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Home My WebLink About353 20TH ST - Building Permits� � CITY OF COSTA MESA ��pMF't9 . BlIILDING D/VIS/ON F`•�� 77 FAIR DRIVE. COSTA MESA. CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.costamesaca.aov °�� FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00576 PERMIT TYPE: B COMBO STATUS: ISSUED Sub Type: RES RRIP DATE ISSUED: 1 211 612 0 0 8 ISSUED BY: YH �08 qpoRess: 353 E 20TH ST CM APN: a2630a02 Zoning: , , Vicinity: Const Type: V-B SQ. FT: 0 Suite/Unit: Primary Occ: R3 Valuation: $1,000.00 SC4pE OF WORK: INSTALL NEW INSULATION THROUGHOUT HOUSE 8 REPLACE DRYWALL. 12/19/08: ELEC: 12 LIGHT FIXTURES, 30 OUTLETS, 10 SW ITCHES, 1 MOTOR TO 1 HP; MECH: 1 HOOD/W DUCT & MECH EXHAUST, 1 VENT FAN TO SINGLE DUCT; PLUMBING: 1 BATHTUB, 1 DISHWASHER, 1 SHOWER, 1 KITCHEN SINK, 1 WASH BASIN, 1 WATER CLOSET, 1 WATER PIPING OWNER: VILORIA,CHRISTOPHER D Phone: APPLICANT: VILORIA,CHRISTOPHER 0 Phone: 949 2923441 CON7RnC70R: OW NER-BUILDER Phone: Cell: AR HITECT: ENGINEER: COMBINATION PERMIT FEE SUMMARY Building Plan Check: Building Fees: Electrical Fees: Mechanical Fees: Plumbing Fees: SMIP Residential: SMIp Commercial: Bldg Std Admin Fund TOTAL FEES: "Rafer to (ee receipts far all toes paid for project AddreSs: 353 E 20TH ST CitylStale/Zip: COSTA MESA, CA Address: 353 E 20TH ST Ciry/State/zZip: COSTA MESA, CA Address: Unit: Ciry/State: License No. Litense No. $0.00 $38.75 $81.75 $41.40 $92.10 $0.50 $0.00 ?? $301.50 License No. 000000 Unit: Unil: : ZipCode PHONE: PHONE: NOTICE: The work authorized by this permit shall wmply with all appliwble handiwp access requirements under Calitornia statutes and related regulations. (Ortl. No. 92-28, § 1. 12-21-92) EXPIRATION: PERMIT EXPIRES 160 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION, IN$PEC710NS: In order for the work authonzed under this permit to be conside�ed IegaC Such work must wmply wfth all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections antl final approval will result in the expiration o( this permit. GOpF• INSPEC710NTYPE PATE IN1171RL5 4QOF�[ INSPECTIONTVPE N A//L11 1616 Fixed System Final Pire Prevention 206 Final Mechanical �� ' {7/j�✓ 1266 Pool Spa Final 208 Final Plumbing T� 200 Final Re-Root 210 Final Electncal 207 202 203 20a Final BIOCk/Retaining Wall Finai Factory Fire Pface Final Sign Final Demolition 272 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 FinalBuilUing/Occupancy .1 u i � � WORKERS' COMPENSATION DECLARATION: I �ere�y aKrm under prnalty of perjury one ot the (ollowing tleclarations: ❑ I have and will mainiain a certi(cate of wnsent to self-Insure for vrorkers' compensation, as provided for by section 3700 ot the Labor Code, for the peAormance o( the work for which this pertnil is issued. ❑ I have and will maintain vrorkers' wmpensatian insu2nce, as repuired by section 3700 of the Labor Cotle, for the pertortnance ol the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier. (TM'.s sec0on neeE not Ee cwnpetedCme pertM b vaN.eC at aro �untlratl dalan (f f00) abu ) Policy Number: ❑ I certiry that in the peAortnance of the work for which this permit is issued, I shall not em0loy any person in any manner so as to become subject to lhe workers' compQnsation laws of Califomia. anC agree thal if I should � become subject to the workers' compensatian Drovisions of Section 3700 of the Labor Cotle, I shall fonhwith comply vnth these provisions. ApplicanYE SignaWre Onm WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SU&IECT AN EMPIOYER TO CRIMINAL PENALTIES AND CIVII, FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SFCTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DELLARATION: I hereby aKrtn that I am licensed untler provisions of Chapter 9(commencing vrith Section 7000) o( Division 3 of the Business and Professions Code, antl my ticense is in (ull forCe and eftect. Lic. # Class # Cmvaaors Sgnature Date CONSTRUCTION LENDING AGENCY: ❑ I �ereby affirtn that there is a consWction Iending agency for the per(ortnance of ihe work for vmich ihis pertnit is issued. (Sec. 3097, Civil CoCe). Lendefs Name: Lenders Atldress: Signamre Da�a OWNER-BUILDER D�CLARATIONS: I hereby affrtm that uqdef penalty of perjury lhat I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the tollowing reason (Sec. 7031.5, Business and Pmiessions Code: Any city or counry which requires a permil to conslruct, alter, improve, tlemolish, or repair any strucNre, prior lo its issuance, also requires Ihe applicant for such permii to file a signed s�atemenl �hal he or she is licensed pursuant to the provisions of the Contraclors License Law (Chapler g(commencing vrith Seclion 7000) ol Division 3 of Ihe Business and Protessions Code) or tha� he or she is exempt therefrom and the basis for the allepetl exemption. Any violalion of Section 7031.5 by any applicant for a permit subjects Ihe applicant to a civil penalry ot not more Ihan frve hundred dollars (5500�.): � I, as owner of t�e properry, or my employees with wages as their sole compensation, WILL DO THE WORK, anA Ne struCNre is not intended or oHered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law tloes not appry to an owner of pmperry who builds or improves thereon, and who daes such work himself or herself or through his or her own employees, provided that such improvements are not iniended or oflered tor 5ale. I(, hOwever, Ih@ building or improvement i5 Sold wit�in one year ot completion, Ihe owner-builder vrill have the burden of proving that he or she did not build or improve for purpose of saleJ. ❑ I, as ovmer of the property, am EXCLUSIVELY CON7RACTING WI7H LICENSED CONTRAC70R5 to construct the project (Sec. 7044, Business antl Professions Code: The contractors License Law does not appy to an ovmer of property who builds or improves lhereon, and who contracts for such pmject wilh a wntracbr(s) license pursuant to ihe Contraciors license Lavrs.). ❑ I am exempt un0er sec. Business and Professions Code for this reason: � Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verifcation of Ownership by (rype of document, i.e. - propArty tax Dil/or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certiry that no excavation fve (5) or more feet in depth into which a person is required to descend, will be matle in wnnection vrith work authorizetl Dy t�is pertnit, and that no building structure, scafloldinp, Falsework. or demolition or dismanUing lhereof, will be more than Nirty-su (38) feet high. (Chap. 3.2, Grp 2, M 2, Sec. 341, Title 8, Califomia Administretive Code). ❑ As owner-builder, I will not employ anyone lo do work whiU woultl require a permit from the Division of Intlustrial Satety, as noled a6ove, unless such person has a permit to do such vrork from the tlivision. Appliwn[s SigneWre Daie Division of Induslrial Safery Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will Ihe applicant or present or future building occupant need to file and certiry a Business Plan for emergency resDonse lo release or Ihrealened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Cali(ornia Health and Salery Code requires, wit� some ezceplions, that a Business Plan be Ned vrith the Costa Mesa Fire Department by every business which has at any one time during a reDarted year a quaniiry of hazartlous matenals equal to or greater Ihan a weight of 500 Dounds, or a volume of 55 gallons, or 200 cubic feet of wmpressed gas at stantlard temperaWre and Dressure). 2. Does or will ihe applicant or present or future building occupant neetl to file a regislration form for aculety hazartlous matenats? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safery Code, vrith some exceptions, requires registration with the Casla Mesa Fire Department by each business which at any one time has on hanC a quantiry of acutety hazardous materials equal to or grealer than a weighi of 500 pounds, or a volume of 55 gallons, or 200 cu6ic teet of compressed gas at standard temperaWre and pressure). 3. Does or will the applicant or present or fuWre building occupant need ro prepare an RMPP (Risk Management and Prevention Program for acutey hazardous matenals)? ❑ Yes ❑ No (Section 25534 of ihe California Health and Safery Code provides that the Costa Mesa Fire Department may require the prepara�ion, certification and filing vnth the Fire Department o( 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 0( ihe Califomia Health and Sa(ery Code been fully complied with? ❑ Yes ❑ No 5. Does or will the apDlicant or present o� fuWre building occupanl require for the vrork which is lhe suhject of this application a permit tor such construction or motlifcation (rom the South Coast Air Qualiry Management District or From any other air polluiion control disMct or agency? ❑ Yes ❑ No (Section 658502 of the Califomia Government Code requires t�at the requested information be fumished on applications for non-residenGal builtling pertnitsJ. 6. Will any part of the facility to be constructed under t�is pertnit be within 1000 feel fmm Ihe outer boundanes ol a school? ❑ Yes ❑ No (If yes'. the facility must meet the requirement of Sections 25534 antl 4230J ot lhe Calitomia Health and Satery Code). 7. I( a permit (rom the South Coast Air �ualiry Management DisMct or other air polWtion control district or agenq is required for the vrork which is the subject of this appliwtion, have all of the diSUosures prescnbetl by Calilornia Healt� and Safery Cotle Section 42303 been made? ❑ Yes ❑ No 8. Qf'yes', attach certifcate of compliance Imm the appmpnate air pollution contml officer). CERTIFICATE OF COMPLIANCE: I certiry that under penalry of perjury Ihe in(ormation given above is cortecL I agree to wmpty wit� all state laws and ciry ordinances regarding Hazardous Materials and Emissions. SignaWre Oale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cetliry under penalry o( perjury that I have read this application and state that the inlormation given is cortect. I agree to compty vrith all state laws and city ordinances relating to building constmction, and authorize representatives of the Ciry of Costa Mesa lo enter upon the above-descnbed pmperty (or inspection purposes agree not to occupy or allow occupancy of any Duilding au�hor zg by Ihi r t until (nal inspection. ' � —'�� SignaWreof Legal Owner s Oate 305146(3N]) , MNor Awhorized AppLCant 1 R � � A � CITY OF COSTA MESA � - . , B(l1LDING DIVISION 77 FAIR DRIVE, COSTA MESA. CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • v+vnv.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754•5626 PERMIT TYPE: B COMBO Sub Type: RES RRIP �og qooResS:�353-E�20TH"Si"CM APN: 42630402 � . Viclnity: � -. Const Type: V-B � SQ. FT: Zoning: , , 0 PERMIT NUMBER: BC08-00576 STATUS: ISSUED DATE ISSUED: 12I1612008 ISSUED BY: YH Suite/Unit: Primary Occ: R3 � Valuation: $1,000.00 SCOPE OF WORK: INSTALL NEW INSULATION THROUGHOUT HOUSE & REPLACE DRYWALL. 12/19/08: ELEC: 12 LIGHT FIXTURES, 30 OUTLETS, 10 SWITCHES, 1 MOTOR TO 1 HP; MECH: 1 HOOD/W DUCT & MECH EXHAUST, 1 VENT FAN TO SINGLE DUCT; PLUMBING: 1 BATHTUB, 1 DISHWASHER, 1 SHOWER, 1 KITCHEN SINK, 1 WASH BASIN, 1 WATER CLOSE7, 1 WATER PIPING . OWNER: VILORIA,CHRISTOPHER D � Ph6ne: APpLICANT: VILORIA,CHRISTOPHER D Phqne: 949 2923441 CONTRACTOR: �� Phqne: Cell: A�HITECT: EN INEER: Address: 353 E 20TH ST Ciry/State/Zip: COSTA MESA, CA Address: 353 E 20TH ST City/State/zZip: COSTA MESA, CA � Address: Unit Cily/State: License No. License No. CqMBINATION PERMIT FEE SUMMARY Building Plan Check: $0.00 Building Fees: $38.75 Electrical Fees: " . $87.75 Mechanical Fees: $41.40 Plumbing Fees: _ $92.10 SMIP Residential: $0.50 SMIP Commercial: $0.00 TOTAL FEES: $254.50 ^Ro}er to tee receipts (or all fees paitl for project License No. Unit: Unit: . ZipCode PHONE: PHONE: � �� r 1HEI� � �� 5 � � � OATE S 26 /� C P NOTICE: The work authorized by this pertnit shall comply wiN all applicable handicap access requirements under California statutes and relaled regulations. (Ord. No. 92-26, § 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 pertnit lo 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. �iQ9Et INSPECTIONTYVE 1LAjF INII71FL5 0� INSPECTONTYGE � INTRI�LS 1616 Fiaed System Final Fire Prevention 206 Final MeUanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electriwl 201 Final BIocWRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning ApDroval 20;� Final Sign 222 Final Site 20q Final Demolition 250 Final BuildinglOccupancy ` :�WORKERS' COMPENSATION DECLARAI. I hereby a�rm under penalry of perjury one of the followinq declaretions: ❑ I have antl will maintain a certifcate of consant to sell-Insure (or workers' compensatlon, as provideC for by section 3700 of the Labor Code, for the peAormance o( the work for which Nis pe�mit is issued. ❑ I have and will maintain xorkers' compensation insurance, as 2quired by section 3700 of the Labor CoOe, fa ihe performance of the work for which this pertnit is issued. My workers' compen5ation Insurance wrtier and policy number are: Carrier. (Tlik saqm naetl rroi De mnpetM ntna permn u�'a�uad af one nunOiM tldlars f3i007 abss ) Policy NumDer: ❑ I certify that in the pertormance of the vrork for which this permit is issuetl, I 5hall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that It I shouid bewme subject to Ihe workers' compen5ation provisions of Section 3700 of ihe Labor Cotle, I shall forthwi[h wmply with these pmvisions. AOdicanl'S SignaWre �ate WARNING: FAILURE TO SECURE WORKERS' COMPENSATION CAVERAGE IS UNLAWFUL AND SHALL SU&IEC7 AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE Hl1NDRED