MASTER BEDROOM AND BATHROOM.CONSTRUCT A DOOR AT THE REAR OF THE HOUSE. • ELECT.PERMIT IS FOR: 12 FIXTURES, 10 OUTLETS, 12 SWITCHES&METER UPGRADE(200 AMP). 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 $13.20 12 up to 50 kva/kw $0.00 0 Recept Outlets $11.00 10 up to 100 kva/kw $0.00 0 Switches $13.20 12 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 530.50 1 Misc.Conduit 50.00 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 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or If work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(WOO) Ij DECLARATIONS , I 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 certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DCLLARE(5103.0011),IN ADDMON 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.IJc.a Class s 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 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 d 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 Lice -ws.). ❑ I am ex• • += s • CITY OF COSTA MESA 4 BUILDING DIVISION ,,,,, ; DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER I Wr � I te PERMIT 04-00676 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 259 22ND ST Status: ISSUED Suite No Applied: 12/20/2004 Issued: 12/20/2004 Vicinity: ppg�� ��'• _ Jf Parcel Number: 42615304 ISSUED BY: {'-I �"' Applicant: SCHALOW, ROBERT 1 Address: Phone: Zip: Owner: GANNON, LAURIE Address: 259 E 22ND ST Phone: 949-637-1153 COSTA MESA,CA Zip: 92627 Contractor: Address: ' Phone: Zip: License: SCOPE OF PERMIT REF:804-01282-346 S.F.EXPANSION TO MASTER BEDROOM AND BATHROOM.CONSTRUCT A DOOR AT THE REAR OF THE HOUSE. MECH.PERMIT IS FOR 2 VENT FANS. - 3%29/05: FAU CHANGEOUT&DUCTWORK ADDED TO EXISTING MECHANICAL PERMIT. ' FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU 514.80 1 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $13.70 1 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 $14.50 2 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 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia 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(aro0) 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. o 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: Carder: Policy Number: (This sec Ion need not be completed if the permit is valued at one hundred dollars(S 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,an roe that If I ould become to the workers'compensation provisions of Section 700 of the Labor Code,I shall forthwith comply with these pro ' 5. -Applicant Signature: /Date:- 2 a S WARNING:FAILURE TO SECURE WORK 5'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI PENALT4ES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOL-ARE(S100,000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE R 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.4 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 end 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($500).): o I,as owner of the property.or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). It—Y I/r as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of properly who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the tractors Lie. se Laws.). ❑ I am exam• der 5$ Business and Professions Code for this reason: 'Signature: /t� ' ( flakes: 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). o 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? ❑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 thee applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Veses 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 en 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? ❑Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application 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 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 pan 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 Califomia Health and Safety Code). • 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? 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 taws 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 atl state laws and city ordinances relating to bull. •1 construction,and authorize representatives of the Cit of Costa Mesa to enter upon the above-describe. • •'`:rty for or lion our., es.1 agree not t• . •• •r a ow occupancy of any building authorized by this permit until al inspec tie 3 9/Of Signature Of-Legal Owner(s) Da And/Or Authorized Applicant Date CODE I INSPECTION TYPE DAIS INRTIALS NODES INSPECTION TYPE eat INTTMLE 1616 Fixed System Final Fire Prevention 206 Final Mechanical e ZZ'QC 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 Jr A . . • 4`p F 9 CITY OF COSTA MESA BUILDING DIVISION Y •r- oialim , ,r DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER PERMIT ttbkiro Racy)" M04 00676 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 259 22ND ST Status: ISSUED Suite No Applied: 12/20/2004 Issued: 12/20/2004 Vicinity: Parcel Number: 42615304 ISSUED BY: l Applicant: SCHALOW, ROBERT Address: Phone: Zip: Owner: GANNON, LAURIE Address: 259 E 22ND ST Phone: 949-637-1153 COSTA MESA,CA Zip: 92627 Contractor: Address: Phone: Zip: • License: SCOPE OF PERMIT REF:1304-01282-346 S.F.EXPANSION TO MASTER BEDROOM AND BATHROOM.CONSTRUCT A DOOR AT THE REAR OF THE HOUSE. MECH.PERMIT IS FOR 2 VENT FANS. 