HomeMy WebLinkAbout325 22ND ST - Building Permits. CITY OF COSTA MESA
BUILDING DIVISION
77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www ci costa-mesa.ca.us
FOR INSPECTIONS CALL: (714) 754-5525
PERMIT NUMBER: P08-00105
PERMIT TYpE PLUM STATUS:
APN: 42616122 DATEISSUED:
ISSUED BY:
—.._-�.rv -�' ' . .' '°.
JOB ADDRESS:� � -22ND-ST CM�a Suite/Unit:
vicinity: � . - � .
ISSUED
04I2112008
KJB
SCOPE OF WORK: CHANGE.OUT�STORAGE TANK WATER HEATER. SAME LOCATION. � -
OWNER: MC INTOSH, KIRK S�.�,� : �Address: 325 22ND ST,�, , EXPIRED
PHONE: -�- . '. City/Slate/Zip: ' COSTA MESA, CA - �/ j
APPLICANT: MIROSLAV;PBARNYASHEV � �-��Address: . - ]�A'j'F;� 1
PHONE: ^,` �;' � - - �City/State/zZip: . � . ; , .. ^
CONTRACTOR: CALIFORNIA DELTA�MECHANICAL INC License No. 811114 �. � lT�✓
Address: 1235 GRAND AVENUE .� ., PHONE: 800-898-0008 '�
City/State: SPRING VALLEY, CA ZipCode:� 91977 � � CELL: � �,� .
ARCHITECT:
ENGINEER: ,
LicenseNo. � �-PHONE:
� � � License'No. - � ' � -PHONE:�
PLUMBING PERMIT FEE SUMMARY
PLAN CHECK FEE:
PERMIT FEE: .
TOTAL FEES:
$0.00
$35.80 .
$35
�r
NOTiCE: The work authorized by this permit shail comply wiM ali applicabte handicap access requiremenLs under Califomia statuies artd re7ated
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
COpE1, INSPECTIONTYPE
1616 Fixed System Final Fire Prevention
7266 Pool Spa Final .
200 Final Re.Roof
201 Final Blp�k/Retaining Wall
202 Final Fa�tory Fire Place
203 Final Sign
204 Final Demolition
DATE I 717IA1 CODEO INSPEC710NTYiE
206 Final Mechaniwl
208 FinalPlumOing
210 Final Elecirical
272 ' Final Fire Prevenlion
220 Final Planning Approval
222 Final Site
250 FinalBuilding/Occupancy
oa iNnnn�s
WORKERS' COMPENSATION DECLARATION:
I hereby aKrm under penalty of perjury one of the following daclarations:
❑ I have and will maintain a ceAifcate of consent to sel4lnsure for vrorkers'
compensation, as providetl for by section 3700 of t�e Labor Code, lor Ihe
performance of ihe vrork for which this permit is issued.
�' I have and will maintain workers' compensation insurance, as required by
sectbn 3700 of the Labor Code, fw the peAormance of the work for which this
pertnit is issued. My vrorkers' compensation Insurynce carner and policy
number are: C P
Carrier: l �Vi.� ''%
(ThisseUionneetl � mm�1�t���valuetlalmehuMretltlpMars(E100)aless.)
Policy Number: 6
❑ I certify ihat in Ihe pertormance o� ihe work for which [his permit is
i55ued, I 5hall not employ any person in any manner so as to become subject
to t�e workers' compensation laws of Califomia, antl agree Ihat if I should
become subject lo the workers' compensation provisions of Section 3700 ot
the Labor Code. I sh fo�omply wilh these prqvisioos2/_ �
�p
Ap icancs5i lure W�e
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE
IS UNL4WFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($700,000�, 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 thal I am licensed under provisions of Chapter 9(commencing
with Section 7000) of Division 3 ot the Business and Professions Code, and
my license is in pfull (orce antl eHect.
Lic. # �I ( �{ � Class # C/ / �
` R � /"��—
�nG vaaw's Sig Wre Da�e
CONSTRUCTION LENDING AGENCY:
❑ I hereby affvm that there is a construclbn lentling agency for the
perfortnance o( Ihe v.vrk for which [his permit is issued. (Sec. 3097, Civil Code�.
