HomeMy WebLinkAbout433 16TH PL - Building Permitsf�
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PERMIT TYPE MECH
F,.. .
APN: 42514114
JOB ADDRESS: 43316TH PL CM
viciniry:
SQ. FT: 0
SCOPE OF WORK: REPLACE 48K BTU FURNACE IN GARAGE
OWNER: HAXEL, DELMAR W
PHONE:
APPLICANT: STEVEN SCHNIERER
PHONE: 951-241�876
� CITY OF COSTA MESA �
BlIILDING DIVISION . ... "''�^"'�
. ..�r.�:
77 FAIR DRNE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • w�nv.costamesaca.qov
FOR INSPECTIONS CALL: (774) 754-5626
CONTRACTOR: SERVICE CHAMPIONS
Address: 22917 SAVf RANCH PKWVUnit:
Ciry/State: YORBA LINDA, CA ZipCode: 92887
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MECHANICAL PERMIT FEE SUMMARY
IYIFECH ITEM FEE: $38.30
pLAN CHECK FEE; $0.00
INVESTIGATION FEE: $0.00
REINSPECTION FEE: $0.00
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TOTAL FEES: $38.30
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PERMIT NUMBER: M12-00026
STATUS:
DATE ISSUED:
ISSUED BY:
Suite/Unit:
ISSUED
02I17I2012
MDM
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Address: 433 16TH PL UniL �
Ciry/State/Zip: COSTA MESA, CA
Address: 25251 ALESSANDRO BLVD Unit:
City/State/zZip: MORENO VALLEY, CA ,
Licensallo. 799170 - »>��"����2'�
PHONE: 714-777-7777
' CELL:
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NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
,x�gulations. (Ord. No. g2-28, § 1, 12-21-92)
�:EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
�{NSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspection5 and Fnal approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
�`yQDF� INSVEGTIONTYVE D� IN�AI�S L0� INSPELTIONTYPE p�/ �f NTIilALS
1(616 Fixetl System Final Fire Prevention 206 Final Mechanical x 3• 7• � L r�
i266 PoolSpa Final 208 Final Plumbing ' '
200 Final Re-Roof 21� Final Eleclncal
201 Final BIocWRetaining Wall 212 Final Fire Prevention
202 Finai Facrory Fire Place 220 Final Planning Appmval
203 Final Sign 222 Final Site
F P'3,.;%P
204 FinalDemolition 25o FinalBuilding/Occupancy � �6.i�is"�:
�WORKERS' COMPENSATION DECLARATION�
I hereby aKrm under penalry of perjury one of the following declarations:
❑ I have and will maintain a certifcate of con5ent to sel(-Insure (or vrorkers'
compensation, as provitletl (or by section 3700 oF the Labor Code, for the
peAormance of the vrork for which this permit is issued.
� I have and will maintain wvrkers' compensation insu2nce, as required by
section 3700 of the Labor Code, for ihe peAormance of the wnrk for which this
permit is is5uetl. My workers' Compensation InsUranCe Caffief and policy
number are:
carrier Ta._�e�r T...c_ C'n. � N`(
(IDis section need irot be mmpeted Athe pe�mR is valued at one �undred CWlars (5100J a less )
PolicyNumber i...)C.�gG��Z�i��
❑ I certify that in the performance o/ the work tor 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 Califomia, and agree that if I should
become subjec� to the vrorkers' compensation provisions of Sec[ion 3700 ot
the Labor Code, I shall forthwith comply with Ihese provisions.
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AOPlican[s SlgnaWre Date
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SU&IECT AN EMPLOYER TO CRIMINAI
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
�LICENSED CONTRACTORS DECIARATION:
I hereby aKrm tha[ I am licensetl untler provisions of Chapter 9(commencing
with Section 7000) of Division 3 0( �he Business and Pro(essions Cotle, and
my license is in full force and eNect.
�ia# '%�'-/q I�1C� Class# CZO
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Comracmr s SignaWre Date
CONSTRUCTION LENDING AGENCY:
❑ I hereby aKrtn that there is a consWction lending agency for the
peAormance of the v.ork fa which Ihis pertnit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender's Address:
SiqnaWre Dale
OW NER-BUILDER DECLARATIONS:
I hereby aKrm Ihal under penalry of perjury that I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the following reason (Sec. 703L5,
Business and Protessions Code: Any city or county which requires a permi[ ro
construct, alter, improve, tlemolish, or repair any sirucNre, prior to its
issuance, also requires the applicant for such permi[ to fle a signed s[atement
that he or she is licensed pursuant to Ihe provisions of the Contractors
License Law (Chapter 9(commencing with Seclion 7000) o( Division 3 0( the
Business and Pro(essions Code) or that he or she is exempt theretrom and
the basis tor the alieged exemption. Any violation of Section 7031.5 Dy any
applicant for a permil subjects Ihe applicant lo a civil penalty of not more than
five hundred dollars ($500�.�:
❑ I, as owner o( the property, or my employees vnth wages as their sole
compensa[ion, WILL DO THE WORK, antl the structure is nol intendetl 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
[hereon, antl who does such vrork himsel( or herself or through his or her ovm
employees, pmvided that such impmvements are not intended or offered foi
sale. If, however, the building or improvement is sold within one year of
completion, the owner-builder will have the burden of proving lhat he or she
did not build or improve for purpose of sale.).
❑ I, as owner of the pmperty, am EXCWSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to construct the pmject (Sec. 7044, Business and
Pmfessbns Code: The contractors License Law dces noi apply.to an owner of
property who builds or improves thereon, and who contracts for such project vnth
a contractw(s) license pursuant to the Cont2ctws License Laws.).
❑ I am exempt under sec.
Business and Professions Code for this reason:
30A-E6 (3I0)�
Owner ID verified by tlriver� se. ❑ Ves ❑ No
Driver's License No. Expires:
Verification of Ownership 6y (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation fve (5) or more feet in tlepth into which a
person is required to descen4 will be made in connec�ion with work authonzetl
by this pertni[, and Iha� no building slrucNre, scaftdtling, falsework, or demoli�ion
or dismantling Ihereof, will be more than thirty-six (36) feet high. (Chap. 32, Gry
2, Art 2, Sea 341, Title 8, Califomia Adminis[rative Code).
❑ As owner-builder, I will not employ anyone to do work which woultl
require a permit from the Division o( Industrial Sa(ery, as no[ed above. unless
such person has a permit to tlo such work from ihe division.
Apph<am'S Signature Oate
Division of Industrial Sa(ety Permit Number.
HAZARDOUS MATERIALS AND EMISSIONS CER7IFICATION:
1. Will Ihe applicant or present or future building occupant need to file antl
certify a Business Plan for emergency response m release or threatenetl
release o( a hazardous material? ❑ Yes ❑ No
(Seclion 25505 of lhe Califomia Health and Safety Code requires, with some
exceptions, Ihat a Business Plan be (led vrith the Costa Mesa Fire
Department by every business which has at any one time during a reported
year a quaniity of hazardous materials equal to or greater than a weigh� o!
500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressetl gas
at standard temperature and pressure).
2. Does or will [he applican[ or present or fuNre building occupant need to fle
a regisiration (orm for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the Cali(omia Health and Safely Code, with some
exceptions, requires regisiration 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 grea[er than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet o( compressed gas at standartl
temperature and pressure).