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 50.00 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 $14.50 2 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 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) 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/Y 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 Idrthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(St W,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,end my license Is in full force and effect.Llc.ii Class N 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 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.). ' 'S1( I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions T 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 =ws.). ❑ lam exempt u.•' -+c. / Busine .nd Pr. ,_ Ions Code for this reason: Signature: _ .�' I_ ��. ,' p Owner ID verified by drivel Icense. '}�`v'es 0 No Driver's License No. Expires: Verification of Ownership by(type of doc 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(38)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 ❑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 matadors)? ❑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. _.____ __ __ .____.._al ._ _..._ s____.__... 4 If an RMPP is presently require?has Section 25534 of the California Heelth and Safety Code been fully complied with? ❑Ves 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 emit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 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). _._.hef._...._ynu_t..____._this _ _. ______ _.. 6 Will any part of the facility to be constructed under ipermit be within 1000 feet from the outer boundaries of a school? 0 Yes ❑No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 6 (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,end 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. /•i.•- a Of Le.. owner(s) - 'sate 2 >O / Ander Authorized Applicant Date ODE A g1SPECTION TYPE PATE pnulALE CODE! INSPECTION TYPE PAIS MALS 1616 Fixed System Final Fire Prevention 208 Final Mechanical 8-ZZ"ar 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 5111 9� CITY OF COSTA MESA �- BUILDING DIVISION > • ,,,,.' �/ � � , DEVELOPMENT SERVICES DEPARTMENT PERMIT UMBER F1 e �• PERMIT '° ° a. PO4-00858 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 259 22ND ST Status: ISSUED Suite No Applied: 12/20/2004 Issued: 12/20/2004 Vicinity: ISSUED BY: Parcel Nunmber: 42615304 Applicant: SCHALOW, ROBERT Address: Phone: Zip: Owner: GANNON, LAURIE Address 259 E 22ND ST Phone: 949-637-1153 COSTA MESA,CA Zip: 92627 Contractor: Address: Phone: Zip: License: Arch / Eng: Address: Phone: Zip: License: SCOPE OF PERMIT REF:B04-01282-346 S.F.EXPANSION TO MASTER BEDROOM AND BATHROOM.CONSTRUCT A DOOR AT THE REAR OF THE HOUSE. PLUMBING PERMIT IS FOR: 1 BATHTUB, 1 SHOWER, 1 SINK, 1 WASH BASIN SET& 1 TOILET. 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 50.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $9.80 1 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) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $9.80 1 Drain,Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain,Rainwater 50.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $9.80 1 Drain,Roof $0.00 0 Shower $9.80 1 Water Heater/vent $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1,12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 244646(6/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. My workers'compensation Insurance carrier end policy number are: Cartier Policy Number (This section need not be completed it the permit is valued at one hundred dollars($t00)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 Idrthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED TH(1JCAND DOLLARE(5100000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.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 fore 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 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 •ntractors Lice.�.i- Laws.). ❑ I am exem. • ••er =usiness and Professions Code for this reason: Signature: I t— Date: /a/'r.c gq Owner ID verified:'driv:r's lice e. r: Yes 0 No Drivers License No. / (. Spires: /0/�0 Verification of Ownership by(type of doc ment,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? ❑Yes 0 No (Section 25533 of the California Health and Safety Code,wllh some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and—Safety Code been fully complied with? ❑Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes ❑No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 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 prescnbed 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 properly for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. !nature Of :•' • devil/ ' An. Wutoriz:7 .plicant Date/ CODE$ Itl$PECDON TYPE PATE llfDhlMLS CODES INSPECTION TYPE PATE WM 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing $22.'x- (sat_ 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy _ • I DEPUTY 1 INSPECTION SERVICE INC. I DEPT. OF BLDG. & SAFETY 25121 DE SALLE ST, LAGUNA HILLS, CA 92653 CITY OF eof/Tftt > -514 1 - 800 - DEPUTY 1 = 1 - 800 - 337 - 8891 COUNTY OF SPECIAL INSPECTION REPORT 3i C�1 L z— Job. No. Date 5- BuildingPermit No. � � "- � 3 "Z-� Job Indentification/Address 5C. tkri'c-o+-Q A-4n0 72t-"tb.'NnW 7,51 2aY- sr. C . wt General Contractor/Address •Ht4411 P€'L rc,N-57-• Sub - Contractor/Address Structural Engineer/Address T7t 54- ljTr.t.tc.