THOUSAND DOLL4RS ($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 DECUIRAYION: I hereby aKrtn I�at I am licensed untler provisions of Chapter 9(commencing vnth Section 7000) ol Division 3 ot the Business and Professions Cotle, antl my license is in (ull force antl effect. Lia # Class # ConVactor's Sgiuture Da�e CONS7RUCTION LENDING AGENCY: ❑ I hereby affrtn that there is a cOnstruction lending agency fa the per(ortnance of the �nork (or wfiich this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lentler's Adtlress: $iryWlure OWNER-BUILDER DECLARATIONS: I hereby aKrm that untler penalty o1 perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for tl+e following reason (Sec. 7031.5, Business and Professions CoCe: Any city or county wl�ich requires a pertnil to constmct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for sVch permit lo file a signed statemenl that he or she is licensed pursuant to the provisions of Ihe CoNractors License Law (Chapter 9(commencing with Seclion 7000) of Division 3 of the Business and Pmfessions Code) or that he or she is exempt there(rom antl the basis for the alleged ezemption. Any violation of Section 7031.5 by any applicant for a pertnit subjects [he applica�t to a civil penalty of not more than fve hundred dollars ($500).): G�I, as ovmer of lhe prOperty, or my employees with v2ges as I�eir sole pensation, WILL DO THE WORK, and the structure is not intended or oHered for sale (Sec. 7044, Business and Professions Code: The Contrectors License Law does not apply to an owner of property who builds or improves thereon, and who dces such work himself or herself or ihrough his or her own employees, providetl that such improvements are not intended or oRered for sale. I(, however, the building or improvement is sold wilhin one year of completion, the ovmer-builtler 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 EXCLUSIVELV CONTRACTING WITH LICENSED CONTRACTORS to construcl the project (Sec. 7044, Business and Professbns Cotle: The contrac�ors License Law dces not apply to an ovmer of property who builds or impmves thereon, and who cont2c[s for such project with a contractor(sj license pursuant to the Cont2c[ors License Laws.). ❑ I am ezempt under sec. Business and Professions Cotle for this reason: � lv i� -a£S Sie�aWre LDate�-� 005'l-46(3/O]) " . Owner ID verified by driv ense. Yes ❑�No Driver's License No.� �Eiipfres: l- z- I 3 Verification of Ownership by (rype ot�document, i.e. - proPerty tax bill or deatl): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certi/y that no excavation frve (5) or more leet in depth into which a person is required to descen4 will be made in connection with work authonzed by this permil, antl that no building struclure, sc�fdding, falsework, or tlemolition or dismantling thereof, will be more than thirty-six (36) fee� high. (Chap. 3.2, Grp 2. M 2, Sec. 341, Ttle 8, Califomia Administ2tive Cotle�. ❑ As owner-builder, I vnll not employ anyone to tlo work which vrould require a permit (rom Ihe Division o( Industrial Safery, as noted above, unless such person has a permit to do such v+ork fmm the tlivision. ApPlicanfs Sgnalure Division of Intlustrial Safely Permil Number. _ HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will lhe applican[ or presenl or future builtling occupant need to file and certify a Business Plan for emergency response to release or threatenetl release of a hazardous matenal? ❑ Yes ❑ No (Section 25505 of the California Health and Safery Code requires, with some exceptions, that a Business Plan be filetl 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 ot 500 pounds, or a volume ot 55 gallons, or 200 cubic leet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupanl need ro file a registration form (or awtely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Heallh and Safely Code, with some exceptions, requires registralion with ihe Costa Mesa Fire Department 6y each business which at any one time has on hantl a quantity of acutely hazartlous materials equal to or greater than a weigh[ o! 500 pounds, or a volume of 55 gallons, or 200 cubic (eet of compressed gas at stantlard temperaNre and pressure). 3. Does o� will the applicant or presant or fuNre building occupant need to prepare an RMPP (Risk Management and Prevention Pmgram for acutely hazartlous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Cotle provides lha[ lhe Costa Mesa Fire Department may require Ihe preparetion, certifcation and filing with Ihe Fire Departmenl o( an RMPP by Dusinesses which are required to register acutely hazardous materials with the Fire Depanment. 4. If an RMPP is presently required, has Section 25534 0( the California Health antl Sa(ety Code been fully complied wilh? ❑ Yes ❑ No 5. Does or will the appliwN or presenl or fuwre building occupant require for tha work which is the subjecl of this appliwtion a permil for such conslruction o� motlification (rom Ihe South Coast Air Quality Management District or from any other air polWtion wntrol district or agency? ❑ Yes ❑ No (Section 658502 of the Califomia Govemment Cotle requires lhal Ihe requested inlwmation be fumished on applications fa rron-resitleniial building permits). 6. Will any part of the facility to be wnstructed under lhis permit be within 7000 feet from the outer bountlanes of a school? ❑ Yes ❑ No Qf'yes", the (acility must meet the requirement of Sections 25534 and 42303 of �he Califomia Heal[h and Satery Code). 7. I( a permit from [he South Coast Air Quality Management DisMct or olher air pollution conlrol tlistrict or agency is required for the woAc which is the subject of this applicalion, have all of the disclosures prescribed by California Health and Sa(ety Code Section 42303 been made? ❑ Yes ❑ No 8. Qf'yes", attach certificate of wmpliance from the appropriate air pollulion contml offcer�. CERTIFICATE OF COMPLIANCE: I certify that under penalty of peryury Ihe information given above is correct. 1 agree lo comply with all state laws and cily ordinances regarding Hazardous Materials and Emissions. CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I ceAify untler penalty of perjury that I have read this application and state that Ihe information given is correcl I agree to wmply with all state laws and cily ortlinances 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 autho e by thi rt until fnal inspection. �.�� i� rz-►9 -o�,.. SignaWreoLLegalOwner(s) Date`�'� Antllo� Aul�onied Applicanl Dele . ► .� - � ' / CITY OF COSTA MESA � % � BYILDING DIVISION ` 77 FAIR DRIVE, COSTA MESA. CA 92626 •(714) 75a-5273 • Fax (714) 754�4856 • www ti-costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT TYpE: B COMBO Sub Type: RES_RRIP �os a��REss: 353 E 20TH ST CM APN: 42630402 . Vicinity: � Const Type: V-B SQ. FT: Zoning: , , 0 • PERMIT NUMBER: BC08-00576 STATUS: ISSUED DATE ISSUED: '12/1612008 ISSUED BY: YH Suite/Unit:: Primary Occ: R3 Valuation: 51,000.00 SCOPE OF WORK: INSTALL NEW INSULATION THROUGHOUT HOUSE 8 REPLACE DRYWALL. OWNER: VILORIA,CHRISTOPHER D Atldress: 353 E 20TH ST Phone: City/SWte2ip: COSTA MESA, CA _ APPLICANT: VILORIA,CHRISTOPHER D Phone: 949 292•3441 � CONTRACTOR: Phone: Cell: ARCHITECT: ENGINEER: Atldress: 353 E 20TH ST City/StatelzZip: COSTA MESA, CA Address: Unit: Ciry/Slate: License No. License No. COMBINATION PERMIT FEE SUMMARY Building Plan Check: $0.00 Building Fees: $38.75 Electrical Fees: $0.00 Mechanical Fees: $0.00 Plumbing Fees: $0.00 SMIP Residential: $0.50 SMIP Comm�rcial: $0.00 TOTAL FEES: $39.25 "Re/er lo fee re�eipts for all fees paid for projoc� License No. Unit: Unit: : '•-i�l� S?'6 ZipCode NOTtLE: The work authorized by this permit shalt compfy with all applicable handicap access requirements under Califania siatutes and relaled regulations. (Ord. No. 92-28, § 1. 12•21-92) EXPIRATION; PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF IAST INSPECTION. INSPECTIONS: In order for the work authonzed under this permit to be considered legal, such vrork must comply with all appliwhle codes, and all required inspections and Tinal approval must be obtained. Faiiure to obWin inspections and Onal apDroval will result in the expiretion of lhis permit. COOE/. IN59ECilON7YPE p�g IN1fML5 S.2Et n+sreenoxrwe pAIE ixmu�s 7618 Fiaed $ystem Final Fire PrevenUon 208 Final Mechanical 7Z86 Paol Spa Final ZOB Final Plumbing - 200 Final Ra.Roof `�,� 10 /I112f'Efe ri I 201 Final Blak/Fietaining Wall 1 Fin F' revention 202 Final Factory Fire Place 220 Final Planning Ap I 203 FinalSign 222 FinalSita 204 Final Demolition 250 Final BuildinryOccupanty WORKERS' COMP NSATION DECLARAI. .� I hereby aRrm under penalty of perjury one o( ihe tollowing deGarations: ❑ I have and will mainUin a certificata of consent to self-Insure tor workers' wmpensation, as provitlad for by section 3700 of the Labor Cotle. for the performance of the work for which this pertnit is Issued. ❑ I have and will maintain v.orkers' compensation insurence, as required hy section 3700 0l the Labor Code, fw the peAortnance of I�e work for which Ihis pertnit is issued. My workers' compensation Insurance carner and policy number are: Cartier. (ilvs.ttc(m nttd nd Oe m'npleletl / flrc M�^�� a rdNetl al me MmWM tlnlars (f IOVI nbss ) Policy Number: ❑ I certify that in the peAormance oF the vrork !or which this permit is issued, I shall nol employ any person in any manner so as to bewme subject lo the workers' compensalion laws of Cali(omia, and agree lhat if I should become subject ro Ne vrorkers' compensation provisions of Seclion 3700 of [he Labor Code, I shall forthvrith wmpiy wi[h Ihese pmvisions. S�greWre Oale WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SU&IECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLIARS ($100,000�, IN ADDfT10N TO iHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. IMEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensad under provisions of Chapter 9(commencing with Section 7000) o! Division 3 of the Business antl Protessions Code. and my license is in full force and eBect. Lic. # Class # Canvactor's Sig�Wre Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affum that Ihere is a consWction lending agency for the performarxe O( Ihe work (a v.fiiCh tlri5 pertnit is is5ue0. (Sec. 3097, Civil Code�. Lender s Name: Lender's Address: Sipnamre Dale OWNER•BUILOER DECLARATIONS: I hereby affirtn Ihat untler penalry af perjury Ihat I am ExEMPT FROM THE CONTRAC70R5 LICENSE U1W for lhe lollowing reason (Sec. 7031.5. Business antl Professions CoCe: Any ciry or couny which requires a permit lo consWct, alter, improve, demolish, or �epai� any sWCNre, prior to its issuance, also requires tne applicant br such permit to file a signed statement l�at he or 5he i5 licensetl pUrsuant to the piovi5ion5 0( Ihe Conifattors License Law (ChaDter 9(commencinq with Section 7000) of Division J o( the Business antl Pro(essions Code) or Ihat he or she is exempl theretrom antl the basis for the alleged exemption. Any violation of Section 7037.5 by any applicaN for a pertnit subjects the applicant to a civil penalry of not more than five hundred dollars (5500�.): 'iYl� I, as ovmer of the property, or my employees with vrdges as their sole compensation, WILL DO THE WORK, antl lhe slnicture is not intended or oRered for sale (Sec. 7044, Business and Professions Cale: T�e Contractors License Law does not apply to an ovmer of propeny who builds or improves �lhereon, and who dces suc� work himself or herself or Ihrough his or her ovm employees, provided that such improvements are no1 intended or otfered for sale. If, however, the building or improvemenl is soltl within one year o( completion, the ovmeo-builder will have the burtlen of proving that he or sha ditl not build or improve for purpose of sale.). ❑ I, as ownerbf the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to wnstmct the projecl (Sec. 7044, Business antl Professions Coae: The wntractors License Law dces not apply to an ovmer of property who builds w improves thereon, and who contracts lor such projecl v,ith a cartractor(s) licensa pursuaN to the Conlractors License LavS.�. ❑ I am exempt under sec. Business and Professions Code for this reason: " IZ- I(.�- � SipnaWre Daie 305]�a6 (3/0]7 OwnerlD verified 6y onv� Expires: -I Z-(3 Venficalion of Ownership by (type o141ocumenh i.e. - property Wx bill or Ceetl): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: • ❑ I hereby certify that no excavation frve (5) or more leet in depth into which a person is required to descend, will be ma0e in connection with vrork authorizetl by this pertnit, and that no building slnicture, scaffdding, false�wrk, a demolition or tlismantling thereol, will be more than thirty-six (36) (eet high. (Chap. 32, Grp 2, Art 2. Sec. 34t, Title B, Califomia Atlminist2tive Code�. ❑ As ovmer-builder, I will not employ anyone to do vrork which woultl require a permit Irom the Division ol Industrial Salery, as noled above, unless such person has a permit lo do such work (rom the division. Ap0liwnfs SignaWre Division o( Intlusirial Safety Permit Number: _ HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 7. Will Ihe applicant or present or fulure builtling occupant need to file and certify a Business Plan for emergency responsa to release or Ihreatened release of a hazar0ous malerial7 ❑ Ves ❑ No (Section 25505 of the Cali(omia Heallh and Safety Code requires, with some ezceplions, that a Business Plan be filed with t�e Costa Mesa Fire Department by every business which has at any one time during a reportetl year a quantity o( hazardou5 materials equal to Or greale! than a weighl of 500 pountls, or a volume of 55 gallons, or 200 cuCic feet of wmpressed gas al stantlartl temperature and pressure). 