3. Does or will the applicant or present or fuNre building occupant neetl to
prepare an RMPP (Risk Management and Prevention Program for aculely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of the Califomia Heaflh and Safety Code provides thai Ihe
Costa Mesa Fire Department may require the preparation, certificalion and
filing with Ihe Pire Departmen[ 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 Seclion 25534 of the Cali(omia
Health an0 Safery Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or presenl or future building occupant require (or
the work which is the subject of this application a permit tor such construction
or modifica�ion irom Ne South Coast Air Qualiry Mana9ement District or (rom
any other air pollution control tlistnct or agency? ❑ Yes ❑ No
(Section 658502 of the Califomia Govemment Cotle requires that the �equested
in(ormalion be fumished on applications fa non-residential building permits).
6. Will any part o( the faciliry to be constructetl untler Ihis permit be within
1000 (eet (rom the oWer boundaries of a school? ❑ Yes ❑ No
Qf "yes", the faciliry must meet the requirement of Sections 25534 and 42303
o( lhe Califomia Health antl Safety Code).
7. If a permit fmm the South Coast Air �uality Manaqement District or other
air pollution control tlistric[ or agency is required for the work which is the
subject o( this application, have all of the tlisclosures prescribed by Califomia
Health and Sa(ery Code Section 42303 been made? ❑ Yes ❑ No
8. Qf "yes", attach certi(cate of compliance from the appropriate air pollution
controloKcer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty ot perjury the
informa�ion given above is correct I agree to comply with all s�ate laws and
ciry ortlinances regarding Hazartlous Materials and Emissions.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalty of perjury that I have read this application and state that
ihe information given is correcL I agree to comply with all state laws and ciry
ortlinances relating to building construction, and authorize representatives o/
the Ciry of Costa Mesa ro enter upon the above-descnbed property (or
inspection purposes. I agree not to occupy or allow occupancy ot any builtling
aWhorized by this permit until fnal inspec�ion.
SignaWreolLegalOwner�s) Date
N�`�� �2 z� �� � i-,_
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SimplifedPrescriptiveCertificateofCompliance:2008Residentia(HVACAItera6ons CF-IR-ALT-AV.
Climah 7mnes.l and 3- 7
2008 Residential Comp/iance Forms Mmch 20/0
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Applicant t0 /III in all spaees exceD� those within
CiTY OF COSTA MESA' CON��RUCTION PERMIT
ProjectAddress �� '� �•
Applicant's Mailin ddress �
Owner's Name ' Phone
Address
Arch/Enq. Lic¢nse No.
Address �
Contracmr's NamP
�1�IU��At.� T�l� F.f��phone� ����
AddresslmailinglL�� A�� ��a��
Ciry License No. � � v
LICENSED CONTRACTOR DECLARATION
I hereby atfirm that I am Ilcensetl untler provisions of Charter 9(commen<Ing
with'sectlon ]000) of DlviSion 3 Of th¢ B iness n PrOfeSsionS Cotle, antl
my Iicense is in tull forc a Hect. ��/i� I l I C/
License 55 Lic o. ��r S
Date � Si9nature
W00.KER5' COMPENSATION DEGLA0.ATION
I hereby afiirm [hat 1 have a certlliwte of consent to snlNnmr or cerUflcate
' Workers' Compensation Insurance, or a certlfietl corpy t ere f Sectl n
rofc�Y No. •' -�'�' `��u ComP Y � `�a .
8 Certifictl copy is hereby fumishetl. �
CerJ� ietl�co0 i fileA with the city Buil i g D vi I i
Date X� 1� Applicant
EXEMPTION FROM WORKERS' COMPENSATION DECLAR ON
(This section neetl no[ be compleletl if the permit is for one hun re ($100) or
IessJ.
1 C¢rtity thal in the Oe�fo�mance of the wOrk tor whiCh thi5 p¢r i5 i55u¢tl I
shall not em0loy any p¢rson in any mann¢r 50 as f0 become suDject [o Ihe
Worker Co�np 153jjpn Lawz of Calitomia.
Da[e �� I�a $i9ndtur¢
'NOTICE: N, after makin9 this tleclaratlon, you shoultl become 5ubject ro tha
Work¢rs' Compensation provisions ot the Labo� Cotla, you mu5t tOrfhwith
comply wilh such provisions or l�is permit shall b¢ Deemetl �evoketl.
CONSTRUCTION LENDING AGENCV
I M1ereby SHirm that there is a constructlon lentling agency for the performance
o/ th¢ wo�k fo� whicb tnis permil is issuetl (Settion 309] Civ. C.)
Lender's Name
Lentler's Atlaress
OWNER BUILOER �ECLA0.ATIOIJ
I hereby affirm Ihat I am ezampt trom the Contractor4 License Law tor the
tollowing reason (Section 7031.5 Businesz antl Professional Cotle: Any city or
county which requires a vermit lo Conztruct, alter, improva, tlemolish or repair
any sVuchre, prlor to its issuance, also requires the applicant for such permit
to file a signetl Sla[ement [ha[ he/sh! IS lic¢nsetl pursuant lo the prOvisions of
the ConvactorY License Law (Chapter 9(commenting�with Sectlon 7000) of
Division 3 0( the Bu5ine55 antl Profe55ions Cotle) or that h¢/She Is exemOt
'herefrom antl the basis tor the allegetl exemption. Any violation o( Section
131.5 by any applicant fo� a permit Subj¢C[s tho applicant fo a clvil
,nalty of not more tnan five huntlretl tlollars (y500).
L� I, as owner of the o�operty or my employees with wa9es as their sole
<ompensation, will tlo the work, antl che structmn Is not Intentletl or ofteretl
for sale (Sec[ion 7044, Business antl Protessional Cotle: TM1e Contractor's
License Law tloes not apply [o an owner of a��property who builtls or improves
thereon, antl who tloes such work himself/�erself or through his or her own
employees, provi0etl [M1a[ such imp�ovements are not Intentletl or otferetl for
ule. If, however, Ihe builtling or improvemmi is soltl withln one ymr of <om-
Oletion, the owner will have the burtl¢n Of Proving he/she tlitl nOt builtl or im-
prove for tne purpose ot sale). . ,
❑ I, as owner of fhe property, am exclusively contracting wilh litensetl con-
t�actorsto const�uc[ the project ($ectlon 7064, BuSlnoss antl Professions Cotlu:
The Contractor's License Law dOes not apply fo an owner of Oroperiy who
builtls or ImDroves tnereon, antl wno contracts for such projects witn a con-
tractor(s1 Ilcense pmsuant �[o the Contractor'i License Law). I am aware tbat
proof of Iheir Worker's Compensatlon Insurance shoultl bo provltled to me.
❑ I am exempt untler Sectlon B. & P. C. for this reason
Date Owner
I hereby cerNfy thabl�have reatl this aOPlicatlon antl state tM1at the above
information is corr I agr e to como�Y with all tlty antl county ortlinances
antl state laws rel tin to G II Ing co tructlon, antl hereby authorize repre-
sentatives ol tnis tl[ to ' i er upo the above-mentlonea OroOerty for
insoection puro se . p j �� �
Signa W re Date��L
Drlvers' Li�^^ • c � �
; Pink - Accounting; Goltlenrotl - Assessor
Service Sink
Sewer Cap �
Sewer Connection '
Solar Collectors
Solar Piping
Solar Tank
Swimming Pool w/Spa
Urinal
Water Closet
Water Heater
Water Service
Auto-Wash
laue Fee
Hood or Type I ❑
Canopy Typell ❑
Refrigeration System
❑aioo,oaoaTu ❑ioo,000
System Repair/AI[eration
Fire Dampers
Registers
Issue Fee
�
FEES
$ 3
FE
$ 3
Automatic Washer '
Consiruction Pole Sub.