Lender's Name:
Lentler's Atldress:
Signawre Da�e
OWNER-BUILDER DECLARATIONS:
I hereby affirm thal�der penalty �erjury that I am EXEMPT FROM THE
CONTRACTOR WCENSE IAW" lhe following reason (Sec. 7037.5,
Business and Pr �, ��eiirdW or counry which requires a permit to
wnstroct, aiter, i �kq���� i��i repair any s[rucWre, prior to its
issuance, also req 2pplican . such permit to file a signed statement
thal he or she i [he provisions of the Contrectors
License Law (C � rne th Section 7000) of Division 3 of the
Business antl P t he or she is exempt therefrom and
the basis for the y violalion ot Section 7031.5 by any
applicant (or a nt to a civil penally of not more Ihan
five hundred tlo ,
❑ I, as owner of the property, or my �Ynployees with wages as Iheir sole
compensa[ion, WILL DO THE WORK, antl the sWCWre is not intended or
ottered for sale (Sec. 7044, Business and Professions Code: The Contraclors
License Law does not apply to an owner ot property who builtls or improves
thereon, and who tloes such work himself or herself or thmugh his or her own
employees, provided that such improvements are not intended or oRered tor
sale. If, however, Ihe builtling or improvement is sold within one year of
completion, the owner-builder will have the burden of proving that he or she
did not builtl or improve for purpose of sale.).
❑ I, as�owner of the property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CON7RACTORS to construct the project (Sec. 7044, Business and
Pmfessions Code: The conlract«s License Law dces not apply to an ovmer o!
property who builds or improves thereon, and who contracts for such project with
a contractw(s) license pursuaN ro[he Contractors Ucense laws.).
❑ I am exempt under sec. �
Business ana Professions Code for this reason:
SignaWre Dale
3051�a613ro1)
Owner ID verifed 6y tlriver's lice �] Yes ❑ No
Driver's Licensa No. Expires:
Verification of Ownership by (rype of documenl, i.e. - pmperty tax bill or deeC):
DIVISION OF INDUS7RIAL SAFEN PERMIT CER7IFICATION:
❑ I hereby certify that no excavation frve (5) or more feet in depth into which a
petson is requiretl to descentl, will be made in connection vnth work authorized
by this permil, antl that no building slrucWre, scaffdding, lalsework, a demolition
or dismantling t�ereof, will be more fhan thihy-six (36) feet high. (Chap. 3.2, Grp
2, Art 2, Sec. 341, Title 8, Califomia Administralive Code).
❑ As owner-builder, I will nol employ anyone to do work which woultl
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.
AO�liwnl'S SignaWre
Division of Industrial Safety Permit Number:
HAZAR�OUS MATERIALS ANO EMISSIONS CERTIFICATION �
7. Will the applicant or presenl or future builtling occupant need lo �le antl
certify a Business Plan for emergency response to release or threateneC
release o! a hazardous material? ❑ Yes � No
(Section 25505 0( the California Health and Sa(ety Code requires, with some
exceptions, Ihat a Business Plan be fled vnth the Costa Mesa Fire
Departmenl 6y every business which has at any one time during a reported
year a quantity of hazardous materials equal lo or greater than a weigM o(
500 p0unds, or a volume o( 55 gallons, or 200 cubic feet of compressetl ga5
at stantlartl temperaWre and pressure).
2. Dces or will the applicant or present or fuNre building occupant need to file
a regi5tfalion (ortn for acutely hazardou5 ma�enals? ❑ Ye5 ❑ No
(Seclion 25533 of ihe Califomia Healih antl Safery Code, wiM some
ezceptions, requires registretion wilh Ihe Cosla Mesa Fire Department by
each business which at any one time has on hantl a quantity of acutely
hazartlous materials equal to or greater t�an a weighl of 500 pounds, or a
volume of 55 gallons. or 200 cubic feet of compressetl gas at standard
temperature and pressure).
3. Does or will the applicant or preseM or tuture building occupanl need to
prepare an RMPP (Risk Management and Prevention Program tor acutely
hazardous malerials)? ❑ Yes ❑ No
(Section 25534 of the California Heallh and Safery Code provides ihat the
Cosla Mesa Fire Department may require the preparalion, certification and
filing with the Fire �epartment of an RMPP by businesses which are requireC
to register acutely hazardous malerials with the Fire Department.