2. Does or vnll the applicant or present or tuture building occupant need to fle a registration form (or acutely hazardous matedals? ❑ Ves ❑ No (Section 25533 of Ihe Calilomia Health and Safety Cotle, with some exceptions, requires regisiration with the Costa Mesa Fire Department by each business which at any one time has on hantl a quantity of acutely hazardous matenals equal to or greater than a weight ol 500 pountls, or a volume of 55 gallons, or 200 cubic feet o( wmpressed gas al standard temperetwe and pressure). 3. Does or will Ihe applicant or present or (uture building occupant need to prepare an RMPP (Risk Management and Prevention Program (or acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Cali(omia Health antl Safery Code provitles thal the Costa Mesa Fire DepaAment may require the preparation, cenification antl filing with the Fire Department ol an RMPP by businesses which are required b regis�er acutely hazardous materials wilh ihe Fire Oepatlment. 4. If an RMPP is presently required, has Section 25534 of Ihe Califomia Health and Salety Code been (ully wmplie0 wi�h? ❑ Yes ❑ No 5. Does or will Ihe appliwnt or presenl or luture builtling occupanl require for me work which is the subjecl of this apPlication a permit lor such consWction or modificalion (rom Ihe SoNh Coasl Air Oualiry Management District or Irom any other air pollution control district or agency? ❑ Ves ❑ No (Seclion 658502 of the Cali(omia Govemment Cade requires Ihat the requestee infortnatbn be fumished on applications fv ra�resitlential building permits). 6. Will any part of lhe faciliry to be wnstructetl under this permit De within t0001ee1 from the outer boundaries of a school? ❑ Yes ❑ No Q( yes", the facility musl meet the requirement of Sections 25534 antl 42303 of the Calitomia Health and Safely Cotle). 7. If a permit from the SouN Coast Air Quality Management District or other air polWtion contml dislrict or aqency is requiretl for Ihe work which is the subjecl of this application, have all o( Ne disclosures presuibed by Califomia Health and Safely Code Seclion 42309 been made? ❑ Yes ❑ No 8. Qf yes', attach cetlificate of wmpliance from the appropriate air pollution control oKcer). CERTIFICATE OF COMPLIANCE: I certity that under penalty of perjury the inlormalion given above is correcL I agree to comply with alLstale laws and city ortlinances regartling Hazartlous Matenals and Emissions. � CERTIFICATE OF COMPLIANCE AND AU7HORIUITION OF ENTRY: I certify under penalty of peryury that I have read this appliwtion and stale that Ihe inlormalion given is correcl I agree to comply vnth all state laws and city ordinances relating to building construction, antl authorize representalives of the City of Costa Mesa to enter upon the. above-0escribed property for inspection purposes. I agree not to occupy or allow occupancy of any building aui�orized by this permit until fnal inspection. , Signawre of Legai Ovmer�s) Da�e � %Z-�(o-O�i Antllor AWhonEeO %p0liLlnl Dalc � � CITY OF COSTA MESA �sT '"F BI/ILDING D/V/S/ON F` � '77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 •�wiw.costamesaca.aov °• 4 FOR INSPECTIONS CALL: (714) 754•5626 ��Driq�m�c � . PERMIT NUMBER: MOS-00149 PERMIT TYPE MECH APN: 42630402 JOB ADDRESS: 353 E 20TH ST CM Vicinity: SQ. FT: 0 SCOpE OF WORK: INSTALL NEW FAU IN ATTIC SPACE. OWNER: VILORIA,CHRISTOPHERD PHONE: APPLICANT: VILORIA,CHRISTOPHER D PHONE: 949 2923441 CONTRACTOR: Address: Unit: PHONE: City/State: ZipCode: MECHANICAL PERMIT FEE SUMMARY MECH ITEM FEE: $38.30 PLAN CHECK FEE: $0.00 INVESTIGATION FEE: $0.00 REINSPECTION FEE: $0.00 TOTAL FEES: $38.30 STATUS: ISSUED DATE ISSUED: 12I03/2008 ISSUED BY: YH Suite/Unit: Address: 353 E 20TH ST Unit: City/State/Zip: COSTA MESA, CA Address: 353 E 20TH ST Unil: City/State/zZip: COSTA MESA, CA License No. CELL: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and relatetl regulalions. (Ord. No. 92-28, § 1, 72-21-92) 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. CWE! INSAFGiWNTYPE D_� INPilALS OE INSPECPONTYPE //%�' �j� � 1676 Fixed System Final Fire Prevention 206 Final Mechanical � 1266 Popl Spa final 208 Final Plumbing 2�0 Final Re-Roof 210 Final Electncal 207 Final B7ocWRetaining Wall 212 Pinal Fire Preven[ion 202 Final Factory Fire Place 220 Finai Planning Approval 203 Final Sign 222 Final Site 20a Final DemoliGon 250 Final Building/OCcupanty w WORKERS' COMPENSATION DECLARA710N: I hereDy aKrm under penalty of perjury one of the following declarations: ❑ I have and will maintain a cenificate of consent to self-Insure for workers' compensation, as provitled for Dy section 3700 of the Labor Code, for the peAormance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required Dy section 3700 of the Labor Code, (or the peAormance of lhe work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrie[ (This section nee0 rol Da cwnP'etetl nme pemm( is valued at orre hurrtlrtH cbCars (St00) wkss) Policy Number: ❑ I certify lhal in the performance of the work for which this permii is issued, 1 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 � 6ecome subject to [he workers' compensation provisions of Sec[ion 3700 of ihe labor Code, I shall forthwith comply with these provisions. FpplicanYs SiqnaWre 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 DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATI�ORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aKrm 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 eftect. Lic. # Class # ConUaclaYs Signamre Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirtn that there is a construction lending agenq tor the peAortnance of the work for which this pertnit is issuetl. (Sec. 3097, Civil Code). tenders Name: Lender's Adtlress: slgnawre oa�e OWNER-BUILDER DECLARA710NS: I hereby aKrm that under penalry of perjury lhat I am EXEMPT FROM THE GON7RACTORS LICENSE LAW for Ihe tollowing reason (Sec. 7037.5, Business and Professions Code: Any city or counry which requires a permit to construct, alier, improve, demollsh, or repair any sUucWre, prior lo its issuance, also repuires Ihe apDlicant for such permii to file a signed statement lhat he or she is licensed pursuant to the provisions o( the Conirac�ors License Law (Chapter 9(commencing with Section 7000) of Division 3 of the Business and Prolessions Cotle) or that he or she is exempt therefrom and the basis for the alleged exemption. Any vlolation o( Section 7031.5 by any appliwnt for a pertnit subjec[s 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 ompensation, WILL DO THE WORK, and ihe structure is not iniendetl or oHered 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, antl who does such vrork himself or herself or lhrough his or her own employees. provided ihat such improvements are not intendetl or oHered for sale. If, however, the huilding or improvement is sold within one year o( completion, the owner-builtler will have the burden of proving that he or she did not build or impmve for purpose o( sale.). ❑ I, as owner of the proDeM, am E%CLUSIVELY CONTRAC7ING WITH UCENSED CONTRACTORS to wnstruct the project (Sec. 7044, Business and Pmfessions Code: The contraciors License Law does not appy to an ovmer ot pmperty who builds or im0��e5 thereon, and who wntracts for such project with a conVactor(s) license pursuant to the Contractors License Lavrs.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signawre Oate 305146 (]IO]) � Owner ID verifed by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Venfcation of Ownership by (rype of document, i.e. - property taz bi!4ar deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certiy that no ezcavation five (5) or more (eet in depth inlo which a person is required to tlescend, will be matle in connection with woB authonzed by ihis pertnit, and that no building sWCWre, scafloltlin9, falsevrork, or tlemolition or dismaniling thereof, will be more Ihan Ihirty-six (36) feet high. (Chap. 32, Grp 2, Art 2, Sec. 341, TiOe 8, Cali(omia Adminislrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permil from the Division o( Industnal Safery, as noled above, unless such person has a permit to do such vrork from the division. Applicant's SiB�aWre Division o( Industrial Satety Permit Number HAZARDOUS MATERIALS AND EMISSIONS GERTIFICATION: 1. Will the applicant or present or fuWre building occupant need to fle and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 0( the California Health and Sa(ety Code requires, wiM some excep�ions, Iha� a Busine55 Plan De fled wiN Ihe CoS�a Mesa Fire Department by every business which has ai any one time during a reported year a quanlity o( hazardous materials equal to or greater than a weight of 500 Dountls, or a volume of 55 gallons, or 200 cubic feet o( compressed gas at standartl temDerature antl pressure). 2. Does or will the applicant or present or future �uilding occupant need to fle a regisVation (orm (or awtely hazardous matenals? ❑ Yes ❑ No (Seclion 25533 o( the California Health and Sa(ery Code, with some eaceptions, requires regisUation with ihe Costa Mesa Fire Department by each business which al any one time has on hand a quanti[y of acutely hazardous materials equal to or greater ihan a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard [emperaNre and pressure). 3. Does or will Ihe appticant or present or (uture building occupant neetl to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Seclion 25534 of Ihe Califomia Health and Safery Code provides tha[ the Costa Mesa Fire Department may require the preparation, certification and filing with ihe Fire Deparimen� of an RMPP Dy businesses which are required to register acutely hazardous materials with t�e Fire DepaAment. 4. I( an RMPP is presently required, has Section 25534 of the California Health and Safery Code been Fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or Po�ure building occupant require for Ihe work whiCh is Ihe Subject Of Ihis application a permit for such consiruction or modification (rom the South Coast Air Qualiry Management Districl or trom any other air pollution con�rol district or agency? ❑ Yes ❑ No (Section 658502 of the Califomia Govemment Cotle requires that the requested information be fumished on applications for nornresitlential building pertnits). 6. Will any part of ihe facility to be consWcted under �his permit be within 1000 feet from ihe ou[er bountlanes of a school? ❑ Yes ❑ No p('yes', the faciliry must mee[ Ihe requiremen� of Sections 25534 and 42303 o( the Califomia Healih and Sa(ery Code). 7. I( a permit from lhe South Coast Air Quality Management District or other air polWtion control district or agency is required for the work which is the subject o( lhis application, have all of the disciosures prescnbed by Califomia Health and Safery Code Section 42303 been made? ❑ Yes ❑ No B. p('yes", attach certificate o( compliance from lhe appropnate air pollution control oKceq. CERTIFICATE OF COMPLIANCE: 1 certify ihat under penalry of perjury Ihe information given above is correct. I agree ro compy with all state laws and city ordinances regarding Hazardous Marerials and Emissions. SipnaWre �ate CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty ot perjury that I have read this application antl state lhat the information given is correCt. I agree lo Comply vriih all state laws and ciry ordinances relating to building consWction, and aulhorize representalives Of ihe Ciry o( Costa Mesa to enter upon ihe above-0escribed property for inspection purposes. I a ee not to occupy or allow occupancy of any building authorizedJ� is pe til fnal inspection. �//��_ �� <� SignaWreo(LegalOwner(s) Date AnNot Aui�o�ixe0 Applitnn� � � � CITY OF COSTA MESA � ' ,, � " �� • � �� BlIILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Faz (714) 754�856 • www.ci.costa-mesa.w.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT TYPE MECH APN: 42630402 � PERMIT NUMBER: M08-00149 STATUS: ISSUED DATE ISSUED: 1210312008 ISSUED BY: YH JOB ADDRESS: 353:E'20TH_S7'�CM ____� Suite/UniY: vicinity: . SQ. Ff: 0 SCOPE OF WORK: INSTALL NEN/ FAU IN ATTIC SPACE. OWNER: PHONE: APPLICANT: PHONE: Address: City/State: VILORIA,CHRISTOPHER D , VILORIA,CHRISTOPHER D 949 2923441 Unit: PHONE: ZipCode: MECHANICAL PERMIT FEE SUMMARY MECH ITEM FEE: . � $38.30 PLAN CHECK FEE: $0.00 INVESTIGATION FEE: -. $0.00 REINSPECTION FEE: - $0.00 TOTAL FEES: $38.30 Address: 353 E 20TH ST Unit: City/State2ip: COSTA MESA, CA Address: 353 E 2pTH ST Unit: CitylState/zZip: COSTA MESA, CA ��k` �1�E� � � a� d��`fi �.-� License No. CELL: ♦. �Y _ L��:A� . :;� :w> �" �:1 i �?