Cooking Unit �
Dishwasher �
Dryers �Gas ❑Electi
Fan
F.A.U.
Fixtures
Device Boxes
Outlets
Switches '
Garbage Dispoul
Generator 065 KW ❑
Fee
7895 , 8/01/85
Accessory Building:
Parking Req./Provided
� , I�o20 TL
zone _
ELECTRICAL
Transtormer ❑ 15-50 KW
' ❑50+KW
KW
Meter LJup to 100 amps
Meter ❑over 100 amps
Sub Panel
Momrs� 1HPO1:4-8 '
InaSolar �9�15 HP �16-15+
Microwave
Pole Light
Range
Sign
Standing Section5
Trash Compactor
FEES
0
$15 � � laue Fee � ' � $ 3
Z
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DEVELOPMENTSERVICESRE�UIREMENTS: �
Zoning Approvad By Data
Building Approved By Data
Appliwtion laued By- Date 8�
SUMMARY OF FEES
BUILDING PERMIT $ SMIP � $;
PLAN CHECK $ ' pU PSSUANCE $
PLUMBING $ �
PLAN CHECK 25% $ ENERGV P.C. $,
ELECTRICAL $ �• 2u GRADING $ �
PLAN CHECK 50% $ MICROFILM $� �
MECHANICAL $ TOTAL FEE $ � za
PLAN CHECK 25% $ �
- CONSTRUCTION AND PLANNING POOL °A - ,
APPROVALS Permit # Date Inspector p�ppROVALS Permit # Date I'nspector
1. Temporory Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. . � 53. Steel Reinforcement .
�3. Electrical Conduit Utility-Undrgrnd. � 54. Forms � �'
4. Electrical Conduit-Undrgrnd. ' 55. Electrical Bonding
5. Steel Reinforcement � 56. Rough Plumbing & Pressure Test
�6. Electrical UFER Grnd�' 57. APPROVAL TO�COVER-GUNITE
� 7. Footings , .�' 58. Electrical Conduit-Undrgrnd. "
8. Foundation ''' � 59. Gas Pipe, O Undrgrnd., Test ' ' �
.9. Water Pipe-Undrgrnd. . , 60. Backwash Lines, P-Trap, O Undrgrnd.
10. Structural Floor System , 61. APPROVAL TO DECK
11. Property Sewer Line & HouseConnection 62. Backwash & Receptor-Final
12. Sewer Cap , 63. Heater & Vent-Final
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing • 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
i 6. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough WiPing Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling -� 69. POOL/SPA SYSTEMS FINAL -
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough•FactoryFireplace APPROVALS Permit#
21. Ducts, in Structure � 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping � Gas ❑ Oil
23. Gas Pipe-Rough & Test .72. Underground Flush
24. Roof Framing 73. Undergrnd. Storage Tank O Gas ❑ Oil
25. Roof Sheathing � 74. Overhead Hydro
26. T-Bai Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe �
' 28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster�Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Elearic Notes: � -
34. Final Heating & Air Conditioning
35. Final Gas Pipe-Test
36. Hood or Canopy •
37. Final Factory Fireplace
38. Final Plumbing �
39. Water Service-Final �
40. Gas Service-Final
41. Solar pomestic-Final � 9 �
42. Backflow Preventer • •
43. Backflow Irrigation �
44. ,Landscape Irrigation System � ,
45. Sound Attenuation �
46. Handicap Regulations •
47. FINAL STRUCTURE & BUILDING �
48. $pecial Requirements Completed
49. Electric Release to Edison � _
50. Gas Release to Southern California Gas Co '
51., CERTIFICATE OF OCCUPANCY
No. Date "
TYPICAL SOLAR DCMESTIC HUP WATER SYSTEM
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PF0.IECT ROOPESS: S 3 3 16TH PL
owxexsxame: DELM,AR HAXEL
nooeess: 4 3 3 E, 16 TH PL
COSTA "�ESA
646-9049
AXCNIENGINEFfl:
ADDNESS:
NEG.NO.:
UNIT:
UNIT:
renminee: DELMAR HAXEL ( 714 ) 646-9049
aooness: q 3 3 E 16 TH Pi,
COSTA MESA CA 92626
IICENSED CONTBACTOB �ECLAFATION: I hereby aflirm tha� I am licensetl untler provisions ol Chap�er 9(commencing wi�h Section
7000� ol �ivision 3 oi ihe Business an0 Prolessions Cotle. antl my license is in �ull force an0 e��ect.
CRY LIC.: STATE LIC.: CLASS:
�ate: Signamre:
WOPREPS' COMPENSp7lON oECIAMTION: I hereby affirm ihal I nave a tenificate oi consent to self-insure or a cenilicate of workers'
Compensation Insurance, or a certified copy �hereof (Semion 3800, Lab. C�.
POLICY NO.: E%P. DATE:
LOMPANY:
❑ Cetlilie0 capy is hereby fumishetl. ❑ CertitieA copy is liled with t0e ciiy BuilOing Division.
.ate: Applicanl:
EXEMPTION F80M WOBREPS' CUMPENSATION OECIANATION: (This sec�ion need no � completeU ii Ihe permit is Iorone hunOreO (E100) or less�.
I cetlity thai in Ihe pedormance ol �he work lor which this Oe�mi� i ss d, I sh � I employ any person in any manner so as to became
suble�� �o I�e WorkerY Compen/s�a}�ion Laws o� Califomia. /
Dale: � — 1�� " � � Signature: S
NOTICE: IL ailer making ihis declara�ion, you shoul0 beco su�jecl to � orkers' C pensation pmvisions o� Ihe Labor
CoOe. you musllonliwiU compty with such pmvisions orihis vermit sh be OeemeO revoketl.
CONSTflULTION LENDING AGENCY: I hereby affirm ihal there is a constmction lenaing agency lor ihe Dertormance ot itre work for
which �his permii is issued (Seciion 3097. Civ. C�.
LFNOEX:
ADDflE55:
OWNEfl BUILDEfl DECLAflRTION: 1 hereby aflirm t�a� I am exem0� imm ��e Contratlors' State License Law for ��e �oilovnng reason
(Section 7031.5 Business antl Pm�essional CoOe: Any city of wuniy which repuires a permi� to constmct, aller, impmve, Oemoiish, or
repair any s�mciure. prior to i�s issuance. also requires the applicant for such permi� Ia lile a SiAned s�atemen� tha� he/she is licensetl
pursuant lo Ihe pmvisions oi the ConVactors' Sla�e License Law (Chap�er 9(commencing wiN Sec�ion 7000) ol Division 3 oi the Business
anG Pmiessions Code) or �hal helihe is exempl �here�mm anJ �he basis for the alleq¢E e�emption. Any viola�ion oi $ec[ion 7031.5 by
any applicam for a permit sublecls ine applicant m a civil penalty o1 not more than five hunOreO Oollars (E500).