4. If an RMPP is presently required, has Section 25534 of the Calitomia
Health and Safety Cotle been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or tuture building occupant require tor
lhe work which is lhe subject of this applicalion a permil for such consWction
or modifcalion from �he Soulh Coast Air �ualiry Managemenl Distric[ or from
any other air polWtion control tlistrict or agency? � Yes ❑ No
(Section 658502 0( Ihe Califomia Govemment Code requires that Ihe requested
inlortnation be fumished on applications fa noo-residential huilding pertnits).
6. Will any part of the facility to be constmcted under this permit be wilhin
7000 (eel from the oUter DOUntlane5 0( a SChool? ❑ Yes ❑ No
(I('yes", the facility must meel Ihe requirement of Sections 25534 and 42303
of the California Health and Safely Code).
7. If a permit from the South Coast Air �uality Management District or other
air pollution control dislnct or agency is required for lhe work which is the
subject of lhis applicalion, have all of Ihe tlisclosures prescnbed by Califomia
Heallh and Safety Cotle Section 42303 been matle? ❑ Yes ❑ No
8. Qf "yes". allach cenificate ot compliance from ihe appropriate air polWtion
control oKcer).
CERTIFICATE OF COMPLIANCE: I certify,that untler penalty,of perjury Ihe
information given above is correcl. I agree to comply with'all state�laws and
city ordinances regarding Hazardous Materials and Emissions. �� �
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRV: I
certify under penalty of perjury that I have read this application and state (hat
the information given is correcL I agree to comply with all state laws and city
ordinances relating to building construction, antl authorize representalives of
the Cily o( Costa Mesa to enter upon the above-described property for
inspection purposes. I agree nol to occupy or allow occupancy of any building
authorized by lhis permit uNil fnal inspection.
/ /Sig ureofLeBal eqs) C ate
Gf� /— � � � �
AnGlorAut�ori EApPliwnt Date
(�ia) �sa-s2�s • Fex ��ia� �sa-aess • www.ci.costa-mesa.ca.us n FniH �N+ve, cosrn nnesa, cn szszs
1ob Address: 325 22ND ST
Suite No
Vicinity: GARAGE
Parcel Nunmber: 42616122
Applicant: DUNN, JON
Address: 17886 LAKE SHORE DR
LAKE ELSINORE, CA
Owner: MC INTOSH, KIRK S
Address 325 22ND ST
COSTA MESA, CA
PLUMBING PERMIT
Phone: B00-727-0977
Zip: 92530
Phane:
Contractor: ALL STAR WATER HEATERS INC
Address: ' 17886 LAKE SHORE DR
Arch / Eng :
Address:
ISSUE FEE
Backflow irrigation
BackFlow Preventer
Balhtub
Clarifier System
Connect Qce,Soda,etc)
Dental Unils
Dishwasher
Drain, Floor
Drain, Rainwater
Drain, Roof
Drinking Fountain
Expansion Tank
Zip: 92627
Phone: 800-727-0977
LAKE ELSINORE, CA Zip: 92530
License: 812894
Phone:
Zip:
License:
Status: ISSUED
Applied: 09/17I2003
Issued: 09/17/2003
ISSUED BY:
SCOPE OF PERMIT
CHANGE-OUT OF A WATER HEATER IN THE GARAGE OF AN EXISTING SFD.
NO OTHER WORK AUTHORIZED WITH THIS PERMIT.