(� �. I b daH � St'''�' txp• 5_�.t6� �l NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia slatules and related regulations. (Ord. No. 92•2B, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspectlons and flnal approval must be obtained. Failure to obtain inspections and final approval will result in the expiration o( this permit. COpE/, IMSYEL710NTYVE g�l� IN7f11 L$ SQEl INSYELTON7YPE �jf, pTll�lS 1878 Fixed Syslgm Final Fire Prevention 208 Final Mechanical 7288 Pool Spa Final 208 Final Plumbing 200 Final Re-Ropf 210 Final EleGtriCal 201 Pinal Block/Retaining Wall 212 Final Fire PrevenJion 202 Final Factqry Fire.Place 220 Final Planning Approval 203 Final Sign ' ' - 222 � Final Site , 204 Final Dertqlitlon _. _ 250 � Final BuildinglOccupanry ' . WORKERS' COMPENSATION DECLARA . - I �ereby aKrm under penalty ot perjury one of the follovring declarations: ❑ I hava antl will maintain a certificate of wnsent to sel(-Insure (or workers' compensation, as provided for by section 3700 of the Labor CoCe, for the peAormanca o1 lhe work for wtilch this permit is issued. ❑ I have and will maintain workers' compensation insurance, as requiretl by secl'an 3700 of the Labor Cotle, fa the peAortnance of the work fa which this permit is issued. My workers' wmpensation Insurance carrier and policy number are: Cartier. (Ina secfion neeC ipfCa cwnpleleOaNeperml'a vaMtl at are nuMretl cbEars (5100) a leu ) Policy Number. ❑ I certily that in the performance of the work for which Ihis permit is issueC, I shall not employ any person in any manner so as lo �ewme subject to the workers' compensation laws of Califomia, anC agree that if I should become subject b lhe vrorkers' compensation pmvisions of Section 3700 0l the LaDor Code, I shall lorthwith comply with these provisions. AOd��'s SignaWre Daie 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 DOLL4RS ($100,000�, IN ADDITION TO THE CAST OF COMPENSATION, DAAMGES AS PROVIDED FOR IN SECTION 3706 OF TNE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aKrtn that I am licensed under provisions of Chapter 9(wmmencing wilh Section 7000) of Division 3 of Ue Business and Professions Cotle, and my license is in full (orce and effect. Lic. # qass # Convactor's SignaWre CONSTRUCTION LENDING AGENGY: ❑ I hereby affum that Ihere is a construction lending agency for Ihe peRormance ot Ihe v.ork far wfiich Ihis pertnit is ssued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: � OWNER•BUILDER DECLARATIONS: I hereby affirm that untler penalry of perjury that I am EICEMPT FROM THE CONTRAC70RS LICENSE LAW for Ihe follovnng reason (Sec. 7031.5, Business and Professions Cotle: Any ciry or counry which requires a Oermit to conslmcl, alter, improve, demolish, or repair any strucWre, pnor to its issuance, also requires Ihe applicant lor such permit to file a siqnetl statement that he or she is licensetl pursuant to the provisions ol lhe Contractors License Law (Chapter 9(commencing with Seclion 7000) of Division 3 of Ihe Business and Prolessions Code) or that he or she is exempt therefrom and the basis lor Ihe alleged exemption. Any violation of Section 7031.5 by any applicaN (or a permit subjects lhe applicanl to a civil penalry o( not more than five hundretl tlollars ($500).): I, as ovmer of I�e property, or my employees with vrdges as their sole ompensalion, WILL DO THE WORK, antl the structure is not intended or offered for sale (Sec. 7044, Business and Professions Cotle: The Contrectors License Law does not apply lo an ovmer of property who builtls or improves Ihereon, antl who does such work himself or herself or through his or her own employees, provided Ihat such improvements are not intended or offeretl for sale. II, however, Ihe buildinq or improvement.is sold within one year of completion, the ovmer-builtler will have the burtlen of proving Uat he or she did not builtl or improve for purpose of sale.). . ❑ I, as owner of ihe property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct lhe project (Sec. 7044. Business antl Prolessbns CoCe: The contractors License Law dces not appty to an avner of pmperty who builds or improves ihereon, and wfio contracts ta such projecl with a cmtractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt untler sec. Business and Protessions Code for this reason: 1 � 3-�� - Signawre ' \ . Dale � 30A-a6 (YO]) Owner ID verifed by Arivi cense. ❑ Yes ❑ No � � Driver's License No. � Expires: �— L�� Venfication o! Ownership by (type ot tlocument, i.e. •'broperty tan�il or deod): ...+ � , DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION:, ' ❑ I hereby certify that no excavatbn frve (5) a mae leet in tlepth into wfiich a person is require0 to tlescentl, will be made in conneclion with �wrk authorized by Ihis pertnit, and thal no building slmcWre, sc�(dding, falsrnork, a Oemolitbn or dismantling thereof, vrill be more Ihan thirty-sa (36) teel high. (Ctiap. 3.2, Grp 2, M 2, Sec. 341, Tlle 8. Calilomia Administ2tive Code). ❑ As owner-builder, I vrill nol employ anyone to do work whic� would require a permit from the Division o! Intlustnal Satery, as noted above. unless such person has a permit to tlo such work from the division. Apolipnl's 9gnalum Division ol Induslrial Salety Permit Number: _ HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or fuNre builtling occupant neeC �o file and certify a Business Plan for emergency response to release or threatened release o( a hazardous material7 ❑ Yes ❑ No (Section 25505 of the Calilomia Health and Sa(ety Cotle requires. with some ezceptions, Ihat a Business Plan �e fileA wit� lhe Costa Mesa Fire Department by every business which has at any one tlme tluring a reportetl year a quantiry o( hazardous materials equal to or greater than a weighi of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressetl gas al s�andard temperalure and pressure�. 2. Does or vnll the applicam or present or luwre building occupant need to file a regislration form for acutely hazardous matenals7 ❑ Yes ❑ No (Seclion 25533 of Ihe Califomia Health and Safety Cotle, with some exceptions. requires regislretion with Ihe Costa Mesa Fire Department by each business which at any one time has on hand a quantiry of acutely hazartlous matenals equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet ot compressed gas at stantlartl IemperaWre and pressure�. 3. Does or vnll the applicant or present or tuture building occupant neetl to prepare an RMPP (Risk Mana9ement antl Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 0! the Califomia Health and Safety Cotle provides 1ha1 the Costa Mesa Fire Departmenl may require the preparation, certi�cation and filing with the Fire Depatlment of an RMPP Dy businesses which are required to register acutely hazardous matenals with Ihe Fire Department. 4. If an RMPP is presently required, has Seclion 25534 0( Ihe California Health and Safely Cotle been fully complied with7 ❑ Yes ❑ No 5. DoeS or will the applicant or present or Nture building occupant require for Ihe work which is the subject o� Ihis applicalion a permil !or such construclion or modification from the South Coast Air Oualiry Management Distria or from any other air pollulion control district or agency? ❑ Yes ❑ NO (SecCwn 658502 0( the California Govemment Code requires Ihat the requested inlortnation be fumished at applications for rromresiCeNial building permits�. 6. Will any part o( lhe lacility to be constructetl untler Ihis permit be wilhin 1000 feet from the outer boundaries o! a schooll ❑ Yes ❑ No Qf "yes", the laciliry must meel Ihe requirement o( Seclions 25534 and 42303 o( Ihe Calilornia Health and Sa(ety Code). 7. If a permit from Ihe South Coast Air Quality Management DisMct or other air pollution control Oistrict or agency is required for the work which is the subject ol this application, have all ol the disclosures prescnbed by Calitomia Health and Safety Cotle Section 42303 been matle? ❑ Yes ❑ No 8. Qf yes", attach cerlifcate ol compliance Irom the appropriate air pollution control officer). ' CERTIFICATE OF COMPLIANCE: I�certify that under �penalty ol perjury the inlormation given above is wrrecl. I agree to comply with all state laws�antl city ortlinances regartling Hazardous Materials and Emissions. „ � CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application antl state that Ihe information given is cortect. I agree lo compty with all slate laws and city ordinances relating to building construction, and authorize representatives of the Ciry of Costa Mesa to eNer upon Ihe above�escribed property for inspection purposes. I agree not to occupy or allow occupancy of any building autho d by Ihis pe i1 until final inspection. �, "`j,�- ]2'3"7.� $iB�lure W Legal Owntt(51 � Da�e Analor AutM1onzeO AOd��nl � � CITY OF COSTA MESA �o " � , B{/ILDING DIV/SION • . >� � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • vN+w.costamesaca.aov r ". ` FOR INSPECTIONS CALL: (714) 754-5626 '`�"a°�"' PERMIT NUMBER: E08-00422 PERMIT TYPE ELEC APN: 42630402 JOB ADDRESS: 353 E 20TH ST CM Vicinity: STATUS: ISSUED DATE ISSUED: 12I0312008 ISSUED BY: YH Suite/Unit: SCOPE OF WORK: UPGRADE 8 RELOCATE 75 AMP. SERVICE TO 200 AMP. SERVICE. OWNER: VILORIA,CHRISTOPHER D Address: 353 E 20TH ST Unit: PHONE: Ciry/State2ip: COSTA MESA, CA APPLICANT: VILORIA,CHRISTOPHER D PHONE: 949 292-3441 CONTRACTOR: Address: UniC City/State: PHONE: ZipCode: ELECTRICAL PERMIT FEES Electrical Plan Check Fee: $0.00 Electrical Permit Fee: $54.00 Reinspection Fee $0.00 TOTAL FEES $101.00 Address: 353 E 20TH ST Unit: City/SlatelzZip: COSTA MESA, CA License No. CELL: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia staWtes 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 le9al, such work must comply 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. LODE I. INSPECiION TYPE DRT �5 4QOjd INSPEGTION 7YPE Q/�¢, IN7IlULS 1616 Fi:eE System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Rool 210 Final Eletlncal I 207 Final BIocWRetaining 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 Builtling/Occupancy � WORKERS' COMPENSATION DECLARATION: I hereby aHirm untler penalty ot perjury one of Ihe following declarations: ❑ I have and vrill maintein a certifcate of consent to sell-Insure for vrorkers' compensation, as provid8d for by section 3700 of the Labor Code, for the peAormance of Ihe vrork (Or which this pertnit is issued. ❑ I have and will maintein workers' compensation insurance, es required by section 3700 ot Ne Labor Code, for the pertortnance o1 the vrork tor which this pertnit is IssueG. My workers' wmpensation Insurence wrner and policy number are: Carrier. (TI�S m[Yw� riae� n0f Ee mnpbro0dme permiis vdluetl at wro nurWretl NLars (f 1W)Wbss ) Policy Number: ❑ I certiry that in the pertormance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to lhe workers' compensgtion laws o( Califomia, and agree [hat if I should � bewme subject ro the workers' compensation provisions of Section 3700 of the Labor Code, I shall foRhvrith comply with these provisions. Applicanfs Sip�¢twe Date WARNING: FAILURE TO $ECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND DOLLAF2S ($100,000). IN ADDITION 70 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 aKrm that I am li�ensed under provisions of Chapter 9(wmmencing with Section 7000) o( Division 3 0( the Business and Professions Cade, and my license is in full (orce dnd eNect. Lic. # Class # Cw�vaqds $iqna(ure Date LONSTRUCTION LENDING AGENCV: ❑ I hereby aKrm that there is a consWction lending agency for lhe pedortnance ol lhe work for which this pertnit is issued. (Sec. 3097, Civil Code). Lenders Name: Lendels Address: signetura oate OWNER-BUILOER DECI,qRqTIONS: I hereby aKrm lhat undef penaliy Of perjury Ihal I am E%EMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Prolessiong Code: Any city or counry which repuires a permit to wnstrucL alter, improv@, demolish, or repair any slrucNre, prior to its issuance. also requires the aDP��nt tor such permit to file a signed statement that he or she is licensed pursuant lo Ihe provisions of �he Conlraclors License Law (Chapter 9(commencing vrith Section 7000) of Divisian 3 ot ihe Business and Professions Cotle) or that he or she is exempt (herefmm antl the basis for the alleged e:emption. Any violation of Section 703L5 by any applicant for a pertnit subjects lhe ap0�icant to a civil penalry of not more than five hundred dollars (5500).): I, as owner ot the property or my employees vrith wages as lheir sole mpensalion, WILL DO THE WORK, and lhe 5[ructure is not iniended or oHered for sale (Sec. 704q, Business and Prolessions Code: The Contraciors License Law does not apply to an owner of property who builds or imDroves thereon, and who tloes such work himsel( or herself or through his or her own employees, provided that such improvements are not intended or oflered for sale. If, however, the building or improvement is sold within one year of completion, lhe owner-builder will have lhe burden o( proving Ihat �e or she did not build or improve for purpose of sale.). ❑ I, as owner of Ihe property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the pmject (Sec. 7044, Business antl Professions Code: The cqntractors License Law dces not appy to an owner of pmperty vfio builds or improves thereon, and who wntracts for such project with a wnVactor(s) license pur5uant to the Contraclors License Laws.). ❑ I am exempt under gec. Business antl ProfessionS Code (or this reason: Owner ID verifietl by driv� nse. ❑ Yes ❑ No Drivers License No. EMpires: Verification of Ownership by (rype of tlocument, i.e. - property taz bill or deetl): DIVISION OF INDUSTRIAL SAFEN PERMIT CERTIFICATION: ❑ I hereby certify thal no excavation frve (5) ar mare feet in depth into which e pereon is requlretl m descend, will be made in connecUon with wnrk authorizetl Ey Mis pertnit, enG that no buildinp s Wcture, scafloldinp, fatsework, or demolitlon or dismantling thereof, will be more than thirty-six (36) leet hiph, (Chap. 3.2, Grp 2, M 2, Sec. 341, Title 8, Calitomia AtlminisVaWe Code). ❑ A5 owner-builtler, I vnll not employ anyone to do work which would require a permit from the Division of Intlustrial Safety, as noted above, unless such person has a permit to do such vrork from the division. ' Applicant's SignaWre Dala Division o( Industrial Safery Permit Numbec HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or fuWre building ocGupant need to file and certify a 8usiness Pian for emergency response to release or Ihreatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of ihe California Health and Satety Code requires, wit� some exceptions, that a Business Plan be filetl with the Costa Mesa Fire Department by every business which has at any ane time Aunng a reported year a quantiry of hazartlous marerials equal ro or greater than a weight of 500 pountls, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standartl temperaWre and pressure). 