L as owner of Ihe D�oDerty or my employees wiih wages as Iheir sole compensalion, will do ��e work, and �he
�. ❑ stmcWre is not inlended or offere0 for sale (Secuon 70A4, Business and Profeuional Cotle: The Coniractors' State License Law
��� tloes noI apply Io an awner o( a pmpe�y who builes or impmves �hereon, antl who tloes SUth wOrk him5e0/her5el� or �Arough
� his or her own ¢mploye¢s, pmvitletl �hat SUCh impmvem¢n�5 are no� intended ot offeretl for Sale. II, however Ihe builtling of
I� impmvement is so10 within one year oi comDlelion, ihe owner will have the DurOen oi Oroving he/she tlitl not 6uiltl or improve
for ihe Durpose of sale�.
,v, I, as owner o� Ihe pmpetly, am exclusively coniracling wi�� IicenseU conVaclors �o con5tmci the pmleci (Section 7044, Business
L^l antl Professions Cotle: The Caniracmrs' Stale Licenre Law aoes not aDPly ro an owner ol certY �o DutlAs ar improves thereon
and who conirac�sfor suc� pmjecis with a contractor(5) license pur5uantia ��e ConV or5' Slaie License Law�.l am aware
ihat Droof of Neir Worker's Compensation insurance snoultl �e pmviAed to me.
� I am exemp� untler Setiion: B. 8 P. C.
br Ihis reason:
Daie: �' \ � —�� Owner
I Do her¢by t¢tlity Ihal I am awar¢ ot antl unOeR�anOlhe r¢Ouir¢menls o� Cali� nia Health antl Sa�ery Code ections 2550.5, 25533, antl
25534 ana Ihat I oranyfulure building occupantwill/willnot(circle one) need I comply wi�h saiA slaie co0es antlthe requiremenislora
permii �or cons�mction or motlifica�ion ir�m the Au Ouabry Managemen� DiSlricL Fesitlen�ial cansimction ap0lica�ion5 are exemp� �mm
Ihese provisions.
Oale: ApPlicanl'. _
I here�y certily ��al I �ave reatl IAis apPlicalian and slate that f
ordinances and 5la�elaw5relatingio �wltling constmclion antl he
pmperiy lor inspeciion purpases.o
oate: , — �� — �' ` Signamre: �
Driver's License or Sacial Securiiy
I JA�ee to comply wi�h all ciry anE county
�ps ciry to ent�r upon ihe above�menlione0
16GLC6 White—BUADing; Green—Cotle EnlorcemenL Canary—Applicam; Pink—Revenue; Gobenroa—Assessor
CITY OF COSTA �ESA — BUILDTNG RN,IT
PERMIT N0: B 058226 PLAN CHECK NO: � N
CONSTRUCTION TYPE: V—N PERMT'i' TYPE: STR
JOB BESCRIPTION : T/OFF RESHT. RERUqF W/COMP i
CLAIM VALUE: 2,0OO.OU CALC—VALUE: �,OOQ,00 G
COMNENTS• 5MOKE DET£CTOR AE�UIRETJ IN THE :iOME
*x�x***��t*�**t�e**1#�ro�x��r�e*�* ��******�*�*x��*�r�*�*��*�r��t*��*
Z O N I N G R E Q U I R E N E N T S
S E T B A C K S
: rv SUYr�:
PCiRPOSE; ALT
SQ FT: 2,000
P OCC: R-3 /
�#***��**��������**
-- -------- MAIN $UII�DING ---------- --------- ACCESSORY/ BUSLDING ---------
FRNT': FT IN REAR: FT IN rRNT: FT IN REAR: FT IN
LEFT; FT IN RGHT; FT IN LEFT; :T IN RGHT: iT IN
PARKING REQ• PROV; PARCEL; 00000000 ZNE; REF NO;
PLANNING ;UnT'ES>
�� i
�1F �1F 1F if �lf-i6 iF iE IF iE iE IE�f iE 3f �JE fE if 3E if� �f iF 3E if If !E R- IF 1E if �f iE IF iE if -?f iF )f if iE iE �E iE ?E if 1E iE 1(� ib �if� if k df iE 3F %� i(� iE if iF iE iE �lE if iF #` iE # fR iF If ji af ii ?F k k)E %
D E V E_L U P M E N T S, E R V I C E S R E Q U I R E,M E h'T S
ZONZNG APPROVED HY DATE:
HUILDING APPkOVED BY ; n DATE:
APPLICATION ISSUED HY•��Ia. � � ��j�� �
�FiEiF1EjE#`�biF3eirikibik3l9'ciEifiFiklFiFi6 �xxxxn� r. F ,�+r UR,c„
iF 3E if i6 af iE i4 iP icie iF?E iF �9E #` 3E jE 3F �c 1k iP3F iElf iF ik jf if i! iF if iF iF jE4f if 3c iE 3f iE If jf 3F if iE at iF 3F i(�
LEGALIZATION:N F E E S U M M A R Y
BLDG PMT PLUMBING ELEC_TRIC MECHANIC
PERMI7' 95.00
�DATE: /7
'�C3FaE1EiPitifMiflEakif #*
iE iF ik if iE iF I(•Y.� �(� iF �)f if ic iF i(� )E jf If iE iE iF ic �3i # iE 1F iF iF
STRUCTtJRAL SEGMENT:Y
FIRE SMIP/RES GRADZNG
.50
SMIP/NON—RES
PLAN
ISSUE FEE
$i7ILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
TOTALS----> 45,50 0,00 0.00 45,50 45.50 .00
REVaNUE DIVISION TOTALS--> COLLECTED• 45.50 OVER/SFiORT; 00
BLDG PMT PiUMBING ELECTRZC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECR
45.00 ,50
fE * 3f If if i(� iE K�7f� if 3k iE iF il� if i't 3f jf iE iE if # aFiF iF �F 1E 3f il� a! iF iE iF iF�E iE iF±F if R 3F �F iFiF i4±(� iE 1f i's if jf i(� iE M� if iF iE iEiE #� 3Fi� if � if � iE 3F-)f it if 3E If aFic 3i� i:� ti� 14
I N D I V I A IJ A I, F E E B R E A K D O W N
TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST
SFR 2000 ALTER BY VALUE RESIDENTIAL NOZONE
END OF FEES
1,00 2,OOU.00
U1_ �911�i.:=-i.C11'a9r2i ". - � .
dbTE: D7�2�7.'"=' Tir1C. 1�c,•.