AMT
$23.50
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
ao.00
$0.00
50.00
$0.00
50.00
so.00
FEE SUMMARY
QTY AMT
Laundry Tub / Washer $0.00
0 Landscape Irrigalion 50.00
0 P-Trap 50.00
0 Pressure Regulator $0.00
0 Process Piping (per 10 ft) 50.00
0 Receptors $0.00
0 Septic Tank $0.00
0 Sewer Cap tor Demo $0.00
0 Sewer Connect 50.00
0 Sewer Private Line So.00
0 Shower $0.00
0 Sink, bar 50.00
0 Sink, commercial S0.00
QTY
0
0
0
0
0
0
0
0
0
0
0
0
0
SumpPump
Swimming Pool
Trap Primer
Urinal
Vacuum Brkr Bkflow(1-4)
Vacuum BrkrBkFlow(5+)
Wash Basin
Wash Basin Set
Waste and Vent System
Water Closet (foilet)
Water Heater/ vent
Water Piping (Inst or RepJ
Water Re-pipe
AMT
50.00
$0.00
50.00
so.00
$0.00
$0.00
$0.00
50.00
30.00
50.00
$12.30
50.00
30.00
QTY
0
0
0
0
0
0
0
0
0
0
1
0
0
NOTICE: The work authorized by this permit shall compty with all applicable handicap access requiremenis under Calitomia statutes and related
regulations. (Ord. No. 9248, § 1, 72-21-92)
EXPIRATION: This permN shall automatically expire and become vold if work is not commenced within 780 days, or it work is suspended or abandoned
tor a period ot 1B0 day5.
INSPECTIONS: In ortler for the work authorized under this permit to be considered legal, such work must comply with all epplicable codes, end ell
raquirad Inspectlons end final epprovel must be obtained. Failure to obtaln inspections and final approval will result in (he explration ot this permit.
FOR INSPECTIONS CALL: (714) 7545626
2408-48(0/00)
WORKERS' COMPENSATION DECLARATION: ,
I hereby aflirm under penalty Of Oerjury onB of ihe lollowing tlecleretions: ,
❑ I have antl will meinteln e certilicate ot consent to self-Insure tor workers' compensation, es provided for by section 3700 of the Lahor Code, tor t�e peAortnence ot the
wOrk lor which t�ls p8rmil is Issuetl.
I heve end will mainteln workers' compensetbn insurence, as requiretl by sectlon 3700 of Ne Lebor Coda, for the penortnence ol Ihe work tar whkh this pertrtit Is issued
My workers' compensatlon Insurance carrler and policy number are: p
Carrier: 1 �T �' �`��"�� Policy Number. � �L/�� /. �
(Thls sectian�ed nat be cnmp/efed I!!be peimit Is velueU et one hundred dallers (5700) or /essJ
❑ I certify that In the peAorm ca ha work for which ihis pertnit is issued, I shell not employ eny person in eny menner so es to become su6�ect to lhe workers'
compensetlon laws at Cal' o ree Ihet il l s�oula Decnme subject to the warkers' compensatlon provislons o�ion 3700��e Labor Catle, I shall lort�with
comply wich these provi � i
Applicenl Signnture: � Date: '� l G�
WARNINO: FAILURE TO C E ORKERS' OOMPENSATION ODVEMGE i$ UNLAWFUL M1D SHALL SUBIECT AN EMPLOVER TO CRIMINAI PENALTIES AND GVIL FlNES UP TO qJE HUNDFED
TViOUSAND DOLIARE 1 �, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES �S PHOVIDED WR IN SECTION 3]080F THE LABOR CODE, INTEREST, AN� FTfORNEV'S FEES.
LICENSEDCONTRACTORS
I hereby ettirm Ihat I em licen:
brte end efleCi. Llc. p_
Con�rectofs Signature: _
CONSTRUCTION L
❑ I hereby affirtn
Lentlefs Name:
Slgnature: _
C�epter 9(commencinp with Sectlon 7000) of DlNsion 3 0l Ihe Bi
Cless M
Date: _
and my license Is In full
e consuuctlon lentling egenry for t�e peAormanca al the work lor which this permit Is issuetl. (Sec. 3097, CiWI Cotle).
Lender's Atltlress:
Date:
OWNER-BUILDER DECLARA710NS:
I �ereby aHirtn thet untler penelry ol Derjury thet I em E%EMPT FROM TME CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business end Professions
Code: Any ciry or county which requires a permit lo construct, elter, improve, domolish, or repeir eny strucWre, pdor lo its issuance, elso requlres t�e eppliwN for such pertnit
m flle e signed statemem that he or s�e Is Ikansed pursuent l01he pmWsions oi the Contractors License Law (Chapter 8(cammendng wit� SecUon 7000) of DMsion 3 ot 1ha
Business antl Profeuions Code) or that he or sha is ezempt thereirwn end ihe basis br the elleged exemption. Any violation ol Section 7031.5 by any epplicant far e pertnit
subjecis ihe epplicant ta e civll penalry of not more ihen live huntlratl Aollare (5500)J:
❑ I, as owner ol the properry, ar my employees wilh wa9es es their sWe compensatlon, WILL DO THE WORK, antl the siructure Is not Intended or ofleretl for ule (Sec.