2. Does or vrill the applicant or present or (uWre builtling occupant need to (le a registration lorm for acutety hazardous materials? ❑ Yes ❑ No (Section 25533 0( the Califomia Health and Safery Code, with some exceD�ions. requires regisiration vrith the Costa Mesa Fire Depariment by each business which at any one time has on hantl a Quantity of acutely hazardous materials equal to oi greater than a weght oi 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperaWre and pressure). 3. Does or will the applicant or present or fuNre building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Seclion 25534 of Ihe California Health and Safery Cotle provitles that the Cosla Mesa Fire Department may require the preparation, certification and filing vnth the Fire Departmenl of an RMPP by Dusinesses which are requiretl to register acutely hazardous materials vrith t�e Fire Department. 4. If an RMPP is presently requiretl, has Section 25534 of t�e California Health and Safety Cotle been tully wmplied vrith? ❑ Yes ❑ No 5. Does or will the applicani or present or Future builtling occuDanl require for �he work which is the subject of t�is application a permit for such constn�ction or modification from the South Coast Air Qualiry Management District or from any other air pollution contml district or a9ency? ❑ Yes ❑ No (Section 658502 of Ihe Califomia Govemmwt Code requires t�a� Ihe requested infortnalion be fumis�etl on applic�atbns for non-re5idenGal building permits). 6. Will any part ot ihe facility Io be constructed under t�is permit be within 1000 teet from the outer boundaries of a school? ❑ Yes ❑ No (It'yes', the faciliry must meet the reduirement ot Sections 25534 and 42303 ol the Califomia Health and Safery Code). 7. If a permit from lhe South Coast Air Qualiry Management DisMct or other air pollulion control disirict or agency is required for the work which is lhe subject of lhis application, have all of the disclosures pre5cnbeA by Califomia Heal(h and Safery Cotle Section 42303 been made? ❑ Yes ❑ No 8. Qf'yes', attach certi�cate of comDliance hom the appropnate air pollution conirol offcer). CERTIFICATE OF COMPLIANCE: I certiy that untler penalry of perjury Ihe information given above is correcL I agree to comply wilh all state laws and city or0inances regarding Hazardous Materials antl Emissions. CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certiry under penalty of perjury that I have reatl this application and stale lhat the informalion given is cortect 1 agree to wmpty with all state laws and city ordinances relating to building wnstruction, and authorize representatives of ihe Ciry ot Costa Mesa to enter upon the above-tlescribed property tor 'rnspection purposes. I agree not to occupy or albw occupancy of any burldng authp�i d by thjs� mit until final inspection. �'' /7 _ I� ��I� 'l Signawre ai Legai O«ner(s) Date 305]d6�1V)) MOIm Authaizad Npplicant � CITY OF COSTA MESA � � �" • • � � • BI/ILDING DIVISION 771FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-0856 • www.d.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT 7YPE ELEC APN: 42630402 JOB ADpRESS: C353-E 20TH'ST"CM ~—� Viciniry: PERMIT NUMBER: E08-00422 STATUS: ISSUED DATE ISSUED: 12I0312008 ISSUED BY: YH Suite/Unit: SCOPE OF WORK: UPGR4DE & RELOCATE 75 AMP. SERVICE TO 200 AMP. SERVICE. OWNER: VILORIA,CHRISTOPHER D� Address: 353 E 20TH ST Unit:� PHONE: "�, City/State/Zip: COSTA MESA, CA APPLICANT; VILORIA,CHRISTOPHER D PHONE: 949 292-3441 � CONTRACTOR: Address: Unit: City/State: PHONE: ZipCode: ELECTRICAL PERMIT FEES Electrical plan Check Fee: $0.00 Electrical Permit Fee: $54.00 Reinspection Fee $0.00 TOTAL FEES $54.00 Address: 353 E 20TH ST Unit: City/SfateBZip: COSTA MESA, CA EX�lr�,�� DATE S".Z�' • �/ �'_�'� ��:•2% License No. CELL: s �,� >�A "'�''�,� .., ' T_ .�� j 'i I 10 day Ic�- � e� : 5 • Zb. • �1 �' NOTICE: 7he work authorized by this pertnit shall Comply wilh all applicable handicap access requirements under Califomia statutes and related regulaGons. (Ord. No. 92-28. § 7. 72-27-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work aulhorized under this permit to be considered legal, such work must comply with all applicable cotles, and all � required ingpe�tlons and final approval musl be obtained. failure to obtain inspectlons and final approval will result in ihe expiration of this permit. 40pE�, INSPE�ONTYPE $1� N �L �10E� INSPELTONTYVE UJ/jg IN7ffIALS 1818 Fixetl System Final Fire Prevention 206 Final Mechaniral iZ68 Pool SDa Finai 2i18 Final Plumbing � 200 Final Re-Roof 210 Final Electrical 201 Final BIxWRe�aining Wall 212 Final Fire Prevention 202 . Final FaIXory Fire Place _r 220 Final Planning Approval 203 � FinalSign - •� � 222 � . Final Site, , � . . � . . 204 Final Demolition 250 Final BuildinglOctupanty � WORKERS'COMPENSAnON DECLARA� I hereby affirtn under penalty of perjury ona ol the followinq Aecla2tion5: ❑ I have and will maintain a cetlificate o( consent to sell-Insure for workers' compensation, as provided for Dy section 3700 ot the Labor CoCe, for the peAormance of the work for whlch this permlt Is issued. ❑ I have antl will maintain workeB' compensation insurance, as requiretl hy section 3700 of t�e Labor Code, for the peAormance ot the woB lor which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: (�na secfion nee0 nd De cnmpletetl Rtna peimR is valuo� at one huntlietlOolWrs (E I00) wless ) Policy Numbe[ ❑ I certify that in the performance of the work for which Ihis permit is issued, I shall not employ any person in any manne� so as to become subject to me workers' compensation laws of Califomia, antl agree thal if I should become subject to the workers' compensation pmvisions o( Section 3700 0! the Labor Code, I shall forthwith comply with these provisions. Pppliwm's SignaWre Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOVER TO CRIMINAL 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 ATTORNEV'S FEES. LICENSED CONTRACTORS DECLARATION: I he�eby affirm that I am licensed under provisions o! Chapter 9(commencing wilh Section 7000) o( Division 3 of the Business and Prolessions Cotle, antl my license is in full force and eHect. Lic. # Class # Gontraqar's SignaWre Da�e CONSTRUCTION LENDING AGENCY: ❑ I hereby affum lhat there is a constructbn lending agency for lhe per(ortnarxe of the xork fa vfiich this pertnit is issued. (Sec. 3097, Civil Code). Lendefs Name: Lenders Address: Daie OWNER-BUILDER DECLARATIONS: I hereby a(firm that untler penalty of perjury tha� I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for Ihe lollowing reason (Sec. 70J7.5, Business and Prolessions Cotle: Any city or county which requires a permit to construct, alter. improve, demolish, or repair any slructure, prior to i15 issuanca, also require5 Ihe applicanl for such permit lo (le a signed statement that he or she is licensetl pursuanl lo the provisions of tha Contrectors License Law (Chapler 9(wmmencing with Seclion 7000) of Division 3 of Ihe Business and Protessions 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 tor a pertni[ subjects the appliwnt lo a civil penalty of not more lhan frve hundred dollars (5500).): ��. I, as ovmer ot the property, or my employees with wages as their sole compensation, WILL DO THE WORK, antl the sWcture is not intended or oftered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law dces not apply to an owner of property who builOs or improves thereon, and wha dces such work himsell or herself or through his or her ovm employees, provided that such improvements are not intentled or offered !or sale. It, however, the building or improvement is sold wilhin one year of completion, Ihe ovmer-builder will have the burden of provinq that he or she did,not build or improve for purpose ol sale.). � I, as ovmer ol�the property, am EXCLUSIVELY CON7RACTING WITH LICENSED CONTRACTORS to construcl the project (Sec. 7044, Business and Professions Code: The contractcrs License Law dces not apply to an owner a( properry who builCs or impmves thereon, and wfio con[racts fw 5uch pmject with a cmtractor(s) ticense pursuant to Ihe Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code tor this reason: � i-2-3 -a4f , Sigwwre " - Daie - ]09�a8(3/Ol) .,-- ' - Owner ID verified by Ariver icense. Yes ❑ No Driver s License No. � Expires: �� Verification of Ownership by (type of tlotument, i,e. -pfope(�y tax bill or tleetl): DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION: ❑ I hereby cetlity thal no excavalion frve (5) a mae (eet in tlepth into wfiich a person is required to descend, vrill be matle in connection with work authorized by Ihis pertnit, and thal no building stmcWre, scaf(dding, lalsework, a demolition or dismantling thereof, will 6e more Ihan thirty-si�c (36) feei high. (ChaD� 3.2, Grp 2, Art 2, Sec. 341, Title B, Cali(omia Adminislrative Code). ❑ As owner-builder, I will nol employ anyone �o tlo work which vrould require a permit from the Division of Intluslrial Sa(ery, a5 notetl above, unless such person has a permit to tlo such vrork from the division. AppllcanYs SignaWre Dale Division of Indus�rial Safery Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or luture builtling occupant need to fle antl certify a Business Plan for emergency response to release or threatenetl release of a hazardous matenal7 ❑ Yes ❑ No (Section 25505 of the Calitornia Health antl Safety Code requires, with some exceptions, that a Business Plan be fled with the Costa Mesa Fire Departmenl by every business which has al any one time during a reported year a quantity of hazartlous materials equal to or greater lhan a weight of 500 pountls, or a volume of 55 gallons, or 200 cubic feet o! compressed gas at standard temperaWre an0 piessure�. 2. Does or will the applicant or present or luture buil0ing occupant need to file a registration form lor acutely hazardous materials? ❑ Yes ❑ No (Seclion 25533 0l the Calilomia Heatlh and Safery Code, with some ezceptions, requires registration with the Costa Mesa Fire Departmem by each business which at any one lime has on hantl a quantity of acutely hazartlous materials equal to or greater than a weight ol 500 pountls, or a volume ot 55 gallons, or 200 cubic feet of compressed gas at stantlard IemperaWre and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program (or acutely hazartlous materials)7 ❑ Yes � No (Section 25534 of Ihe Califomia Health and Safety Cotle provides ihal the Costa Mesa Fire Department may require the preparalion, certifcation and fling wiih �he Fire Depanment of an RMPP by businesses which are required to register aculely hazartlous materials vrith the Fire Department. 4. If an RMPP is presently required, has SetliOn 25534 0( l�e California Health antl Salely Code been fully wmplietl with7 ❑ Yes ❑ No 5. Dces or will lhe appliwnt or present or future Duiltling occupaN require for �he v.ork which is the subject ol lhis application a permit for such consWction or modificalion Imm Ihe Soulh Coast Air Ouality Management Dislrict or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 658502 of ihe Califomia Govemment Code requires �hat the requested infwmal'pn be (umished on applications fv ro�rresidential builtling permits). 6. Will any part of the faciliry to be wnsWcted under this permit be within 7000 feet from Ihe outer bountlaries of a schod? ❑ Yes ❑ No (If yes", the facility musl meet the requirement of Seclions 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 polluiion control tlistnct or agency is required for the work which is Ihe subject ol this application, have all of the disGosures prescnbetl by Califomia Health and Satety Code Section 42303 been matle? ❑ Yes ❑ No 8. (If'yes". attach certifcate of compliance from the appropriate air pollution control oKcer). � CERTIFICATE OF COMPLIANCE: I certify that untler penalty of perjury the inlormation given above is wrtect I agree lo wmply with all state laws and city ordinances regarding Hazardous Materials antl Emissions. �� Da�e � CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalry o( perjury that I have reatl this appliwtion and stale that the information given is cortect. I agree to comply with all state laws and ciry ortlinances relating lo building wnstruction, antl authorize representatives of the Ciry of Costa Mesa to enter upon the aDove-tlescnhed pmperty for inspection purposes. 1 agree not to occupy or allow occupancy o( any building aut z 0 by th' rmi ' nal inspeclion. �,�.�.+�. 