CONSTRUCTION AND PLANNING- . POOL L A
APPROVAIS Permit # Date Inspector qpPROVAIS Permit # Date I�spector
t. TemporarY Electrical Service or Pole _ 52. Pool & Equipment Location '
2. Soil Pipe-Undrgrnd. - 53. Steel Reintorcemen[ '
3. Electricai Conduit Utility•Undryrnd. 54. Forms
4. Electrical CondUit�Undrgmd. 55. Electrical Bonding -
5. Steel Reintorcement 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL T6 COVER-GUNITE
7. Footings 58. Electrical Cqnduit-Undrgrnd.
8. Foundati0n � 59. Gas Pipe, O Undrgrnd., Test -
9. Water Pipe-Undrgrnd. . 60. Backwash Lines, P�Trap, O Undrgmd. �
� 10. Structusa� Ftoor System - 61. APPROVAL TO OECK
t t. Property Sewer Line & House Connection " 62. Backwash & Receptor�Final .• ��
72. Sewer Cap 63. Heater & Vent-Final .
73. Roof Dra�ns 64. Plumbing SYstem - Final � ��' �" '
14. Rough Pl�mbing 65. Elecvicai-Final
75. Rough Electrical-Conduit fi6. Solar SYstem�Final �
16. Rough Electric Wiring 67. Fencing & Access ApP�oval
17. Rough Wiring Sign 68. APPflOVED FOR PLASTERING
18. Rough Elsctrical�T Bar Ceiling 69. PQOUSPA SYSTEMS FINAL
19. flough Heating & Air Condixioning F1RE DEPT. iiEQU1RfMENT
20. Rough Factory Fireplace APPROVALS Permit #
27. Ducts, in Structure 70. Undergro�nd Hydro
22. Ducts,Ventitating 77. ProductPipin9�Gas �Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd. Srorage Tank O Gas O Oil
25. Roof Sheething � Z� � 4,* 74, Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat ' 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding � 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing � -'�- HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat � 79. FINAL INSPECTION
r
32. Electrical Power Meter-Flnal � � ' 80. FOOD CERTYFICATE ISSUED
33. Finai Electric � i �' Notes:
34. Final Heating & Air Conditioning � �
�
35. Final Gas P�Pe-Test � �
36. Hood or Canopy
37. Finai Factory Firepiace
r
38. Final Plurnbing '
39. Water Service-Final
40. Gas Service-Final � ;
�
47. Solar pomesticFinal � "
42. Backflow P�eventer
43. Backflow Irrigation
44. Landscape Irripation System
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING � �
48. FINALPLANNING �
49. Electric Release to Edison ��', �
50. Gas Release to Southern California Gas Co ' , '
51. CERTIFICATE OF OCCUPANCY
No. Date
AOGlicant to fill in all soaees exceo< <�osa within heavY bortler lines an0 sign all aporoprlate Oeclaratians.
CILY OF COSTA M SA CONS7RUCT�N PERMIT PERMIT NO. TRACT NO. LOT NO. UN1T NO.
Project Address /
Applicant's Mailin,gIAddress ''
Owner's Name �T�'� �L Phone � Or,
Address ��m'��
Arch/Eng. License No.
Address
Contrector'sNamrEhvl4or�w�eA�phone �33'/S3
�
Address Imailingl �d � A) ^' P �14R �D lLl{r], -e�
City License No.
LICENSEO CONTRACTOR DECLARATION
I hereby aftirm that I am licensetl untler provi5ion5 0( Charte� 9(commentin9
wi[n section 7000) of Division 3 of t�e Business antl Protezzions Cotle, antl
my license is in full f and eifect.
License Class�cr— � Litense No.
DateJ�iSi Si9nature �
WORKERS'COMPENSATION DECLAqqTION
,I hereby atflrm that I have a certiticate of consent to Self-inmre or a certificate
�1 Worke�s' Compensation Insuranto, or a certifi¢tl copy ihereof ($ectlon
.800, l.db C.
oB2 -ZZ£r3(oY co t= K.f�tlokJ \
cy N mpany _
Certitietl copy is M1ereby fumishea.
Certiti o y's filetl with the city q��iltlin_,@ sion.
Date_I�� Applitan[��`��� � .
EXEMPTION FROM WORKERS' COMYENSATION DECLARATION
(This section neetl not be completetl if the permit Is for one huntlretl ($100) or
Icss).
I certify that in the p¢rformdnce of the �york for wM1lch this pe�mk is i55u¢tl I
Shall n0[ employ any pe�son in dny rttdnne� so as to become Subject to l�e
Workers' Compensation Laws of California.
Date Signatura
NOTICE: Ii, after making this tleciaratlqn, you shoultl become suDject to tha
Workers' Compensation pmvisionz ot the Labor Cotle, you musl forthwith
comply with SUCh prOvizions o� thiy, p¢rmit zhall Ge tleemetl revOk¢a.
CONSTRUCTION LENDING AGENGV.
I hereby atOrm tnat there is a consVucUon lentling agency for tne pertormance
of tho work for whlch tnis permit is issuetl (Section 3097 Civ. C.)
Lender's rvame
LenUer'S P.atlress
OWNER BUILOER DECLARATION
I herebv atfirm that I am exeFnpt from the Contractor's License Law for [be
iollowing reason (Sectlon 7031.5 Busl�ess antl Professional Cotle: Any city or
county whith requires a permit to con5truct, alteq improva, tlemolish or repalr
any struclure, prlor to its issuance, alsry requires the applicant for such parmlt
to fiie a signetl SWtemen[ that he/she is Iicensetl pursuant ro the provisions of
the Contractor'S License Law (Chapter 9��pmmencing with Section 7000) of
Oivision 3 ot the Business antl Profe;sions Cotle) or that ne/she is exempt
'heretrom antl the ba Is for the allegetl exemplion. Any violation of Sectlon
031.5 by any appl cant tor a perr�l[ suDjects the appllcant to a civil
�etldity ot not mo�e an five huntl�etl tlolla�s (E500�.
I, a5 owne� of lh¢ p/ope�ty or my emplOy¢es with wag¢5 as tnel� Sole
compensation, wi Eo the work, antl the sfructure is not intentletl or o(feretl
br ule (Section 7044, Business antl Profeisional Cotle: The Gontractor's
LicenSe l2w tloes no[ apply to an owngr of a proper[y who builtls or improves
thereon, antl who tloes such work tilmself/nersall or through his or her own
omployeos, provitletl tM1at such improvCments aro not intentletl or offeretl (or
sale. If, however, t�e builtlin9 cr imprVvemen[ is solA withln one year of com-
pletioq lhe owner will have the burtleh ot p�oving he/she tlitl not builtl oi Im-
�lova for ttle purpOSe of sale).
I, as owner of Ihe p�o0erty, am eztlusiv¢ly Cont�acting with licensetl con-
tractors to tonstruct tne project (Settion �044, Business antl Professions Coae:
The Contractor's License Law tloes npt aOPly to an owner of property who
builtls or Improves thereon, antl who contracts for such projects with a con-
[ractor(s1 Ilcense pursuant-to the Contractor's License Law). I am aware tnat
p�oof o( Iheir WorkeYs CompensaHoq insurdnCC SM1oultl be provitletl to mo.