7044, Buslneu antl Professions Code: Tha Contractors LJcense lew does not apply to an owner of property who builtls or Improves thereon, entl w�o tloes such work
himself or herself or Ihrough his or her own employees, pravitletl t�at such improvements are not intended or oHered lor sale. If, however, Ihe building or improvement is
sold within one year of comple�ioq the owner-builder will have the burtlen ot proving that he or she tlid noi builtl or improve lor purpose ot saleJ. '
❑ I, es owner of the property, am EXCLUSIVELV CONTRACTING WI7H LICENSEU CONTHACTORS to construct the project (Sec. 7044, Business and Prafessions
Code: The contwctors Ucensa Lew tloes not appty to an owner of propeny who builtls or improves Ihereon, entl who wntrec�s for such project wit� a contrecior(s)
license pursuan� �o t�e Conirector5 Litense Lews.).
❑ I em exempt under sec. Business antl Professions Coda for this reason:
Signawra: Date:
Owner ID verifletl by drivers license. Ves ❑ No Drivers License No.
Vedficetlon of Ownershlp Dy (type ol document, i.e. - pmperty taz �ill or tleed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
Expires:
� I �ereby certlly ihet no excavatlon INe (5) or more feet In tlep�h Imo which e parson is require0 to descend, wlll be mede In connectlon with work euthodzed by this
pertnit, and Ihat no huilding siructure, scaHolding, talsework, or demolition or tlismantling Ihereol, will �e more �han ihirty-six (38) leet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, 71t1e 8, Celilomle Adminlstretive Cotle).
❑ As owneabuiltler, I will not employ enyone ro do waB which would require a permit from Ihe Division of Intlustrlal Safety, es noted ehovo, unlesa such person has e
permlt to do such work Irom the aivision.
SigneWre: Dele:
Divislon of InAustrial Selery Permit Number:
CERTIFlCA7E OF COMPLIANCE AND AllTT10RIZATON OF ENTHV: I cenity untler penalry of perjury that I heve read this eppllcatlon antl stete t�at ihe Information given,is
correct. I egree m wmply with ell st le laws nd ciry ordinances relating to Duilding construction, and euthodze representellves ot Iha Ciry of Costa Mesa to enter upon the
above-descnbetl properry tor inspe�on purp�es. I egree not to occupy or allow occupancy ol eny building au�horizetl by t�is permit until tinel inspection.
CODE I, INSPECTIOpTYPI
1818 Fixed Svstem
1268 Pool Spe.Pfna
Fire PrevenUon
200 Finel Re-Rool
201 FIneI BIacWRetelning Wall
202 Final Fenory Fire Place
203
204
Final Sign
Final Demolition
PA� II�IDELS
CODE� �xsvernoNnae
208 Flnel Mec�anicel
20B Final Plumbing
210 Finel Electrical
212 Finel Fire Prevenllon
220 Final Planning Approval
222
xso
Final Site
Final Building/Occupency
� o����G' \
Deta
QAg II4�L�
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(714) 754-5273 • Fax (714) 754-4856 • www.ci.coste-me5a.ta.Us 77 FAIR DFIVE, GOSTA MESA, GA 92626
PLUMBING PERMIT
Job Address: 325 22ND ST Status: ISSUED
Suite No
Vicinity:
Parcel Nunmber: 42616122
Applicant: NOCK, CANDY
Address: 11612 KNOTT ST -
SUITE 217
GARDEN GROVE, CA
Owner: MC INTOSH, KIRK S
Address 325 22ND ST
COSTA MESA, CA
Contractor. NOCK PLUMBING
Address: 11612 KNOTT ST
SUITE 217
Arch / Eng :
Address:
ISSUE FEE
BackFlow irrigation
BackFlow Preventer
Bathtub � ,
Clanfier System �
Connect pce,Soda,etc)
Dental Units
Dishwasher
Drain, Floor
Drain, Rainwater
Drain, Roo(
Drinking Fountain
Expansion Tank
Gas Earthquake Valve
GARDEN GROVE, CA
REPLACE WATER HEATER