—, Arch. REINFORCED CONCRETE MASONRY HI-TENSILE BOLTING CHEMICAL ANCHORG) PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE OTHER lkELDEF. RECEIPT NUMBER WELDER RECEIPT NUMBER DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED 3 -7- 05- ,f-r 5/rhE4,C c-t.'4t . /h' EXIST , 01^ {v2 Ui35a e7 /sl57m-c f17&N a>< tpZ) cCx.t."1-7- 57e r'-$_"TS e O. Roos w/ Ii" ' 18EP Stk?f5o'/ 5-Er Fft'Xy 5?i7 'tot_ 5 /is v o vte$r Z]"r g445/4cp i -j4L c efritJ I ^L5 tc.-cW Pitt- Z &7>11LS - 9' /s17-1 a1H7,t5 Fe-5, HOURS SAMPLES DATE Reg. OT Time In Time Out Grout Mortar Concrete I Block Density ( Prisms ----- All inspections based on a minimum of 4 hours&over 4 hours-e hours ---_- ----- minimum. inspectionextending pastthe noon r will billed as hur minimum. In addition,any inspection extending pastan a our pe- riod, or Saturday inspection will be billed at time and a half. ATTORNEY'S FEES - If any action at law or in equity is brought to enforce or interupt the terms of this Contract, the prevailing party shall be entitled to reasonable attorney's fees,costs and necessary disbursements in addition to any other relief to which such party maybe entitled. . yoi ` SPECIAL INSPECTION REPORT L Inspector's Name: y Inspector's Signature: I.D. No. U a S YL-.Liles},as been filed and it states that the above work to the b 71 of his er kno ledge complies with the provisions of the Uniform Building Code and meets approved plans and specification rRespectfully Su ed, Approved by: Project Superintendent By: Larry carter \,:ar 4`,501 F 9 CITY OF COSTA MESA BUILDING DIVISION 4nt DEVELOPMENT SERVICES DEPARTMENT 011 PERMIT N BER F 1 a4 PERMIT 1 E03 544 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 259 22ND ST Status: ISSUED Suite No Applied: 06/24/2003 Vicinity: Issued: 06/24/2003 Parcel Nunmber: 42615304 Applicant: GANNON, LAURIE ISSUED BY: Address: 259 E 22ND ST Phone: 949-637-1153 COSTA MESA,CA Zip: 92627 Owner: ' . GANNON, LAURIE 4,-�tilt Address 259E 22ND ST p Phone: 949-637-1153 AL0 S,j0�. COSTA MESA,CA Zip: 92627 eXP/ i at Contractor: OWNER-BUILDER • S Address: Phone: Zip: License: 000000 - SCOPE OF PERMIT ELEC PERMIT IN CONJUNCTION WITH INTERIOR TI IN AN EXISTING SFD.20 LIGHT FIXTURES, 11 OUTLETS,7 SWITCHES REF:803-00614 AND 803-00412 • 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 $22.00 . 20 - up to 50 kva/kw $0.00 0 Recept Outlets $12.10 11 up to 100 kva/kw $0.00 0 Switches $7.70 7 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 1hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 .. 0 Fireworks Stand $0.00 0 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 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)7545626 2446-46(6/00) DECLARATIONS I 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 s bon 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 pr vis ns. ,- ^ '7 C-5-3 R Applicant Signature: ( .lN 1 n(Y\ Date: —G..L'� -v : WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES ANO 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.A Class it 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: 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).): ❑ f,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 so ithin 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.). ❑ 1 am exet under sec. Business and Professions Code for this reason: Signature: (A A A.. `Xi (�n cY'� Expires: (o-f K-0`1 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). O 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 ❑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 aapermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U 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? 0 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 ❑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. LCA A (_.)cL 1rbel — 2C{-0� Signature Of Legal Owner(s) Date And/Or Authorized Applicant Date CODE 1 jNSPEC1QN TYPE DATE RILLS coDE( INSPECTION TYPE PATE dill • - 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 'Y' — f, 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 041519 CITY OF COSTA MESA BUILDING DIVISION ). ; ' DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER t ,'�n��Z 1 PERMIT le P03-00163 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 259 22ND ST Status: ISSUED Suite No Applied: 03/13/2003 Issued: 03/13/2003 Vicinity: Parcel Nunmber: 42615304 ISSUED BY: Applicant: GANNON, LAURIE Address: 259 E 22ND ST Phone: 949-637-1153 COSTA MESA,CA Zip: 92627 '(� Owner: GANNON, LAURIE .2115q9 (\ F'']/ Address 259E 22ND ST Si' r �1(� 1/0 Phone: 949-637-1153 ' VVV I COSTA MESA,CA Zip: 92627 DRQ Contractor: Address: - Phone: Zip: License: Arch / Eng: , Address: Phone: Zip: License: SCOPE OF PERMIT CHANGE OUT SINK IN KITCHEN.CHANGE OUT WATER HEATER. 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 50.00 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) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $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 $12.30 1 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 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(6ro0) • 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: erne Policy Number: i ction 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 700 of th Labor Code,I shall forthwith comply with thes pr visions. Applicant Signature: /LA t _Cer—An CMY" Date: ? [31 5 WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect.Lic.It Glasse 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 end Prdfes@ions 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 ubje s the applicant to a civil penaltyof not more than five hundred dollars($500).): owneriof the ofty, o meloyhes wonth wages i their sole compensation,not apply WILL DOn THE WORK,and the structure is intendederofferedwo 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 oder sec. Business and Professions Code for this reason: L • O Signature: Date: 1 it CNnV Owner ID verified by driver's license. Yes ❑No Driver's License No. Ekpires: 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 materiel? 