1 �-3 -o� � Slgnawreo/LegalOwneqs)) �` Da�e An4lOrAUlhonietlAp0licanl Date M CITY OF COSTA MESA � 4C,�'�pME'rq .._,-. ...V� , BUILDING DIVISION > . � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.costamesaca.aov r �. � FOR INSPECTIONS CALL: (714) 754-5626 ar�+nn.am`A PERMIT NUMBER: BX10-00010 PERMIT TYPE B MISC STATUS: ISSUED APN: 42630402 DATE ISSUED: 01I2212010 Zoning: , ISSUED BY: BE JOB ADDRESS: 353 E 20TH ST CM Suite/Unit: Vicinity: Primary Occ: Const Type :?? SQ. FT: 0 Valuation: $3,000.00 SCOPE OF WORK: 10 WINDOWS AND ONE GARAGE MAN DOOR CHANGE OUT OWNER: VILORIA,CHRISTOPHER D Address:: 353 E 20TH ST City/State: COSTA MESA, CA Zip Code: 92627 Phone: APPLICANT: VILORIA,CHRISTOPHER D City/Stale: COSTA MESA, CA Phone: 949•292•3441 CONTRACTOR; Address: City/State: Zip Code: ARCHITECT: Phone ENGINEER: Phane FEE SUMMARY Building Plan Check: Building Permit: Electrical Permit: SMIP Residential SMIP Commercial Bldg Std Admin Fund Address: 353 E 20TH ST Zip Code: 92627 License No. Phone Cell: License No. License No. $54.11 $83.25 $0.00 $0.50 $0.00 $1.00 Unit Unil: Unit TOTAL FEES 5185.86 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 311812010 - PER CMMC Sec. 13•279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays -9:00 am lhru 6:00 pm. Prohibited all hours - Sundays and the tollowing Federal Holidays: NOTICE: The work authonzed by this permit shall comply with all applicable handicap access tequirements 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 wnsidered 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. yOpE�. INSPECPONT9F ORTE IN AL ODEC INSPEC110NTYPE 9p1E N1111AL 1616 Fixed System Final Fire Prevention 206 Final Mechani¢yl 1266 Pool Spa Final 208 Finai Plumbing 200 Final Re-Roo� 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Faclory Fire PlaCe 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy ° �� WORKERS' COMPENSATION DECLARA7tOF�1: I hereby aKrm under penalty o( perjury one of the follovring declarations: ❑ I have and will maintain a certificate of consent to sell-Insure for vrorkers' compensation, as provided for by seaion 3700 of the Labor Code, for the pedormance of ihe vrork lor which t�is permit is issued. � I have antl will maintain vrorkers' compensation insurance, as required by section 3700 of t�e Labor Cotle, tor the pedortnance ol ihe work for which this permit is issuetl. My workers' compensa�ion Insurance carner and policy number are: Carrier: (This section naod irol �e mmplefed �/tlre permrt �s vaWeC at o�ro nuMratl dMers (f f 00) aloss ) Pqlicy NumGer: ❑ I cerfify that in the peRormance of the work for which this permit is isgued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws oi Califomia, and agree that it I should � become suDject to lhe vrorkers' compensation provisians of Seciion 3700 of the Labor Cotle, I shall lort�vrith wmpy with these provisions. Appliranfs SiB�eWre Oalo 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 DOLLARS (5100,000), 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 DECLARATION: I hereby affirm ihat I am licensetl under provisions of Chapler 9(commencing with Section )000) ot Division 3 of lhe Business and Professions Code, and my license is in full (orce and eHect. Lic. # Class # Convaciu's Sigrutve Data CONSTRUCTION LENDING AGENCY: ❑ I hereby affirtn lhat Ihere is a consWctlon lending agency tor lhe pertormance o( the vrork for whiU this pertnil is issued. (Sec. 3097, Civil Cotle). Lenders Name: L@ndefs Atldress: Signature Daro OW NER-BUIIDER DECLARATIONS; � hereby aKrm that untler penalry of perjury that I am EXEMPT FROM 7HE CONTRACTORS tICENSE LAW (or the tolbvring reason (Sec. 7031.5, BUsiness anU Pmfessions Code: Any ciry or wunty which requires a permit to construct, alter, improve, demolish, or reDair any sirucNre, prior to its issuance, also requires the applicant for such permit to file a signetl statement that he or she is licensetl pursuant to lhe provisions ot the Contractors License Law (Chap�er 9(wmmencing wiN Section 70D0) of Division 3 of Ne Business and Professions Cotle) or that he or she is exempt therefrom and ihe basis for ihe allegetl exemption. Any violation of Section 7031.5 by any applicant for a pe�mit subjects Ihe applicant to a civil penalry ol not more than five �undred tlollars (5500).): I, as owner of the property, or my employees with wages as their sole �Ompensation, WILL DO THE WORK, and the strucWre is not intended or oHered for sale (Sec. 7044, Business and Professions CoOe: The Contractors License Law tloes not apply to an ovmer ot Droperry who builds or improves thereon, antl who does such vrork himself or hersel( or lhmugh his or her ovm employees. pmvitled Ihat such improvements are not intended or oftered for sale. If, however, the building or improvemeni is sold within one year of cbmpletion, ihe ovmer-builder vnll have the burtlen of proving that he or she did not build or improve for purpose ot sale.). [] I, as owner of the property, am E%CLUSIVELY CONTRACTING WITH LICENSED CONTRAC70R5 to consiruct t�e project (Sec. 7044, Business and Professions Code: The contrectors license Law dces not appy to an owner of properry who builds or impmves t�ereon, and who contrads for such pmject wilh a contractor(s) license pursuaN to the Contractors license LavS.). ❑ I am exempt under sec. Business and Pmfessions Code for this reason: Signeture 3o57rs 1�]) � `. OwneND verifietl by driver's license. ❑ Yes � NO Driver's License No. � Expires: Verifcation of Ownership by (rype ol documenL'i.e. —pmperty tax bill or deed): DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION; ❑ I hereby cettify that no excavation five (5) or more feet in depth into which a person is requiretl to descend, will be made in connection with work authorizetl by this permiC antl lhat no building slrucWre, swBolUing, falsework, or tlemolition or dismanUing thereo( will be more ihan thirty-six (36) (eet high. (Chap. 32, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Cotle). ❑ As owner-builder, I will not empl0y anyone ro tlo work which woultl require a permil from ihe Oivision of Intlustrial Safety, as noted above. unleSS such person has a permit to do such work from the division. Pppliwnfs SipnaWro Da1e Division of Intlusinal Safety Permit Numher: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICA710N: 1. Will ihe apDlicant or present or future huilding occupant need lo file antl certi(y a Business Plan for emergency response to release or ihreatenetl release of a hazartlous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health antl Safety Code requires, with some eaceptions, that a Business Plan be fled with the Costa Mesa Fire DeAartment by every business which has at any one time during a reportetl year a quantity of hazardous matenals equal to or greater than a weight ot 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressetl gas at standartl temperaWre antl pressure). 2. Does or will the applicant or present Or fuWre building occupant need to file a regislration torm for acutely �azartlous materials? ❑ Yes ❑ No (Section 25533 ot t�e Calitornia Health and Safery Code, with some exceptions, requires registration with Ihe Costa Mesa Fire Depariment by each business which at any one time has on hand a quantity of acutely hazardous matenals equal ro or greater than a weight o( 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standartl temperature antl pressure). 3. Does or will the applicani or present or Poture 6uilding occupant need to prepare an RMPP {Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health antl Safery Code provides that the Cosia Mesa Fire Department may require the preparation, certification and fling with ihe Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire DepartmenL 4. If an RMPP is preseNly required, has Section 2553a of the Calitomia Health and Safery Cotle been fulty complietl with? ❑ Yes ❑ No 5. Does or vrill the applicant or present or (uture building occupant reduire (or the work which is fhe subjeCt ot this appfiwtion a permit for such construction or modification From the South Coast Air Ouality Manapement Districl or (rOm any other air pollution control district or agency? ❑ Yes ❑ No (SeCtion 658502 of the Califomia Govemment Cotle requires that the reduested infortnation be fumished on applicalions tor non-residential building pemirts). 6. Will any paq of the faciliry to be consWcted under this permit De wil�in 1000 teel (rom the outer boUndarie5 of a 5ch0ol? ❑ Yes ❑ NO (If "yes", the faCility must meet Ihe requirement of Sections 25534 and 42303 ol lhe Calitomia Heallh and Salery Code). 7. If a permit fmm �he South Coast Air Qualiy Management DisMct or other air pollution control district or agency is required for Ihe vrork which is Ihe subject o( lhis application, have all of the disGosures prescnbetl by California Health and Safery Code Section 42303 been made? ❑ Yes ❑ No 8. (If'yes", attach certificate of compliance from the appropriate air pollution control oKcer). CERTIFICATE OF COMPLIANCE: I certify that under penalry of perjury the information given above is correct. I agree to compty vrith all state laws and city ordinances regarding Hazardous Materials antl Emissions. Signnmre CERTIFICATE OF COMPLIANCE AND Af1iHORIZftTION OF ENTRY: t certify under penalry of perjury that I have read this application and stale thal the information given is correcL I agree to compiy with all state laws and city ordinances relating ro building wnstruction, and authorize representatives of the Ciry of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not ro occupy or allow occupancy of any buiiding autl,pn ed tiy this e t untilfnal inspection. `/�! � 7� C% SignaWre ol Legai pwnar(s) Oate MO/or Amtwnzetl Npplicem � ' � � CITY OF COSTA MESA os f - BUILDING DIV/SION FJ�� 77 FAIR DRIVE. COSTA MESA. CA 92626 •(714) 754-5273 • Fax Q14) 754-4856 • �wiw.ci.costa-mesa.ca.us �+'�o� FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BX10-00010 PERMIT TYPE B MISC STATUS: APPLIED APN: 42630402 DATE ISSUED: Zoning: , ISSUED BY: BE JOB ADDRESS: 353 E"20TH'ST`CM Suite/Unit: Vicinily: Primary Occ: Const Type �? SQ. FT: 0 Valuation: $3,000.00 SCOPE OF WORK: 10 WINDOWS AND ONE GARAGE MAN DOOR CHANGE OUT OWNER: VILORIA,CHRISTOPHER D Address:: 353 E 20TH ST Unit City/State: COSTA MESA, CA Zip Code: 92627 Phone: APPLICANT: VILORIA,CHRISTOPHER D City/State: COSTA MESA, CA Phone: 949-292-3441 CONTRACTOR: Address: City/Slale: Zip Code: ARCHITECT: Phane ENGINEER: Phane FEE SUMMARY Building Plan Check: Building Permit: Electrical Permit: SMIP Residential SMIP Commercial Bldg Std Admin Fund TOTAL FEES Address: 353 E 20TH ST Zip Code: 92627 License No. Phone Cell: License No. � License No. ' $54.11 $83.25 $0.00 $0.50 $0.00 $,.00 $138.86 ��.�1�� -!�� oazE 5/ Unit Unit: NOTICE: The work authonzed 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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authonzed 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 fnal approval will result in the expiration of this permit. OC OE t, INSiECTIONTYPE DRTE IN7771RL5 GOUER INSPEC110NTYPE OAi� INT171RL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electncal 201 Final Black/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Appmval 203 Final Sign 222 FinalSite 204 Final Demoli�ion 250 Final Buil�ing/Occupancy � WORKERS' COMPENSATION DECLARATION: 1 hereby affirm under penalty of perjury one of Ne following tleclarations: ❑ I have and vrill maintain a certifcate of consent to self-Insure for workers' wmpensation, as provitletl (or by section 3700 of the Labor Cotle, for �he peAormance ot the work !or which this pertnit is issued. ❑ I have and will main�ain workers' compensation insurance. a5 required by seclion 3700 ot Ihe labor Code, fw the perfortnance ot the v.ork Iw which this permit is issued. My workers' compensation Insurance carrier and policy numberare: Carner (Tnrs scabn neetl ipf Oe [wnpleleo d Me peirtW s value0 dl one hund¢d tlollars (f 100) a less ) Policy Number: ❑ I certify that in the peAormance of the work for which this permit is issued, I snall not employ any person in any manner so as ro become subject to the workers' compensation laws of California, and agree that if I shoultl become subject to the v.orkers' compensation provisions o( Section 3700 of the Labor Code. I shall forthwiN comply with'these provisions. Apqvam's Sipnawre Daie WARNING: FAILURE TO SECURE WORKERS' CAMPENSATION COVERAGE IS UNLAWFUL AND SHALL SU&IECT AN EMPLOVER TO CRIMINAL 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 DECLARATION: I hereby atfrm that I am licensetl under provisions of Chapter 9(commencing with Section 7000) of Division 3 of the Business and Professions CoCe, an0 my license is in full force antl eHect. Lic. # Class # Canvana's 5�0^a�ure Da�e CONSTRUCTION LENDING AGENCY: ❑ I hereby affum that there is a consimctbn IerMing agency for the performance o( the v.ork fa which this pertnit is'ssued (Sec. 3097, Civil Cotle). Lender's Name: Lender's Atltlress: Signalum OW NER•BUILDER DELLARATIONS: I hereDy aKrm Ihat undef penalty o( perjury that 1 am E%EMPT FROM THE CONTRACTORS LICENSE U1W for the (ollowing reason (Sac. 7031.5, Business and Professions Cotle: Any city or county which requires a permit to conslruct, alter, impmve, demolish, or repair any structure. prior to its issuance, also requires the applicant for such permit lo fle a signed statement that he or she is licensed pursuant lo the provisions of the Contractors License Law (Chapter 9(commencing wi�h Section 7000) o( Division 3 0l the Business and Professions Code) or that he or she is exempt Iherefrom antl the basis tor the alleged exemption. Any violation ol Section 7031.5 by any applicant for a permit subjects the appliwnt to a civil penalty ol not more than 5ve hundred tlollars ($500�.