AMT
523.50
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
QTY
Applied: 01/13/2005
Issued: 01/13/ 5��
ISSUED BY:
Phone: (714)895-1246
Zip: 92841
Phone: �T��
Zip: 92627 �Y� l�
i�' a� 0
OA'�
Phone: (714) 895-1246
Zip: 92841
License: 707775
Phone:
Zip:
License:
SCOPE OF PERMIT
� FEE SUMMARY
AMT
Laundry Tub / Washer 50.00
Landscape Irrigation 50.00
P-Trap 30.00
Pressure Regulator $0.00
Process Piping (per 10 R) 50.00
Receptors 50.00
Septic Tank 50.00
Sewer Cap for Demo 50.00
Sewer Connect 50.00
Sewer Private Line 50.00
Shower 30.00
Sink, bar 50.00
Sink, cromme�cial ' $0.00
Sink, Floor $0.00
�TY
0
0
0
0
0
0
0
0
0
0
0
0
0
0
SumpPump
Swimming Pool
Trap Primer
Urinal
Vacuum Brkr Bkflow(1-4)
Vacuum Brkr BkFlow(5+)
Wash Basin
Wash Basin Sel
Waste and Vent System
Water Cbset (ToileQ
Water Heater / vent
Water Piping (Inst or Rep.)
Water Re-pipe
Water Service
AMT
$0.00
50.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$12.30
$0.00
$0.00
$0.00
QTY
0
0
0
0
0
0
0
0
0
0
1
0
0
0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regula�ions. (Ord. No. 9248, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or i� work Is suspendetl or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under ihis permit to be considered legal, such work must comply with all applicable codes, and ell
requlred Inspeetlona and final epproval must be obtained. Failure to obtain inspections and final approval will result in the ezpiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
zaawe (s�oo)
WORKERS'COMPENSAnON DECLARATON:
I hereby a8irtn untler penalry ot per�ury one of the tollowing tlecleretlons:
❑ I have and will melntain e certlficete of consent to self-Insure far workere' compensatlon, es provided for by sectlon 3700 of the Lebor Code, ior the pertormence of the
wark for whlch this pertnit is Issuetl.
I have antl wlll mflin in workers' com nsation Insura�ce, as required by sectlon 3700 of the Lebor CoCe, for the pertortnance of ihe work for wNch this pertnit is issued.
M w /�p �a�o� Ingura ca er entl p�l numbar ere: C �
Cerrier.Y��� � �� ����(�C/ �� PolicyNumber. �1I��6��.liC
(Ihis section need nol be compleretl i/ the permit Is ve/ued et ane huntlretl tlallers (5100) or IessJ �C�
❑ I certity thet in Ihe pertormance ol the work lor which this permit is Issued, I shell not employ eny person in eny manner so as to become subjeq to ihe workers'
compensetlon lews oi Celifomle, enA egree that If I shoultl become sub�ect to the workers' compensetion provisions of Section 3700 of the Lebor Cotle, I shell torthwith
comply with Ihe96 pr�ovisions. �� / ��y} \
Appllcan�5igneture: .� / %/�C'/' Date: "1" �� � 1
WAHNING: FAILLIRE TO SE E WORKERS' COMPENSATION COVERAGE IS UNUWFUL AND SHALL SU6IECT AN EMPLOYER TO CR�MINAL PENALTIES AND dVIL FlNES UP TO ONE HUNDHED
T/IIXISAND OOLLARE (S10p.000�.IN ADDfTION TO THE COST OF WMPENS4TION, DMl4GES AS PROVIDED FOR IN SEGTIdJ 3lOB OF TME LABOR CODE, INiEREST, PND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARA710N:
I here6y affirm that I em lice���� tleeejjj,I�r s�ons of Chaptar 9(commencing with Section 7000) ol Divislon 3 of Ihe Busine tl mfessions Code, and my license is in full
torce and eHect. Llc. a f(1�l Class q �� �/%
Contrectols SlgnaNre: �,�, � � Date: � � " l
CONS7RUC710N LENDING AGENCV:
❑ I hereby aflirtn that thera is a constructlon lentling agency lor the peAortnance of tha work for w�ich Ihis permit is Issued. (Sec: 3097, Civil Code).