❑ I am exempt untler Section 8. & P. C. �or this reason
Date Owner
I hereby certify that I have reatl this aoP�ication antl state that the above
iMormation is mrrecL 1 a9ree to comply with all city antl county ortlinances
antl state laws relating to builtling coqsfrucHOn, antl hereby au[ho�iEe repre-
sentativ s o/ this cl to enter upon the above-mentionetl property• for
inspecp r e c�
Signat re Date �'3�' 6�
TVPE OF CONSTRUCTION LI NEW I.J ADD L� ALTERATION LJ REPAIR
d CONVERSION ❑ DEMOlISH ❑ OTHER q,p.�6
DESCRIPTION OF WOFK/USE OF BLDG. a'� �� C
;,� ^ �G 5 Main Buildi
»� E
TVPE OF PERMIT GRADING FOUNDATION STRVCTURAL T Front
❑ TENANT ❑ ELECTRICAL ❑ PLVMBING ❑ MECHANICAL B R2df
❑ OTHER A
PROJECT DESCRIPTION Sa.FT. � ocCUPANCv C Right
K Left
CONSTRVCTIONTVPE VALUATION$ $
20NE GRADINGCU.vDS. ACRES p�ng Ref �}
ReTarks:
Bar Sink
Backflow Preventer
Backflow Irrigation
Bathtu6s
Clarifiers
Dishwasher
Drinking Fountains
Floor Drains
Floor Sinks
Gas Service Outlets
s—g�s Planning Notes:
cR�g
<itchen Sink
Lavatories•
'—Trap
Roof Drains
Reinspection Fee . $15
Boiler
Ducl- UnderGround
Duct - Structural
Duct - Ventilating
ExhaustSystem ❑ MWtiple
Firepl/Fact Blt. ICBO #
Heating System & Ducting
❑ai oo,000 eTu o i oa.000
Drivers' License or 55 3� I I Reinspection Fee I $15
CMF 0865-46, �e�. 4/04 White - Builtl�n9: Canary - Applicant; Pink - ; Goldenrotl - Assessor
PLUMBING
Service Sink
Sewer Cap
Sewer Connection
Solar Collecmrs
$olar Piping
Solar Tank
Swimming Pool w/Spa
Urinal-
Wa[er Clout
Waier Heater
Water Service
Issue Fee
Hood or Typel ❑
Canopy Type I I ❑
Refrigeration System
❑0.100,000 BTU ❑100,000 BTU
System Repair/Alteration
Isue Fee
$ 3
S 3
Auiomatic Washer
Construction Pole Sub.
Cooking Uni[
�ishwasher
Dryers �Gas ❑Electric
Fan
F.A.U.
Fixtures
Device Boxes
Outlets
Switche5
Garbage Disposal
Generator 00�5 KW �5-75
�ea� 2io7ies
Zone
Accessory
Parking Req./Provided
ELECTRICAL
Transformer ❑ 15-50 KW
❑ 50+ KW
Meter ❑up ro t00amps
Meter ❑over 100 amps
. Sub Panel
� Motors �/�0-1 FIP � 1%- 8
InaSolar 09-15 HP �16�
Microwave
Pole Light
Range
$ign
' Standing Sections
TraSh Compactor
IGP%Q rl:
FEES
2
O
N
1
N
G
R
E
�
M
T.
$.
- Reinspection Fee � S15 luue Fee $ 3
DEVELOPMENT SERVICES REQUI�REMENTS:
Zoning qpproved By Date
Building Approved By Date
Appliption Issued By Dat �$
� SUMMARV OF FEES
BUILDING PERMIT $ SMIP $ ,
— PLAN CHECK $ PFRMIT
— PLUMBING $ � -4'� �SSUANCE $ '
PLAN CHECK 25% $ ENERGV P.C. $-
ELECTRICAL $ -� GRADING $
— "� MICROFILM $
PLAN CHECK 50% $ - '
— MECHANICAL $ TOTALFEE $ ��
PLAN CHECK 25% y
� CONSTRUCTION AND PLANNING � POOL . ,PA
APPROVALS Permit# Date Inspector AppROVALS Permit# Date Inspector
� 1. Temporary Electrical Service or Pole � 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms �
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test -
.6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7..Footings "' 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgmd. � - - 60. Backwash Lines, P-Trap, 0 Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11. Proper[y Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final
- 13. Roof Drains 64. Plumbing SYstem - Final
14. flough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Vermit #
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping �Gas ❑Oil
23. Gas Pipe-Rough & Test � 72. Underground Flush
24. Roof Framing � 73. Undergrnd. Storage Tank O Gas ❑ Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes: /6 �S �-C�/�, (��
34. Final Heating & Air Conditioning (,{ 8S- /�d �tJSW� ��r7
35. Final Gas Pipe-Test �
36. Hood or Canopy
37. Final Faaory Fireplace -
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final
41. r pomestic-Fin �.
42. ackflow Pre er 3 � s' �f'
43. Backflow Irrigation . .
44. �Landscape Irrigation System .
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING
48. Special Requirements Completed
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
SZ411tUhUKU WAY
YORBA LINDA, CA 92�
714/9748389
July 25, 1985
Dear Buiilding Department:
The following address had,a so)ar permit taken out on it
Haxel ' ��
433 16th Street
Costa Mesa
646:9049
Permit // PE17470
According to the building department, this permit has expired.
The job has been completed, but not final inspected. Please
renew this permit and we will ca.hl for inspection.
Thank you and if you have any questions please call
714-970-8389. Environmentai Engineering Company.
�j ,,,/'� ��171�9f �u a..«.....r fG/Z£ o4�i
�-G�-'� ,a✓
Linda Stratz
h'/i�l �r— � �
'`/�,� 9�p � xa ���-
TJ'
7/�i/sf — i'y � ��TT�' ,Z:,xf� S�,�T 6r�6.����
Tl,oy G,,;(< ro7,�-4, �lor�,��T.�.-,-, �,�< � ,,,�.,�7:0-..'
:-,`��
�t�, OWNER MARINO� FRANK
� JOB ADDRESS 33 E. 1�
Place
� V��YLRMLLVI\II�MI.IVR -
'� ' - LOT T
IN�YClI1VN�
` SOIL
j�v._`\ GAS . _... _. .
WATEF
PROP. $WR. LINE U HOUSE CON.
SPRINKLING SYSTEM
MISCELLANEOUS
AN
UNOERGROUND � POWER
ftOUGH WIRING
BONO BEPM ❑ STEEL REINFORCE
SHEATHING
FRAME ANO FLASHING
�qTHING - IN n OUT
P� -'TEP, BROWN COIT
SURAL, FINAL
MEATING, VENT., REFRIG. ,
DATE
SUBCONTRACTOR
- ' ;38534
��,� �.��A_� s..�fi�
COSTA MESA BUILDINGSAFETY DEPARTMENT �� 1 i-7 �,.� OO $13'�' � OSO
P.O. BOX 1200 COSTA MESA, CALIfORN1A 92626
LI ATION FOR BUILDING PERMIT
For Applicant t0 Fill in Completely
REC Y DATE RECEIVED DATE ISSUED
BUILDING 33 �G� P/a �— �
ADDFESS �
`� A.P. NO./ —31 �— P .�O
OWNEP / /y Q
MA�L .�{/ BUILDING / �
Z .
ADDRESS 3 J" /' ADDRESS
W� U TEL. TRAC LOT BLOCK
CITV CQS'� a NO-
Z
Z Q CANSTRUCTION W AD A TER P
O � LENDER
1 m
J � BRANCH
J � OWNER
� W ADDRE55 VA UE
AFCHITECT TEL S Q C F� $ �L�
— N OR ENGINEER N
U Q FIRE
W 2 ADDRESS ZONE YPE� GROUP
p, W
APPROVED
W Z CONTRACTOR � BY DATE �
J p
m Z
J � ADOFESS
w w TEL. ZO NO.OF USE OF NE
Z� CITV NO. / P�� BUILDING �J
�V ��
w� STATE CITV �'ARDSAPPROVED VARDSAPPROVED
� CL LIC. NO. LI0. NO. MAIN BUILDING ACCESSORV BVIIDING
�O (FROMGLST ' T)
SIZE NO.OF BLDGS. �/
OF LOT NOW ON LOT � RONT _."I �S � FT.