�: I, as owner of the property, or my employees with wages as their sole co pensation, WILL DO THE WORK, antl the structure is not intended or oftered for sale (Sec. 7044, Business and Prolessions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who tloes such work himself or herself or t�rough his or her ovm employees, providetl lhat such improvements are not intended or ofleretl for sale. If, however, the buildinq or improvement is sold within one year of completion, the ovmer-builder will have the burtlen o( provin9 thal he or she did not build or improve for purpose of sale.). ❑ I, as ovmer of the property, am EXCLUSIVELY CONTRACTING WITH UCENSED CONTRACTORS to consWct the projecl (Sec. 7044. Business antl Professions Code: The contractors License Law dces not appy to an owner o( property who builds or improves thereon, and who contracts !w such project vrith a contracta(s) license pursuant tothe Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code tor this reason: ` I- Zz- Ip iB��ure Date 305]36 (3/0)) � . Ovmer ID venfied by tlriver's license. ❑ Yes ❑ No Driver's License No. i E�vjires: � Verifcation of Ownership by (rype of document, i�e. = propeity tax bill or Ceed�: DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no ezcavation frve (5) or more feet in depth into wfiich a person is requiretl to descend, vrill Oe made in connectbn wilh work authorize0 by this pertnit, antl that no builtling sWCWre, scaffdding, (alsev.ork, p tlemolition or tlismantling thereof, vrill be more than thiny-sa (36) /eet high. (Chap. 32, Grp 2, M 2, Sec. 341, Tlle B, California Administrative Code). ❑ As ovmer-builder, I will not employ anyone to tlo work which would require a permit Irom the Division o( Industrial Safety, as notetl above, unless such person has a permit to tlo such wnrk from t�e tlivision. ApOlicnm's Sgnolure Oa�e Division of Industrial Salety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or presem or fuwre building occupaN neetl to file and certify a Business Plan for emergency response to release or Ihreatened release o( a hazardous material7 ❑ Yes ❑ No (Section 25505 of the Calilomia Health and Safery Cotle requires, with some exceptions, Ihat a Business Plan be filed with the Costa Mesa Fire Department by every business v+hich has at any one lime tlunng a reported year a quan[ity o! hazartlous materials equal to or greater than a weiqht o! 500 pountls, or a volume of 55 gallons, or 200 cubic feet ol compressed gas ai standard temperaWre antl pressure). 2. Does or will the applicant or present or future building occupant need ro file a registration form (or acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Healih and Safety Cotle, with some exceptions, requires regist2tion vnth the Costa Mesa Fire Depatlment by each business which at any one lime has on hand a quantity ol acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of SS gallons. or 200 cubic feet of compressed gas at stantlartl temperaNre and pressure�. 3. Does or will ihe applicanl or present or fuWre building occupaN need to prepare an RMPP (Risk Management and Prevention Program /or acutely hazartlous materials)? ❑ Yes ❑ No (SeGlion 25534 of the Califomia Health and Safety Cotle prOvideS lhat lhe 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 Ihe Calilomia Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the apDlicant or present or future building occupan� require for lhe work which is lhe Subject ol this applicalion a permit for such wnslmction or modifcation (rom Ihe SoWh Coast Air Qualiry Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Sectbn 658502 0l the Califomia Govemment Cotle requires that �tre requestetl informalion be fumished on applications for non-residential building pertnils). 6. Will any part of the faciliry ro be constructed under Ihis permit be within 1000 leel from the outer boundaries of a school? ❑ Yes � No p( yes", the faciliry must meet the requirement of Sections 2553a ana 42303 of the California Health and Salery Code). 7. I! a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the vrork which is the subject of this application, have all ol the disclosures prescribed by Calilomia Health and Salety Cotle Section 42303 been matle? ❑ Yes ❑ No 8. Qf'yes", attach certificate of compliance from the appropriate air pollution coMrol oKcer�. CERTIFICATE OF COMPLIANCE: I certify lhat under penal[y Of perjury the information given above is cortecl. I agree to comply with all state lav5 and city ordinances regarding Hazardous Materials antl Emissions. SgnaWre CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalry of perjury that I have read this application and state that the in(ormation given is correcL I agree to comply with all state laws an0 city ortlinances relating to building construction, and authonze representatives of the City of Costa Mesa to enter upon the above-descnbed property for inspection purposes. I agree nol to occupy or allow occupancy of any building aut r' ed b ' 9a{iil-pn �I al inspecti ,�- I-LZ- �o Sig Wre ot Legal Owneqs) Date MClor AuthOnzeE ApqiCOnl ld 'Q'S .0-.SI —' ,� 9—,St � � � � Bulaslx3 a s .o-.az �1.��.�� I�i 11 . CITY OSTA MESq � �y � Y - F;U F R CppF: COM LIA g�, N� The set of ' -- ----- — ��'° � arid sMCdrcations 1Si ho 4cOt M In�s'M, I. dIE, . r. ' , I �'3 �^CsaM$k iiy ol Cc:c;a Mrsa �"' ° en pnrmissqn Q�,m � D� ��pgWlhbpUn.anOsc�Mvatir.�s;HALI P W tlIB vbletion of eny provisions c� yn �i be heb to �,m;t a b bg � �P�Sa�dAermtsha9expirebY� �'uonarqstaMcuOrd�airceanNa ��'M�t 1! IIG OOlIMt12110Qd &Id mal(1�gjfl�Q &flVB CBC bCNme IplG 8110 YpIE A�B ce' Sec. 1055 wi@yn iB0 tlays o —.Ol—,6E � ' AP�➢2��:D ci��v or cusr;, �ii , � �LANN�Nr n�� .. � �r` SUQJI:("!'T01311�G f�� f'I'. R! ��. ,uorF: ;ui��Tio�vs. i,i:i.� � i� �.., orz c�iitrtFc��inv.ti �ii:�, r �tii APPRQVIiU f3Y' 7'If;� !�I.:��'��I�� 11 av:.�l� _ „�i�: 1 2z�/O � -- ��w �/Q��" � � �� f�'\ ��.lJ�./ � /J rc mw. r. • � � _`_�. � 3D�0 [S m�"�' � � � ��ryolC o!A'y�galhis 'Mm .�bWEb" °� an K� � � � 5016 %0 I � � � O � N 0 0 111 0 � 3'-6"�7'-10"---� �V CT�U('�UILU� 'IEWF,p F �F COSTA M SSAF�'Y ; O q --�R cODE CpMPG�qNCE � ��afnns � �� pr A' obDale " ( MUST rye �—�j , w� n;�: �L i ��aQ� a�` '�� MahnotB Y ro ' � fTi a eadmamf C: um�ra�y�dS�Mesa dina�ce ��F nr�yi C bect, 4^ u a� Va� nd/or Sfete �. 105.5 µ;qhrn 19p�1'sol� �i 11'-4' �2 2030 SN � O `� " %%—��--� —_-� �-�� Costa Mesa •� City of Costa �l�lesa BuiCding 1�ivision 77 Fair Drive, Costa Mesa, CA 92626 714-754-5273 / Fax 714-754-4856 OWNER BUILDER VERIFICATION Permit # ��(�'- V �U` � Disclosures & Forms for Owner- Builders Applying for Construction Permits IMPORTANT! NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-6uilder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. and initial each statement below to signify you understand or verify this information. (� 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder �and m aware of the limits of my insurance coverage for injuries to workers on my property. 2-1 understand building permits are not required to be signed by property owners unless they are resp/onsible for the construction and are not hiring a licensed Contractor to assume this responsibility. �IY 3 ul nderstand as an "Owner-Builder" 1 am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or he� name instead of my own. ��a I understand Contractors are required by law to be licensed and bonded in California and to list their �licen e numbers on permits and contracts. 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and-tlie total value of my construction is at least five hundred dollars ($500), including labor and materials, I may �be co sidered an "employer" under state and federal law. 'I�understand if I am considered an "employer" under state antl federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contrfb te to unemployment compensation for each "employee." I also understand my failure to abide by these laws �iay subject me to serious financial risk. � 7_I understand under California Contractors' State License Law, an Owner-Builder who builds single-family resitlential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 3148-30 CALBO Jan 1, 2009 OB Packet template 1 of 2 �8-1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be,hzld IRc ble fo�y financial or personal injuries sustained by any subsequent owner(s) that result from any latent ' con ruction defects in the workmanship or materials. 9�1 understand I may obtain more information regarding my obligations as an "employer' from the Internal eV ne ue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contr ctors' State License Board (CSLB) at 1-800321-CSLB (2752) or www.cslb.ca.gov for more information abou licensed coniractors. "T0: I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand t at I arp the paRy legally and financially responsible for proposed construction activity at the following address: '�11, _I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicabl� laws and requirements that govern Owner-Builders as well as employers. -/�' Y2: I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unficensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you wiil be responsible for verifying whethar or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Before a building pprmit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Noie: A copy of the property owner's driver's license, fo�m notarization, or other verification acceptable to the agency is required to be presented when the permit � ssued to verify the pro y owner's signature. �Signature of property owner � �� cDate_ � �!/Z ��u , Note: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the owner's dnver's license, lorm notarization, or other verification acceptable to the agency is requi�ed to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: 3148-30 CALBO Jan 1, 2009 OB Packet template 2 Of 2 � CITY OF COSTA MESA � • BI/ILDING 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) 754-5626 , PERMIT TYPE B_ROOF2 APN: 42630402 JOB ApDRESS: 353 E 20TH ST CM viciniry: Squares: 0 PERMIT NUMBER: B08-00340 STATUS: DATE ISSUED: ISSUED BY: SuitelUnit: Valuation: ISSUED 12I1612008 YH $2,000.00 SCOPE QF WORK: REROOF HOUSE & ATTACHED GARAGE: TEAR OFF COMP. SHINGLES, REPAIR SHTG. AS NEEDED, INSTALL 2 LAYERS OF 15#FELT. & INSTALL APFROX. 10 S�R'S OF COMP. SHINGLES ON 125 PITCH ROOF. OWNER: VILORIA,CHRISTOPHERD PHONE: APPLICANT: VILORIA,CHRISTOPHER D PHONE: 949 292-3441 CONTRACTOR: . Address: Unit: Ciy/State/Zip: ARCHITECT: ENGINEER: FEE SUMMARY Reroof Plan Check: Reroof Permit Fee: Reinspection Fee: TOTALFEES Address: 353 E 20TH ST City/State/Zip: COSTAMESA,�CA Address: 353 E 20TH ST - Ciry/Stale2ip: COSTA MESA, CA PHONE: License No. License No. License No. CELL PHONE: PHONE: $0.00 � $69.25 $0.00 569.25 � � � Unit: Unit: : ',.r�=i•�i � NOTICE: The work authorized by this pertnit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) � � EXPIRATION: PERMIT E%PIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work aulhorizetl under this pertnit to be considered legal, such work must comply with all applicable codes, and all required inspections and fl�al approval must be obtained. Failure to obtain inspections and fnal approval will result in the expiretion of this permil. CQOE/. IN59FC110NTYPE Q� I�¢ �� INSPECTIONTYPE Q�¢� IN7IML3 1818 Fixed Syslem Final Fire Prevention 208 Final Mechanical 1288 Pop15pa Final �� .t' 208 Final Plumbing 200 Final Re-Roof �-a�./o ./��/yp/y�c�� 210 Final Elecinwl ' 201 Final Blotk/ReWining Wall 212 Final Fira Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Fi�al Sign 222 Final Site 204 Fi�al Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby aKrtn under penalty of perjury ona of the following declarations: ❑ I have antl will maintain a certifiwte of wn5ent to 5el(•Insure for workers' compensallon, as provided for by section 3700 of the Labor Cotle, for tha peAormance of lhe vrork lor which this pertnit is issued. ❑ I have antl will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, fa Ihe perfortnance of the wvrk fw which this pertnit is issuetl. My wnrkers' compensation Insurance carrier and policy number are: Carrie[ (T��s sepnn neetl rpl pe tumpefetll Me pemM is valuM al me �unOreE MYlars (S100J a less ) Policy Number: ❑ I cetlify that in the peRormance of the vrork lor which lhis permil is issued, I shall not employ any person in any manner so as to become subjecl to the workers' compensation laws ol Califomia. and agree that i( I shoultl become subject to tha workers' compen5ation provisions of Seclion 3700 of Ihe Labor Code, I shall forthwith comply with thesa provisions. AOGliwnl's Signalure Dalc WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDREO THOUSAND DOLIARS ($100,000�, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND ATTORNEV'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby aKrtn that I am licensed under provisions of Chapter 9(commencing with Seclion 7000) o( Division 3 of the Business antl Prolessions Cotle, antl my license is in full torce and eftect. Lic. # Class # Conuanar'S Signawre CONSTRUCTION LENDING AGENLY: ❑ I hereby affum that [here is a consWction lending agency br the peAormance of the xork fa wfiich tttis permit is issuetl. (Sec. 3097, Civil Code�. Lender s Name: Lenders Address: OW NER•BUILDER DECLARATIONS: I hereby aKrm that under penalty of perjury �hat I am EXEMPT FROM THE CONTRACTORS LICENSE LAW br the lollowing reason (Sec. 7031.5, Business and Professions Cotle: Any city or counry which repuires a permit ro wnswct, alter, impmve, demolish, or repair any sWcture, prior �o its issuance, also requires the applicant for such pertnit to file a si9netl starement that he or she is licensed pursuant to the pmvisions of the Contraclors License Law (Chapter 9(commencing vnth Section 7000) Of Division 3 0( Ihe Business and Pro(essions Code) or that he or she is exemp� therefrom anC the basis (or the allegetl exemption. Any violation o( Seclion 7031.5 by any applicant (or a permit subjects lhe applicaN to a civil penalry ot not more than five hundretl tlollars (5500).): �I, as ovmer of the property, or my employees vrith wages as their sole mpensation, WILL DO THE WORK, and the struclure is not intendeG or oKered for sale (Sec. 7044, Business and Professions Code: The Contrectors License Law tices not apply to an owner of propeny who builds or improves thereon, and-who dces such vrork himself or hersel( or Ihrough his or her ovm employees, provitleA that such improvements are not intended or offeretl for sale. If, however, the building or improvement is so10 within one year ol completion, the ovmer-builder will have lhe burden of proving thal he or she ditl not build or improva for purpose of sale.). ❑ I, as owner of the propeny, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS lo constn�ct the project (Sec. 7044, Business and Professions Code: The cont2ctors License Law dces not appy to an ovmer of property who builtls w improves Ihereon, and who cont2cts fw such project with a conUactor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business antl Protessions Code for Ihis reason: ` ��Z—lc�—�� Signawre Oa�e ]OS]J6 (3I0]) �;;.: Owner ID venfied by Ariveix':;�::.