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 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. 411 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 ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes I�No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes ❑No (If yes-,the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 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 f the City of Costa Mesa to enter upon the above-descried operty for Inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this e t until fi spection. � 60—In 1,3 I Signature Of Legal Owner(s) \ D I And/Or Authorized Applicant Date ;ODE}, IySPECTION TYPE ;ATE INTITIALS ODE I INSPECTIONTYPE 29IE INT111AL9 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1286 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 4`h'" "'rl CITY OF COSTA MESA BUILDING DIVISION � Y• 1„„,1. ! , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 1. 1 t PERMIT +� B03-00614 tbm R (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.aus.LDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 BUIJob Address: 259 22ND ST Status: ISSUED Suite: Applied: 04/11/2003 Vicinity: Issued: 05/23/2003 Parcel Number: 42615304 Zoning: Applicant: GANNON, LAURIE ISSUED BY: Address: 259 E 22ND ST Phone: 949-637-1153 COSTA MESA,CA Zip: 92627 Owner: GANNON, LAURIE / Address .259E 22ND ST - 9Ilk 4 Phone: 949-637-1153 JJJ COSTA MESA,CA” - Zip: 92627 1,40; Contractor: OWNER-BUILDER Address: Phone: • Zip: License: 000000 Arch : Eng: Address: Address: Phone: Phone: Zip: • License: License: SCOPE OF PERMIT DEMOLISH EXISTING LOAD BEARING WALL CURRENTLY DIVIDING THE DINING ROOM AND FAMILY ROOM. FEE SUMMARY Plan Check: $54.11 Calc Valuation: $2,500.00 Permit: $83.25 Claim Valuation: $2,500.00 SMIP Res: $0.50 • SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 ..Total: _ $137.86 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 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 end 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 certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions, Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100.000),IN ADDITION TO THE MST 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.Lk.It Class 4 Contractor's 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). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDERDECLARATIONS: 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 thathe 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).): O I,as owner of the properly,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 Iold within one year of completion,the owner-builder will have.the burden of proving that he or she did not build or improve for purpose of sale.). as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). t under sec. Business and Professions Code for this reason: Ignemature' -GJI — • nor ID verified by driver's license. s 0 No D' s License No. - 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 tile 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 thisapplication aggermit for such construction or modification from the South Coast Alr Quality Management District or from any other air pollution control district or agency? LJ Yes u No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6 WIlI any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 5— —03 slurs Ot Legal Owned) Date And/Or Authorized Applicant Date COQEy. INSPECTION TYPE PATE IUTRIALS CODEC INSPECTION TYPE DAIS INTRIALa 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy CITY OF COSTA MESA • 9 BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 4, PM) PERMIT 1B01-01583 f4.bo `s+ , .mm (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 259 22ND ST Status: ISSUED Suite: Applied: 10/05/2001 Vicinity: RESIDENCE AND ATTACHED GARAGE Issued: 10/05/2001 Parcel Number: 42615304 Zoning: Applicant: BALDWIN, AUDREY ISSUED BY: Address: 259 E 22ND ST Phone: 949-646-5522 • COSTA MESA,CA Zip: 92627 Owner: BALDWIN, TERENCE D Address 259 E 22ND ST Phone: COSTA MESA,CA Zip: 92627 Contractor: Address: Phone: Zip: License: Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT REMOVE EXISITNG ROOF COVERING,REPLACE SHEATHING AS NECESSARY,APPLY 1 LAYER OF 30 LB FELT,AND APPLY 35 YEAR COMP SHINGLES. FEE SUMMARY Plan Check: $0.00 Calc Valuation: $4,500.00 Permit: $111.25 Claim Valuation: $4,500.00 SMIP Res: $0.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $111.75 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 2446-48(WOO) 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'co eAnsation^InAsuAran'ce carrel end policy number are: � Carrier: _Q/yyl� '( r 1 Policy Number: is section nee���"`llr���of be mplefed if(permit Is valued at one hundred dollars($100)or less.) certify that in the performance of he 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 provisi -/ Applicant Signature: �Y� Date: /0-5-0 WARNING:FAILURE TO SECURE WORKgRS'OOOOOMPENSA COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DOLLARE(Sta0.D00),IN RADE I7 ON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under 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: 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 Cade). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a pent sub cts 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 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 em exempt un c. Business and Professions Code for this reason: Signature: .----/ Date: /0— "? "" 1 Owner ID verified by drivers Ii se. ❑Yes 0 No Driver's License No. Expires: Verification of Ownershid.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 then 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 Califomia 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 aRPermit 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 Califomia 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 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 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-des d pro rty fori oses.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. g� p i 0 r 5 - DI // Signature Of Legal Owner(s) Date �/ And/Or Authorized Applicant Date CODE 6 INSPECTION TYPE DATE INTRIALS CODE! INSPECTION TYPE PATE IMAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 1 C 200 Final Re-Roof 210 Final Electrical 201 Final BIocWRetalning 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 •S CITY OF COSTA MESA 4. ►. BUILDING DIVISION F• _ 4 . DEVELOPMENT SERVICES DEPARTMENT X10�j PERMIT NUM ER Vic% PERMIT �� �' !�'`�s' BO -0 14 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 259 22ND ST Status: ISSUED Suite: Applied: 04/11/2003 Vicinity: Issued: 05/23/2003 Parcel Number: 42615304 Zoning: Ate Applicant: GANNON, LAURIE ISSUED BY: . •/ Address: 259 E 22ND ST Phone: 949-637-1153 COSTA MESA,CA Zip: 92627 Owner: GANNON, LAURIE ti7.472, Address 259 E 22ND ST �i ,C`'y Phone: 949-637-1153 444® 'SIO T COSTA MESA,CA Zip: 92627 cPo 1 IV Contractor: OWNER-BUILDER ` l,Oi Address: 4:7 Phone: Zip: License: 000000 Arch : - Eng: Address: Address: Phone: Phone: Zip: • - License: License: SCOPE OF PERMIT DEMOLISH EXISTING LOAD BEARING WALL CURRENTLY DIVIDING THE DINING ROOM AND FAMILY ROOM AND INSTALLATION OF 4 POST AND A BEAM. 6/24/03:REVISION OF PLANS TO RELOCATE THE FRONT ENTRY DOOR.CHANGE-OUT 4 WINDOWS AND 1 SLIDER(SAME SIZE). FEE SUMMARY • Plan Check: $54.11 Calc Valuation: $2,500.00 Permit: $83.25 Claim Valuation: $2,500.00 SMIP Res: $0.50 SMIP Corn: $0.00 Other: $0.00 . , . . Inspection: $0.00 - Total: $137.86 . 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 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No.92-28,§1.12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days•or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46 WOO) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 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 it the permit is valued at one hundred dollars($100)or less.) VP,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 1 should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with theserCovisions. Applicant Signature: C.�.L A (20-4n(lU'� Date: t - 11.1 -U WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARE(S10g000),IN ADDIIION 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 end effect.Lic.# Class# Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I 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,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 self 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 havetheburden 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 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: l Signature: W^ A - 1/ 1n(Y1 Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: • ❑ I hereby certify that no excavation five(5)or more feet In depth into which a person Is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑N0 (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 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 apeermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? YesI No (Section 65850.2 of the California Govemment Code requires that the requested information be fumished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code)....__ _._ __— _C _ __....._control.................._..._...__—____ — _ ___ 7 If a permit from the South Coast Air Quality Management District or other air pollution district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No 8 (If yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-de cribed property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. C wu� C9a.0 nvn (p-Z.,I -oJ Signature Of Legal Owner(s) Date - And/Or Authorized Applicant Date CODE r INSPECTION'TYPE PAIS BRIDALS CODE! INSPECTIONTYPE PAIS I[NLS 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 [�}(/ja����/,�/�,. 203 Final Sign222 Final Site ' " ! I 204 Final Demolition 250 Final Building/Occupancy r• fir.. CITY OF COSTA MESA • 4 BUILDING DIVISION > ..�I DEVELOPMENT SERVICES DEPARTMENT PE T NUMBER 1+1 PERMIT -"+•o ,4. 