VSE OF � Wc �' 'I �T. FT
EXISTING BLDG. ir
�' SIZE OF x NO.OF
Z NEW BLDG. FOOMS STOFIES / L. SIDE FT. FT.
U EXTERIOR WALL ROOF
COVERING COVERING REAfl T. FT. �'
J USE OF BUI�DING AND WOF1K TO eE PERFOFMED DISTANCE BET. BEf. MAIN &
C MAIN BLOGS. ACCESS. BLOGS.
Pa , r vP'q' # DATE
O C.U.P. yW APPROVEO
~ APPROVED/ % / �
(n •�✓
Z
�
VI �ereby acknowleEge thet I hava reatl this application antl state
� that the above information is correct and agree to comply w(th
� all laws regulacing builtling construction, antl I shall no2 employ � 5.��
F any person in violation of the "+orkman's compensation laws ot
the State of Celifomia. ` r7 .S - �
ZI hereby certify thai I am properly licensed as a convactor under `� SQ. FT. o
the State ot California Busines5 antl Professions Code, Divisicn 3, TH AMOUNT SHOWN UNDER VALUATION IS FOR
Chapter 9, antl tha2 suc� licen4es are in tull force antl etfect, or 1 THE PURPOSE OF ESTABIISHING A PERMIT FEE ONLY: Q
am exempt from tl�¢ p�ovision4 ot the State of Calitornia Business
antl Professions C ivizion Chapter 9. VALUATION m
M� PEFMIT FEE $ � �
Sip^ature ot 9 � � m
Petmittee J / 'I` L�'��� $/Q � PLAN CHECK $ E
0
Authorizad Agent a / u
TOTAL FEE 5
, ' 29235
COSTA MESA BURDING-SAFETY DEPARTMENr
P.O. BOX 7M0 COSTA MESA. CALIFORNIA B26Z6
for Appl7cant to F(1! In Complet��y
TYPE OR PRINT
BUILDINO � �,1
ADDRH8D —
COSTA ME3A. CALIFORNIA
owNeR New ort Balboa Savin s&Loa
MAIL ..... i ... . . .
B ea ch
�ereer FAIA
733130
408833
ach
AD RHII{ 4501 Birch St.
��,�, Newport Beach
uc No. 146423 NHL 540 8833
81ZH 8 3� x�i 0� xo. or �tao�.
OF LOT NOW N
U8E OP
EXIHTINO BLOQ.
�tTl11CIf LIX[ fROY
DESCRIPTION OF WORK
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UD6 OP EUILDINY AND WORK TO 0[ P[RF011M[D
Family dwelling w/attached garage
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AND BT�TB THAT TM[ AGOV6 It CORR6R�I�ND AOR[[ TO COM•
PLY WITN ALL CIA ORG}�N� AND /TAT{ LAW� MtOYLATIHO
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OCT 16-68PA��OO 881+� *+�� S
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APPLICATION FOR PERMR
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for Offfce Ux Only
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` CITY OF COSTA MESA '
os`" F=, ' BUILDING DIVISION
F�� 77 FAIR DRIVE. COSTA MESA. CA 92626 •(714) 754-5273 • Fax Q14) 754-4856 • w�wv.ci.costa-mesa.ca.us
� FOR INSPECTIONS CALL: (714) 754-5626
'k���^°"' PERMIT NUMBER: BC10-00514
PERMIT TYPE: B COMBO STATUS: ISSUED �
Sub Type: RES_ALT DATE ISSUED: 1 1%1 712 01 0
ISSUED BY: KJB -
�os aooRess: 433 16TH PL CM
APN: 42514114
Vicinity:
Const Type:
Zoning: , ,
SQ. FT: 0
Suite/Unit:
� '�Prima'ry Occ ti �
Valuation: $9,500.00
s
SCOPE OF WORK: NON-STRUCTURAL INTERIOR KITCHEN REMODEL AND (1) BATHROOM REMODEL. INCLUDES: DRYWALL,
TILE, REPLACE ONE WINDOW -SAME SIZE. PLUMBINGTO INCLUDE: GAS PIPING FOR STOVE, 1 DISHWASHER, 1 KITCHEN
SINK, 1 SHOWER, 1 TOILET, 1 WASH BASIN. MECHANICAL TO INCLUDE: 1 HOOD/ SINGLE DUCT. ELECTRICAL TO INCLUDE:
14
LIGHT FIXTURES, 20 OUTLETS, 4 SWITCHES. ALL LIGHTING TO COMPLY WITH TITLE 24 REQUIREMENTS.
OWNER: HAXEL, DELMAR W
Phone: 949-646-9049
APPLICANT: GLYCHER, ELINOR
Phone: 818-038-2022
CONrr�CTOR: TOP CONSTRUCTION
Phone: 888-351-0090
Cell:
ARCHITECT: -
ENGINEER: -
COMBINATION PERMIT FEE SUMMARY
Building P�an Check:
Building Fees:
Electrical Fees:
Mechanical Fees:
Plumbing Fees:
SMIP Residential:
SMIP Commercial:
Bldg Std Admin Fund
TOTAL FEES:
Address: 433 16TH PL
City/State/Zip: COSTA MESA, CA _
Address: -`• ,
City/State/zZip: .
�� ,��, �
� License No. 546792
Address: '143 S GLENDALE AVEUnit �
Ciry/State: ' GLENDALE. CA �
License No.
License No.
$0.00
$18125
$65.30
$34.15
$78.65
$0.95
$0.00
$1.00
$361.30
Unit:
Unit: :
�� � � . . -
SUITE 202
ZipCode 97205
PHONE:
PHONE:
^Rater to fae recel L5 for all fees ald tor ro ect
HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3H812010 - PER CMMC Sec. 13-279
Monday thru Friday -7:00 am thru 7:0o pm. Saturdays- B:oo am thru 8:00 pm. Pfohibited all hOurs - Sundays and the following Federal holidays:
NOTICE: 7he work authorized by this permit shall comply wilh all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28. § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must wmply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and fnal approval will result in the expiration of this permit.
L OE i. INSPEC110NTYPE DRTE INi111RL5 CO�ER INSPEGTONTYPE DATE INTRIRlS /�
I!_
1616 Fixed System Final Fire Prevention 206 Final Mechanical � a—I(o —// mo AY
1266 Poo15paPinal 208 FinalPlumbing � d' �iL—/! �
�(v
200 Final Re-Rwf 210 Final ElecMcal X o2 ��V '�l ���
201 Final BloCk/Retaining wall
202 Final Factory Fire Place
203 Final Sign
� � � � ,
204 Final Demolition
212 Final Fire Prevention
220 Final Pianning Approval
222 Final Site ..„p
250 FinalBuilding/Occupancy x �'�/s��/ //4�
WORKERS' COMPENSATION DEC,�ARATIO�
I hereby aKrm under penalty o( perjury one ol the following declaralions: '
❑ I have and will maintain a certificate of consent to self-Insure for vrorkers'
compensation, as providetl tor by section 3700 of Ihe Labor Cotle, for Ihe
peAormance f the wvrk for which this permil is issued.