LenCels Name: Lentlefs Atlaress:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby al(irtn Ihel under penalty ol perjury Ihet I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for Ihe following reason (Sec. 7031.5, eusiness end Professions
Code: Any ciry or county which requires e Dermit to construct, elter, improve, tlemolish, or repair eny strucNre, prior to its issuance, elso requires the applicant for such pertnit
to fle a signed stetement that he or she Is Iicensetl pursuent lo Ihe pmWslons of Ihe Contrectors License Lew (C�apter 9(commencing with Sectlon 7000) of Division 3 of the
Business anA Pratesslons Code) or Ihet he or she is exempt therefrom entl the �esis for t�e allegetl exemption. Any Woletion oi Sectlon 7031.5 by any appllcant tor e pertnit
suCjects ihe epplicant to e civil penelty ol not more than tive hundred dollars ($500).):
❑ I, es owner of Ihe proDerty, or my employees wlih weges es their sole compensatlon, WILL DO THE WORK, entl tha structure Is not imendetl or oHered for sale (Sec.
7044, Buslness and Professions Coda: The Contractors License Lew does not epply to an owner of property who builds or improves Ihereon, and who tloes such work
himself ar herself or through his or her own employees, provided ihet such Improvements ere not Intended ar oHered for sale. I(, however, the builtling or improvement is
sold within one year of completion, Iha ownar-builder wlll heve the burtlen oi proving ihel he or she did not build or imprave tor purpose of sele.). '
❑ I, as owner oi Ihe properry, em E%C WSIVELV GONTRACTING WITH UCENSED CONTRACTORS to construct t�e project (SecJ04d, Business and Pmfessions
Code: The contractors License Lew does nol flpply t0 en owner of proparty who OUIIQs or Impmves thereon, end who conlrects far such project with a contraclor(s)
. license pursuent to the Coniractore License lews.).
❑ I am exemp� under sec. Busin855 end Prof85sion5 Coda tor this reeson:
Signature: Data:
Owner ID venfietl by tlriver's license. ❑ Ves ❑ No Driver's Licensa No. Expires:
Vedficetion of Owners�ip by (type of dwument, I.e. - property tax blll or deetl):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certity that no excavatlon Ilve (5) or more feet In depth Into which a person Is requiretl to Oescentl, wlll be mede in conneclion with work authonzed by this
pertnit, and Ihat no builtling strucWre, scaHolding, talsework, or tlemolitlon or Olsmantling thereoi, will be more than thlrty-six (36) teet high. (Chap. 32, Gry 2, Art 2, Sec.
341, Tltle B, Callfarnia Administrellve Cotle).
❑ As owner-builder, I will not employ enyone to tlo work whlch would requlre a permit irom the Division of Indusirlal Satety, as noted above, unless such person hes e
permit to do such work irom the divislon.
SigneWre: Date:
Division of Indusirial Sefery Pertnit Number:
CEHTIFlCATE OF COMPLIANCE AND AUfHORIZA710N OF ENTAV: I cetlity untler penalry of perjury that I have reaG this application and state that the information given is
correct. I agree ro compy with all stete laws end city ordinences relating to building consiruction, antl euthorize represenlatives ot Ihe Ciry ot Costa Mesa to enter upon the
ebove-described property for inspection purpases. I egree not to occupy or ellow occu0ancy of eny building authonzed Dy �his permit until final inspection.
nature Ot Legal Owner�s) ��e
�� �il � ��) ��
An[UOr Autho zed AppliCent ate
COpE I, INSPECTIONTYPE Qdff II�LS
1616 Fixed System Final Fire Preventlon
1266
200
201
202
203
204
Pool Spe Finel
Final Re-Roof
Finel BIocWRetaining Well
Final Factory Fire Placa
Final Sign
Final Demolitlon
COOE 1 INSPECTION TYPE
208 Final MBc�anical
208 Final Plumbing
210 Final Eleciricel
212 Final Fire Prevention
220 Final Planning Approval
222 Final Site
250 Final BuiltlingiOccupancy
D� Q�L$