604 01282 (714)754-5273 • Fax(714)754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 259 22ND ST Status: ISSUED Suite: Applied: 07/16/2004 Vicinity: MASTER BEDROOM/BATH Issued: 11/16/2004 Parcel Number: 42615304 Zoning: -tea Applicant: GANNON, LAURIE ISSUED BY: Address: 259 E 22ND ST Phone: 949-637-1153 COSTA MESA,CA Zip: 92627 Owner: GANNON, LAURIE Address 259 E 22ND ST Phone: 949-637-1153 COSTA MESA,CA Zip: 92627 Contractor: CIS Address: Phone: Zip: License: Arch : Eng: LHOTSKY, MIROSSLAV C Address: Address: Phone: Phone: Zip: License: License: 3572 SCOPE OF PERMIT 346 S.F.EXPANSION TO MASTER BEDROOM AND BATHROOM.CONSTRUCT A DOOR AT THE REAR OF THE HOUSE. FEE SUMMARY Plan Check: $313.72 Calc Valuation: $33,307.20 Permit: $482.65 Claim Valuation: $0.00 SMIP Res: $3.33 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $799.70 PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 44-0 Left 5-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 4 Required: 4 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 / • 2446.46(6/00) U WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the folio ing declarations: 0 I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 0 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: Carder: Policy Number: (This section need not be completed it the permit is valued at one hundred dollars($700)or less.) • Erl-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 it I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these PPro ' ions. c Applicant Signature: l 5C) YvCL-<< 3 Date: I —I(O - U 1-1 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 SECnON 3705 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect.Lic.# Class a 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 subjectssuthe applicant to a civil penalty of not more than five hundred dollars($500).): ltd I,as owner of the properly,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.). • E/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 expmEt under sec. Business and Professions Code for this reason: Signature: (Lad—, Expires: (D—(e.±-0"-{ 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, 1 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 t0 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? 0 Yes ❑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 Ouality 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-Sescribed property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. SC-Arc ,( ( I — ((n-3q Signature Of Legal Owner(s) Date : And/Or Authorized Applicant Date CODE 1 INSPECTION TYPE SATE 1NTmAIa DODEr INSPECTION TYPE PATE DITITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Well 212, Final Fire Prevention 202 Final Factory Fire Place • 220 Final Planning Approval 203 Final Sign 222 Final Site n 204 Final Demolition 250 Final Building/Occupancy 0 T"Z'0S • V . LAWMASTER & C ‘.. . , INC . 7940 MAIN STREET — STANTON, CALIFORNIA 70CMS-403I-302 828-8040 Field Data on Test Specimens Core Concrete Oce Grout/Mortar K. D. Brennan Pool Project Permit No. 31347 Project Location 259 East 22nd St. , Costa Mesa, Calif. Contractor Anthony Pools Architect Location in Structure Engineer Date Moulded 2/25/70 No of Specimens 6 Slump Specimens Marked Specified Strength at_-38_days ag®g—P.S.I. Mix Designation 4} to 1 Age to be tested. days 28 days days days READY MIX PLANT AGGREGATE SOURCE Weather Condition I Yd. ,Yd. Batch Cement Monolith Type I/II Cement, lbs. Admix Sand Specimens made by #4 Data by #3 RECEIVED BtltLBINB-SAFETI`-BERT. Delivered by #2 MAR 2-7-1910 Date Delivered ryr zq PM /( �—� (I3l91101111121:a2L3L4t5e8 REMARKS: -9�J Water, Gals. FOR LABORATORY USE ONLY Lab. No. 70244 70245 70246 70247 70248 70249 7 Day Test 7 7 Day Test 28 28 Day Test 28 Day Test Date of lest 3/4 i/A 3/25 3/25 3/15 6.17 6.09 6.29 6.05 Specimen Dimensions _x12.5 12._75 A2.s X12.5 6..1_7_012._125 6.17 X 12__7$— Area 29.90 39.13 31 .07 28.75 29.90 29.90 Ultimate Load 56,000 70,000 54,500 57,000 61 ,000 81 ,000 Lbs. per sq. in. 1 ,872 2,403 1 ,754 1 .983 2,040 2,709 H/D Corrected RCE6207 ;,1 'Cif! : . UWNtK alit:V1VAN, IS..11.,A VAIL "�-I" JOB ADDRESS 259 E. 22nd. St. BUILDING PERMIT N0. 313141GENERAL CONTRACTOR Anthony tools DESCRIPTION of WORK Pvt. b191111 Pool AP No. LOT TRACT FIRE ZONE VALUE $ 1,900.00 r;.-,"p-2.CTIONS Signature Date GROUP TYPE ZONE sV: i��M n ' ��r� PERMITS ISSUED ` -P6/"'n "3"' S2"�?"�� SUBCONTRACTOR •GAJ rr ,l �(y� Date Number I Signature WATER il.,41 6. 14444:t'ld tr_rtfa.-i4 ti.0 lumbin. /`/ �/ ROUGH PLUMBING�'�I �v c Y1�7�II ��i / .L 2-%' OL/M �� PROP. SWR. LINE El HO CON. /�-. g./ 'Y NTv515/1�/ SPRINKLING SYSTEM / /''� C� MISCELLANEOUS ROUGH HEATING AND AIR CONDITIONING �w—V TEMPORARY SERVICE OR POLESerOje� VS 2--zz'e1 XJ UNDERGROUND D POWER ❑ ROUGH WIRING Heating and Vent. TRENCHES ❑ FORMS ❑ STEEL REINF. El FLOOR SYSTEM p� Oi!� BOND BEAM [Dr STEEL REINFORCE pr— j24 •1---24416" SHEATHING FRAME AND FLASHING LATHING — IN OUT n L PLASTER, BROWN COAT ' 'C ,t,./S3Tga-, e HTP""TUBAL, FINAL rto- . ,l.� f/+J EI�tyy��1/�x�. 9 /y�r (9 r M. G �J.Qi' .-:16�4M�-A-C�PNIAL IeGSy z-�'!� ! lAf�- %.t N .�Oi1�7 PLUm SING, FINAL, '/41„5-?-e4-112C7 ELECTRIC, FINAL _....------ ti(/�yf� l iL,r.T--J nii'' n'un PMNAI r1 Til 31347PAID AIcris00 032* ****28.50 • FEB 2 7CPCOSTA MESA BUILDING-SAFETY DEPARTMENT P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 APPLICATION FOR BUILDING PERMIT For Applicant to Fill in Completely C(� RECEIV D BX. DATE RECEIVED GATE ISSUED BUADILDINGDRESS 259 E. 22nd Street ' 2-2-�o - O�I����`1J-�'7Ja OWNER K. D. Brennan A.P.NO./// `��. A d Pg/c'J 7 / BUILDINGMAIL C _ADDRESS same ADDRESS 2259 E. 224, Street W W TEL. .Tog J• I LOT BLOCK ..U CITY NO. ZZ < CONSTRUCTION 0 / NEW ADD ALTER REPAIR MOVING DFMOI ISH - I- LENDER ((,�. /Ll 0- m A J 7 BRANCH J to OWNER K. D. Brennan Q ADDRESS q swimpool VALUE 1 900.00 • J Q OR ENGINEER G . Adams NE p3229-0 USE _ $ 7 U In FIRE WIZ ADDRESS ZONE -TTYYPPEE/ // GROUP A-W APPROVED %{'%n � - U.12 CONTRACTOR Anthony Pools BY // �Ov DATE L -.11-;:0 J z R]z J q: ADDRESS 5871 Firestone Blvd. 00 , W W L.. r�� ZONE,..., NO.OF K USE OF NEW.../4.