❑ I e and will maintain v.orkers' compensation ins n, as required by
n 3700 of Ihe Labor COde, lor the peAortnance of e (or which this
pe it is issueC. My rk@rs' compensation Insuran e ta 'er and policy
number are:
Carrier.
(Th6sedqnneetlrof0ec m g�ItlrppnnW'�vaurtlBjMe�un ' brs(f10 Jaless)
Policy Number:
3 i � �r% ���
❑ I certify lhat in the pgAortnance ol the vrork lor which Ihis permit is
issued, I shall not employ any person in any manner so as to become subject
to the vrorkers' compensation laws of Califomia, and agree lhat if I should
bewme subject to l�e cers' w en ation provisions o Section 3700 of
Ihe Labor CoOe, I sh rthwitl pl th the5e provisio .
!I l�
� e
WARNING: FAILURE TO S RE WORKERS' CAMPENSATION COVER4GE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINFS UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000�, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTIQN 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEV'S FEES.
LICENSED CONTRACTOR$ DECLARATION:
I hereby aKrm that I am licensed under provisions ot Chapter 9(commencing
with Section 7000) ol Division 3 0( Ihe Business and�sions Code, and
my license is in full rc antl efle h /
�% �rass:a
� .
r � 'SignpC�re �'
CONSTRUCTION LENDIN6 AGENCY:
❑ I hereby a(firm that there is a cortshucCan IerWi'g agency ta the
perfortnance of the work for wfiich this pertnil is issuetl. (Sec. 3097. Civil Code).
Lender's Name:
Lender's Address:
OW NER-BUILDER DECLARATIONS:
I hereby aKrm Ihat under penaly ol perjury Nat I am E%EMPT FROM THE
CONTRACTORS LICENSQ LAW (or the following reason (Sec. 7037.5,
Business and Professions Code: Any city or county which requires a permit to
construcl, alter, improve, demolish, or repair any slrucWre, prior to its
issuance, also requires the applicant lor such permit lo file a signeC statement
lhat he or she is licensed pursuant to the provisions of lhe CoNraclors
License Law (Chapter 9(wmmencing vrith Section 7000) of Division 3 0l the
Business and Prolessions Code) or that ha or she is exempt therefrom and
the basis lor the allegetl exemption. Any violation ot Section 7031.5 by any
applicant for a permit subjecls the applicant to a civil penalty of not more than
five hundred dollars ($500).):
❑ I, as ovmer of the property, or my employees with vrdges as their sole
compensation, WILL DO THE WORK, and the structure is not intended or
offered for sale (Sec. 7044. Business and Professions Cotle: The Contractors
License Law dces not apply to an owner ol property who builds or improves
thereon, and who tices such vrork himsel( or herself or through his ar her ovm
employees, provided that such improvements are not intentled ar oNereC far
sale. If. however, tha builtling or improvement is sold wiNin one year of
completion, the ovmeo-butltler vnll have the burCen of proving that he or she
did nol builtl or improve (or purpo5e o( sale.).
❑ I. as ovmer ol Ihe property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to consWct Ihe project (Sec. 7044, Business and
Pro(essions CoOe: The contractors License Law dces rrot appy to an ovmer ot
pmpeny who builds or improves thereon. and who cont2cts Iw such project with
a contractor(s) ticense pursuant to the Contractas License Lavrs.).
❑ I am exempt under sec.
Business and Professions Code (or this reason:
Signawre
]OSP46 (3101)
Owner ID verified by tlrie, ..cense. ❑ Ves ❑ No
Driver's License No. � Expires:
Verifcation of Ownership by (type o( tlocument, i.e. - property lax bill or deed):
DIVISION OF INDUSTRIAL SAfETY PERMIT CERTIFICATION:
❑ I hereby ce�Ay thal no excavation frve (5) or more feet m depth into xfiith a
persm is requiretl to tlescend, vrill be made in connection with v.ork authorized
by Ihis permit, antl that no building structure, scaf(dding, falsev.ork, or tlemolilion
or dismantting thereof, vrill be more than thirty-sa (36) feet hiqh. (Chap. 3.2, Grp
2, iii 2, $CC. 34i, T11�2 8, (�.d�liOff112 Af1ff11f1151f21N2 COdB�.
❑ As ovmer-builder, I will not employ anyone to do work whith would
require a pertnit trom the Division of Industrial Safery, as notetl above, unless
such person has a permit co tlo such work fram the division.
APd����'S SignaWre Date
Division of Intlustrial Safety Permit Number:
HAUIRDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or (uture building occupant neetl to fle and
certify a Business Plan for emergency response to release or threatenetl
release of a hazartlous malenal't ❑ Yes ❑ No
(Section 25505 of the CaGfomia Health antl Salery Cade requfres, vrith some
exceptions, lhat 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 quantiry ot hazardous malerials equal to or greater than a weighl of
500 pounds, or a volume of 55 gallons, or 200 cubic (eel of wmpressed gas
at standard temperawre and pressure).
2. Does or will the applicant or present or future building occupant need to file
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the Califomia Health and Safery Cafe. vrith some
exceptions, requires registration vnth t�e Costa Mesa Fire Department by
each business which at any one time has on hand a quantiry ot acutely
hazartlous matenals equal to or grea[er than a weigM of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at 5landard
temperaWre and pressure).
3. Does or vnll the applicant or present or future building occupant need to
prepare an RMPP (Risk Management antl Preven[ion Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of Ihe Cali(ornia Health antl Safely Code provides that the
Cos[a Mesa Fire DepaRment may require Ihe preparation, certification antl
filing with the Fire Department of an RMPP by businesses which are required
lo register acutely haxardous matenals vnM the Fire Department.
4. If an RMPP is presently required, has Section 25534 of Ihe Califomia
Health and Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or WWre building octupant require for
the work which is the subject ol this application a permit (or such wnslruction
or mOdifiG2tion from lhe South Coast Air �uality Managemam District or from
any other air pollution control disMct or a9ency? ❑ Yes ❑ No
(Soctbn 658502 0l lhe Califomia Govemment Code requires that the requesled
information be fumishetl on applications fv rao-residential buiWing permits).
6. Will any part o( lhe facility lo be ConSlructe0 untler this permit ba wilhin
1000 feet from the outer bountlaries ot a school7 ❑ Ves ❑ No
(If yes", the facility must meet the requirement of Sections 25534 antl 42303
o( the California Health and Safety Cotle).
7. If a permit !mm the Soulh Coast Air Qualily Management District or ot�er
air polNtion control tlistrict or agency is required for the work which is lhe
subject of lhis application, have all of the disclosures pre5cribeC by Califomia
Health and Safety Code Seclion 42303 been matle't ❑ Ves ❑ No
8. Qf yes', attach certificate of compliance fmm the appmpriate air pollWion
wntrol oKcer).
CERTIFICATE OF COMPLIANCE: I certity lhat under penalty of perjury Ne
intormation given above is cortect. I a9ree to comply with all state laws and
city ordinances regartling Hazardous Materials and Emissions.
Siqnature
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify untler penalty of perjury that I have read this application and slate that
the information given is cortecL I agree to comply vnth all state laws and city
ortlinances relating to building wnswction, and authorize representatives ol
the City of Costa Mesa to enter upon ihe aDove-described property for
inspection purposes. I agree not to occu y or allow occupancy of any building
authonzed by ihis permit until final in �g ion. -
Wre galOn Dale
GC /
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