++'t . Z0 r H- CITY South Gate NO`.SP3221O +/ (PLANS BUILDING ( JR-,Q STATE CITY YARDS APPROVED YARDS APPROVED co CC LIC. NO. 190179 LIC. NO. MAIN BUILDING ACCESSORY BUILDING 7 O (FROM C/L STREET) SIZENO.OF BLDGS. .ff' OF LOT , ►t'I I NOW ON LOT FRONT FT. r3 FT..4Z.Z. USE OF EXISTING BLDG. residence and garage R.SIDE FT. /4 FT. I- SIZE OF 380 t NO.OF 2 NEW BLDG. ROOMS STORIES L.SIDE FT. 9 FT. UEXTERIOR WALL ROOF COVERING I COVERING _ REAR FT. i/ FT. --I USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN& MAIN BLOCS. ACCESS. BLDGS. o DATE rivate swim pool in rear C U.P# APPROVED I- of single family dwelling APPROVEDJpd4 y _HY DATE ZI. - .2.- 7O z O UI hereby acknowledge that I have read this application and state D that the above information is correct and agree to comply with CC all laws regulating building construction, and I shall not employ F any person in violation of the workman's compensation laws of the State of California. to b z I hereby certify that I am properly licensed as a contractor under SO. FT. o the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: e ix am exempt from the provisions of the State of California Business and Professions Code, Division 3, Chapter 9. VALUATION 0 /t/7 im PERMIT FEE $ (/ N Signature of I © 5O ] Permittee dL/ ./n9)( i.d I 0O / r E $ 900. PLAN CHECK $ E � 5� Authorized Agent TOTAL FEE $ c2 f BREW,BRE , KOERT D. DAIt 5-16-6ti 'JOB ADDRESS 259 E. 22nd Street BUILDING PERMIT NO.28591 l GENERAL CONTRACTOR Owner-Builder DESCRIPTION of WORK Block Wall AP No. u8_152_20 LOT 284. TRACT .t. sFIRE ZONE VALUE $1}00.00 1 ECTIONS Signature Date GROUP J TYPE ZONE R-1 PERMITS ISSUED GAS SUBCONTRACTOR Date Number Signature WATER Plumbing ROUGH PLUMBING PROP. SWR. LINE ❑ HOUSE CON. ❑ SPRINKLING SYSTEM MISCELLANEOUS ROUGH HEATING AND AIR CONDITIONING TEMPORARY SERVICE OR POLE UNDERGROUND ❑ P WER ROUGH WIRING �,.� Heating and Vent. TRENCHES FORMS ❑ STEEL REINF. V G Q JY.24 FLOOR SYSTEM BOND BEAM U STEEL REINFORCE n SHEATHING FRAME AND FLASHING LATHING - IN n OUT n PLASTER, BROWN COAT STRUCTURAL, FINAL Electric H IG, VENT., REFRIG. AND A.C., FINAL PL_...SING, FINAL AND GAS TEST n ELECTRIC, FINAL �� BUILDING, FINAL 4 .04 28591 Ra 1646 p OO 911 d*****3.00 COSTA MESA BUILDING-SAFETY DEPARTMENT I P.O. BOX 1200 COSTA MESA. CALIFORNIA 92626 For Applicant to Fill In Completely APPLICATION FOR PERMIT V. TYPE OR PRINT BUILDING For Office UES Only a: SUILDING 02.4-7-e_ L �p- c- t 1 ./� ADDRESS .i RECEIPT NO. yyTT��NO, COSTA MESA. CALIFORNIA a `J� / RACEI DRY TAR CHIVE DA 0BU OWNER lfnFS .✓) 9L31i Pa/JAI JO Y�j�84--ibje,iJ 6—/(J-FJ� ., MAIL 7 ADDRESS �S9 °I,* �d emiumaADDRESS t�/{lSa/ �• ^'c79�T� p . /, FIRE .S TYPR ..,/./f+ GROUP CITY 19 44-.4/9 NOL6ST- .QS/? ZONEg [[[ppp \ / jPE // �A ARCHITECT 77 .-� . TEL 1117,1 V�pi}J G/i6 / DATE�-/�/-('� ENGINEER NQ. ZONING ,..DRESS ZONE No.or USE OFNEW LONG. /3LK t G�/ PLANE A BUILDING �hLL a CONTRA -R �I I K LEGAL �J DESCRIPTION \��Gf/ . .ie.--1 Ril 71-171 . L- . _ ADDR- ' A.P.NO. //IS— 1L!a• r_I..I J - n Oa- CITY STATE �! TEL NOTE; NO SAVE OVERHANG SHALL OE LESS THAN LIC.NO. NO. 30'TO SIDE a REAR p.i.... EAVES '• SIZE — I — NO.OI CLOGS. ALLOWED (U.B.C.REQUIREMENT) OF LOT I/ a NOW ON LOT YARDS APPROVED YARDS APPROVED USE OF Ante— //j+ MAIN BUILDING ACCESSORY BUILDING EXISTING BLDG. i SETBACK UNE FROM / / ) (FROM C/L STREET) ^4 / CA. � CENTER OF STREIT REAR YARD 41 7 FRONT PT. G Fr. az tie SIDE YARDI LEFT RIGHT RIGT S f R.SIDR PT. �j 1. PT. 4 P- a DESCRIPTION OF WORK L SIDE FT. PT. I, - REARALTERATION ADDITION DIST PT. PT. DISTANCE BIM BET.MAIN B REPAIR MOVING DEMOLISH MAIN BLOCS. ACCESS.BLDG'S. s BUILDING NO.OF VAR.4R DATE i# SIZE ROOMS STORIES C.U•P•# n APPROVED EXTERIOR WALL I COVERING _ APPROV[D«�� / / /(� COVERING .VIv(` DATE �� �(�-[Jd USE OF BU I LOINS AND WORK TO BE PERFORMED "9 / •— % /`cam •/ m /.t..2 / Cso. . 1444)";:g de GI 1 HEREBY ACKNOWLEDGE THAT.1 HAVE READ THIS TON THE AMOUNT SHOWN UNDER VALUATION IB FOR TN 7 AND STATE THAT THE ABOVE.13 CORK���•yyy jjy •EU TO •E. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. PLY WITH ALL CITY ORMAN• REOULA NG VALUATION .: BUILDING CONSTRUCTION. f� / / / C. j PERMIT FEE S (/(/ E PERMIT-Er RI : SIGNATURE OF .... ..4.4..--6-C....-"‘ r PLAN CHECK S W \ AUTHORIZED AGENT L f}y) 'Y;.-.::'.. -x l ..t• .4e r - . ..y.- .. .. . TOTAL.PEE (/(/ JIT L\141 f)fflhIJStul, f1.1./. LA-AUc-1 VV JOB ADDRESS 259 E. 22nd St. BUILDING PERMIT NO. 28183 •*GENERAL CONTRACTOR Air Vent Awn.Co. DESCRIPTION OF WORK Add Alum.Pat.Coy.to Res. SAP No.118-152-20 LOT TRACT FIRE ZONE VALUE S 200.00 I ECTIONS Signature Date GROUP IV TYPE 3 ZONE 81 St_ PERMITS ISSUED Gas SUBCONTRACTOR Date Number Signature Water Plumbing Rough Plumbing \ Prop. Swr. Line 0 House Con.0 \Sprinkling System Miscellaneous Rough Heating and Air Conditioning Temporary Service or Pole Underground 0 Power 0 Rough Wiring Heating and Vent. Trenches 0 Forms 0 Steel Reinf. 0 Floor System Bond Beam 0 Steel Reinforce 0 Sheathing Frame and Flashing _ Lathing—In ❑ Out ❑ Plaster, Brown Coat S' tural, Final Electric 1. ng, Vent., Refrig. and A.C., Final Plumbing, Final and Gas Test 0 Electric, Final Building, Final - . 28183 FEB-s 6a °ae 095 *«*3.00 COSTA MESA BUILDING-SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 . For Applicant to Fill In Completely APPLICATION FOR PERMIT TYPE OR PRINT BUILDING r A/ For Office U» Only RESS ADDLL ce 22 ,S� RECEIPT NO. PERMIT NO. COSTA MESA. CALIFORNIA �- 2R.1 ,/ {1 R�cR{���so,�[r DATE RECEIVED DATE ISSU �/ OWNER k. f�, laGm inn Yl.(/ a -5-6g ,-:5-_- MAIL BUILDING a6 9 8. Rd'uD.Z' ADDRESS.2C9 C. 2.24-112-.Sr- ADDRESS ,j /. yy1� ,, TEL 16.46— ZONE SCJ TYPR T CITY / . Sr_,L,1' /l!=ted NO. c?SA GROUP �" /gyp TEL 6�Z- BYPROVED ./i7/�.7 DATE 2- 4.• -‘6 NOINHHR r�/ /� /ALEy NO. 179n �L TT ADDRESS .3/74Aa 1/442/11-011/41r., 1.l�� ZONING ZONE NO.or On OPN[W� / K_/ PLANS C. IBUILDING CUYYyf CONTRACTOR Ale-1L Gi/r A,-✓M/ N 9-IPA /1 LsoAL P �/T -/ ADDRESS/A09 Sd �/✓LRD-STI SCRIPTIDN y � ,T Il ?� ����// A.P.NO. Mg -- /SZ - Z O CITY /AVM k/�r✓1 NOTE: NO EAVE STATE ey TEL SO'TO SIDE&REAR F.L. SHALL BE LESS THAN LIC.NO.dr%/-/7C/CZ NO. 570--3366 F. EAVES SIZE NO.OF BLDG/. / ALLOWED (U.B.C.REQUIREMENT) OF LOT NOW ON LOT YARDS APPROVED YARDS APPROVED UESBPNG BLDG. /+/C/Y, G Con,/`Y F'SOMAIN BUILDING ACCESSORY BUILDING (FROM C/3.STpHET) OUTBACK UNE FROM / �'I I FRONT / .FT, ld �X 4,111.- PT. CENTER OP STREET REAR YARD SIDE YARD) LEFT 0 RIGHT J19 R.SIDE /V 7'FT. FT. DESCRIPTION OF WORK L.SIDE 17Z T.,c Ex //� ' ALTERATION ADDITION REAR PT. -- FT. DISTANCE err. BET.MAIN& REPAIR MOVING DEMOLISH MAIN BLDGS. ACCESS.SLOGS. VAR.* DATE BUILDING SIZE 2/ JC NOOFS / STORIES / C.U.P.AF'/,/ APPROVED EXTERIOR WALL I ROOF //�I APPROV ! 2 - f'C� COVERING COVERING/in/s//.I//IIsi BY u9 ve��e'//'' DATE USE OF BU ILDINN/D AND WORK TO BE PERFORMED (/Pi' 0. / /J h., ',gin Le +.. _Se^lyl-f/G9'J `9 fl I?P-/4-R OG C,A'Q-Lvi Liaa,.� t 3 Res to . SQ.PT. I HEREBY ACKNOWLEDGE THAT.I NAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS POR THE C AND STATE THAT TEE ABOVE,ID CORRECT AND AGREE TO CON. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. PLY WITH ALL CITY ORDINANCES AHD BATE LAWS RESULATINS VALUATION BUILDING CONBTRULTON. �9-y� y/ /f / PERMIT FEE S • C/(J PERMITTED SIGNATURE O/� �T/R-//E'TY% CP SP OP PLAN CHECK S w° AUTHORIZED AGENT �j q.� I TOTAL PEE :45 Ur? OWNER STYLELINE HOMES, INC. DATE 2-19-62 JOB ADDRESS 259 22nd St. BUILDING PERMIT NO.1: 3: GENERAL CONTRACTOR Owner-Bldr. VALUE $ 141990.00 AP No. 118-150.34 LOT TRACT FIRE ZONE DESCRIPTION OF WORKReS.w/att.Gar. I*""'DECTIONS Signature DATE GROUP 18c trYPE V ZONE Rl S /WS 3-2-Gz PERMITS ISSUED Gas MI-C 3-29-62. SUBCONTRACTOR DATE NUMI3ER Water Lig dot-/S 3-L.'6z Rough Corn. Reftig. 0 Air Cond. 0 Rough Heating �G4/ Z.2-7-C.:,/ � / i ...fi g/2 .?-4, S=�3- - L11_,/ Rough Plumbing ALMS__0�,9.,�..a. 16l//i Err % a .'-1 6.2_a a_S(6 Miscellaneous ��r� Prop.Swr.Line Err-louse Con. IfrSt.Swr. 0 Lfl& q fprr.L - —�f't`-44-i ?Pic 't- S/G 1 -- Sprinkling System / Construction Pole Underground ❑ Power ❑ J2 _2 Rough Wiring / _ e2- —13d..= _ _L7LO_CcV�� 'Flo r Forms Steel Reinf. ❑ ..Y" l_ U r� Floor System �����(���(((LLLL "'��� Bond Beam 0 Steel Reinforce 0 or Sheathing13-inc „J — .�,� mayor Frame and Flashing ��� -3-3 6_CL ./ Lathing — In 6Q Out 6(may '� Plaster, brown coat ,, ZC- 6,--- r �Y / / r t. ❑ Air Cond. p Final b h. -mg, Final re� ' Plumbing Fixtures, Final „/ 1-C • _ _� LLl Final Gas Test /G{'.454,- id• ' - -r ' 3/ Electric Fixtures, Final - / �S 1�_y, !' �t �P V Building, Final �CSS O e OCCUPANCY r rene oum u. 1" ..,..f rno onrrr•I nren,rnrt rrv'a 10.L O$ - 16438 FEE RECEIVED COSTA MESA BUILDING-SAFETY DEPARTMENT 4 FEB 1 91962 P. O. BOX 917 COSTA MESA. CALIFORNIA �fNANDE DEPT. For Applicant to Fill In Completely APPLICATION FO�yK'PER�/jj1G11'Y(T"" TYPE OR PRINT BUILDING BUILDING ADDRESS ?-5...? //7--€1 S l COSTA MESA. CALIFORNIA For Office Use Only RECEIPT NO. E MJ"T_NO. OWNER STYLEL I NE HOMES, INC, I I l fid MAIL ,/S"' • t' 2 /S_I' £ RECEIYED BY I DAaQ=E774.3F�DAT 981962 ADDRESS 7 a 1 / ]'[ 'r b �j 6'0 }- TEL./4/4 .lily BUILDINGU CITY N4jA.1 "O� I �e�LC NOI0 ��11 ARCHITECT Lie TEL. G 1 OR " NNEE/R ola t Wr `�`e No.LI A "f�f� COSTA MESA. CALIFORNIA (�,- ADDRESSLit �{�. O /W' I/�`^ fli FIRE ZONE TYPE V GROUP.J�'/r CONTRACTOR Q W / y'e `� APPROVED DAA U ADDRESS ZONING ZONE NO.OF USE OP NEW S h., CITY R-( I PLANE Z BUILDING W/,`- STATE TEL. LEGAL N /^'\ LIC.NO. NO. /y DESCRIPTION /fan Zf" V /I/T/zii T� SIZE yg 9L - x. 131,s91 NO. OP BLDGS. O /,d — J SAO -. 3 4--/ OF LOT Now oN LOT A.P.NO. USE OF - YARDS EVES EXISTING BLDG. APPROVED ALLOWED SETBACK LINE FROM �[ (CENTER LINE BT.) CENTER OF STREET �U REAR YARD ]7'' FRONT 'S FT. IN. SIDE YARD I LEFT C I RIGHT R.SIDE S FT. -- IN. DESCRIPTION OF WORK -9— L.SIDE FT. IN. NE1' I XII ALTERATION I II ADDITION I REAR /G� FT. / 7I IN. REPAIR I II MOVING I II DEMOLISH I BYPROVED 42/1.et DATE Z//Y/GZ- BUILD/NG �j iI NO. OF SIZE (`l 1-) 4t ROOMS (-!.ROOF (J rSTORI�ES ^�/ (� HOLD FOR SPECIAL REQUIREMENTS EXTERIOR WALL TL1 CC 0I COVERING I)8-/ 0 )]0C/c i� t ,lp� -c44/. EXTERI R a / v USE OF BUILDING AND WORK TO BE PERFORMED/ / a __ a . U-4-Y a S P 1/ �' �� g.3-7 I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. PLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING BUILDING CONSTRUCTION. VALUATION ,/ SIGNATURE OF I�1,, PERMIT FEE $ 3 — PERMITTER /(.-I 7-� /4/9 9O— p / -/ $ / / PLAN CHECK $ / 7 R. AUTHORIZED AGENT ✓t.—` o NN TOTAL FEE $ E