�nse. � Yes ❑ No Driver's License No. � + Expires: �� Z_. L� Verifcation of Ownership by (type of document, i.e. • property taz bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: � ❑ I hereby certi(y that no excavation fve (5) or mwe feet in depth into v.hich a person is required ro descend, vnll be made in connectbn vrith work authorized by this permit, and thal no building stmcture, scaffdding, lalsexork, or demolition or tlismanlling thereof, will be more Ihan thirty-six (36) (eel high. (Chap. 3.2, Grp 2, Art 2, Sec. 347, Tiqe 8, Califomia Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which woultl require a permit 6om the Division o! Industrial Salery, as noted above, unless such person has a permit to tlo such vrork Irom the division. AOPI¢am's SignaWrc Date Division ol Intlustrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will Ihe applicant or present or fulure building occupanl need to file and certify a Business Plan for emergency response to release or lhreatened release of a hazartlou5 ma�erial? ❑ Ye5 ❑ No (Section 25505 of the California Heall� antl Safety Code requires, wilh some ezceplions, Ihat a Business Plan De filed with lhe Costa Mesa Fire Department by every business which has at any one time during a reported year a quantiry o( hazardous matedals equal to or greater than a weight of 500 pounOs, or a volume of 55 gallons, or 200 cubic feet of wmpressed gas at standard temperaWre and pressure�. 2. Does or vrill ihe applicant or present or luture builtling occupant neetl to file a registration form for acutely hazardous maledals? ❑ Yes ❑ No (Seclion 25533 0! the Calilomia Health anA Safety Cotle, with some ezceptions, requires registration vnth Ihe Costa Mesa Fire Department by each business which at any one lime has on hand a quantiry of acutely hazardous materials equal to or greater than a weight ot 500 pountls, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperaNre and pressure). 3. Does or vrill the applicant or present or future building occuDant need to prepare an RMPP (Risk Management antl Prevention Program for acutely hazartlous materials�? ❑ Yes ❑ No (Section 25534 of ihe Califomia Heall� antl Sa(ery Code provitles thal the Costa Mesa Fire Department may require the preparation, certification antl flinq with Ihe Fire Deparlment of an RMPP by businesses which are required ro register acutey hazardous materials vrith Ihe Fire Deparlment. 4.� If an RMPP is presently required, has Section 25534 of the Califomia Health and Safely Code been (ully complied vnth? ❑ Yes ❑ No 5. Does or will Ihe applicant or present or fWure building occupant require tor tha work which is the subject of thi5 application a pertni� for such con5[ruclion 0� motlificalion Irom Ihe SouN Coasl Air Quality Management District or (rom any olher air pollution control district or agencyP ❑ Yes ❑ No (Sectbn 65850.2 of Iha Calilwnia Govemment Cotle requires that the requested intortnation be lumished on applicatbns tor ran-resitlential building permits). 6. Will any part of the facility to be consWctetl untler this permit be within 1000 feet Irom Ihe outer bountlanes of a school? ❑ Yes ❑ No (II'yes', Ihe lacility must meet Ihe requirement of Sections 25534 and 42303 of Ihe Calilornia Health and Safely Cotle). 7. I( a permil IrOm Ihe South COa51 Air Quality Managemen� Dislrict or olher air pollWion coMrol tlistricl or agency is required (or the work which is the subject of this application, have all ot the disclosures prescnbed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (It yes", altach certifcale of compliance from Ihe appropriate air pollution coNrolOfficer). � CERTIFICATE OF COMPLIANCE: 1 certi(y Ihat under penalty of peryury the information given above is covecl I agree ro wmpty with all state laws and city ortlinances re9ardinq Hazaraous Materials and Emissions. CERTIFICATE OF COMPLIANCE AND AU7HORIZATION OF ENTRY: I cenify untler penalry of perjury that I have read lhis application and state that lhe information given is correcL I agree to comply wi�h all state laws antl ciry ortlinances relating ro building wnstruction, and authorize representatives of lhe City of Costa Mesa lo enter upon Ihe aboveEescribed property (or inspection purposes. I agree not to occupy or allow ocCupanGy of any building authorized by lhis permit unlil final inspection. . SignaWr i�eqalOwner�s� Date �/n�. l� �� An�/ AutM1OnzeC AOOIIran1 te � � CITY OF COSTA MESA � BUILDING DIV/SION 77 FAIR ORIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa•mesa.ca.us FOR INSPECTIONS CALL: �714) 754-5626 PERMIT NUMBER: POS-00293 PERMIT TYPE PLUM STATUS: ISSUED APN: 42630402 DATE ISSUED: 1 2/1 612 0 0 8 ISSUED BY: YH JOB ADDRESS: 353 E 20TH ST CM Suite/Unit: vicinity: . . � - . � .. . . SCOPE OF WORK: REPAIR SEWER LWE 0N PRIVATE PORTION OF PROP. • OWNER: VILORIA,CHRISTOPHER D��- Address: 353 E 20TH ST PHONE: _ � City/Slate/Zip: COSTA MESA, CA APPLICANT: VILORIA,CHRISTOPHER D � Address: 353 E 20TH ST ; PHONE: 949 292-3441 City/State/zZip: COSTA MESA, CA . CONTRACTOR: - - � License No. Address: PHONE: CirylState: ZipCode: CELL: ARCHITECT: ENGINEER: License No. License No. PHONE: PHONE: �. n �,.� � PLUMBING PERMIT FEE SUMMAR PLAN CHECK FEE: $0.00 � PERMIT, FEE: $48.15 _ ' TOTAL FEES: $48.15 � �� a NOTICE: The work author'rzed by this pertnit shall compty wifh all applicable handicap access requirements under Califomia statutes and related regulatlons. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION; PERMIT EXPIRES 180 DAVS 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 inspeclions and final approval will result in the ezpi2tion of this permit. cooei. ixsrEcnoHrme 2TS �N.�45 or ixsr�cnoxTrve p�g �ixmu�s 7818 Fixed System Final Fire Prevention 208 Final Mechanical r� ,�.n 1288 Pool Spa Finaf 208 Final Plumbing �' t p' V 1 � 200 Final Rg_Roof 210 Final Electncal ' 201 Final 81ock/Relaining Wall 212 Final Fire Prevention 202 Final Feclory Fire Place 220 Final Planning Approval 203 Final 5{gn 222 Final Site 204 Final Dertrolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereDy aHrtn under penally of perjury one of Ihe following tleclarations: ❑ I have antl will maintain a ceAifcate of consent to selbinsure (or workers' compensation, as provided /or by section 3700 ot the Labor Code, for the peRormance of the work for which Ihis permit is issued. ❑ I have and will maintain workere' compensation insurance, as required by section 3700 of Ihe Labor Code, for Ihe pBRamance o! the work (or which Ihis pertnit i5 i55ued. My workers' Compen5ation Insurance carrier and policy number are: Cartier. (Tlus seCun neetl �rol0e twnp¢IeC/H�e pnml is rdhrc�at me �untlredMllars (51001 a leu 1 Policy Number ❑ I ceAify that in Ihe performance of the work tor which this permit is issued, I shall not employ any person in any manner so as to become subject to Ihe vrorkers' compensation laws of Cali(omia, and agree that i( I shoultl become subject lo Ihe vrorkers' compensalion provisions of Seclion 3700 of the Labor Code, I sha0 foMwith comply with Ihese provisions. ADOliwm's SgnaWre WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL 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 DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000) of Division 3 of lhe Business and Professions Code, and my license is in full force and eflect. Lic. # Class # Conlranor's SipnaWre Date CONSTRUCTION LENDING AGENCY: ❑ I he2by affum that Ihere is a conslmctbn lending agency fw the peAormance ot the v.ork for wfiich tltis pertnit is'ssued. (Sec. 3097. Civil Cotle). Lender's Name: Lender's Address: �dle OWNER-BUILDER DECLARATIONS: I hereby aKrm Ihal under penally of perjury lha� I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the tollowing reason (Sec. 7037.5, Business antl Professions Code: Any city or county which requires a permit to consWct, alter, improve, demolish, or repair any sWcture, 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 antl Professions Cotle) or thal he or she is exempt therefrom antl the basis for ihe alleged exemption. Any violation of Section 7031.5 by any applicanl tor a permit subjects the applicant to a civil penalry of not more than five huntlretl tlol�ars (S5o0�.): I, as owner Of the property, or my employees with wages as Iheir sole compensation, WILL DO THE WORK, antl the structure is not intended or oftered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does nol apply to an ovmer of property who builds or improves thereon, and wh0 tl0e5 Such work him5elf or her5elf or Ihmugh hi5 or her own employees. providetl ihat such improvements are not intended or oftered for sale. If, however, Ihe builCinq or improvement is soltl within one year of wmpletion, the owner-builder v,ill have the burden of proving that he or she did not build or imprOve for purpo5e Of 5ale.). . ❑ I, as ovmer of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to conSWct Ihe project (Sec. 7044, Business and Professions Code: The contractas License Law dces not appty to an ovmer of property who builds or impmves thereon, and who cmtracts for such project with a cont2cta(s) license pursuant b the Coniractors License Laws.�. ❑ I am exempt untler sec. Business antl Professions Cotle for this reason: l�- SignaWre Date 3o5�<s��ro�� Owner�ID verifietl by AIrinvrei �_ ..,.ens �)Yes ❑ No („� �� `� Oriver's License No. ,,( �� Expires: Verifcation of Ownership by (type of tlocument, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: • ❑ I here�y certify tha� no excavation frve (5) or more feet in dep�h into v.fiich a person is required to descend, will be matle in connection wii� vrork auttrorizetl by this permit, and that no builtling struclure, scaffdding, falsev.ork, or tlemolition or dismantling thereof, will be more than thirty-s6c (36) (eet high. (Chap. 3.2, Grp 2, M 2, Sec. 341, Tille 8, Calilomia Adminisl2tive Code�. ❑ As owner-builtler, I will not employ anyone to tlo work which would require a permil lrom the Division ot Industnal Safety, as noted above, unless such person has a permit [o do such work from the tlivision. Appliwm'S Signalure Dale Division o( Industrial Safely Pertnil Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future DuilOing occupant need to file antl cerli(y a Business Plan !or emergency response to release or threatened release of a hazardous material? � Yes ❑ No (Section 25505 of the Cali(ornia Health and Safery Code requires, vnth some exceptions, Ihal a Business Plan be fled with the Costa Mesa Fire Department by every business which has at any one time durinq a reported year a quantiry of hazartlous 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 fuWre builtling occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Heallh and Safery Code, with some exceptions, requires registretion with the Costa Mesa Fire Department hy each business which at any one [ime has on hand a quantity of acutely hazardous matenals equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic fee[ of compressed gas at slandartl temperaNre and pressure). 3. Does or will Ihe applicaM or present or fu[ure building occupant need to prepare an RMPP (Risk Management and Prevention Program (or acutely hazardous materials�? ❑ Ves ❑ No (Section 25534 of the Calilomia Health and Safery Code provides thal the Costa Mesa Fire Department may require Ihe preparalion, certification and filing with ihe Fire Depanment of an RMPP by businesses which are required to register acutely hazartlous materials with the Fire �epartment. 4. If an RMPP is presenUy required, has Section 25534 of lhe Cali(ornia Health and Safety Cotle been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or fuNre building cecupant require for the work which is the subject of this applicalion a pertnit (or such consWction or modifcation from the South Coast Air Quality Managemen[ District or from any o�her air polWtion control tlisMct or agency? ❑ Ves ❑ No (Seclion 658502 of the Califomia Govemment Code requires that the requesled infortnation be (umished on applications for non-residential builtling permits). 6. Will any part of lhe facility to be consWcted under this pertnit be within 1000 feet from Ihe outer bountlaries of a school? ❑ Yes ❑ No Qf "yes", the lacilily must meet the requirement of Sections 25534 and 42303 ot the Califomia Health and Safery Code). 7. If a permi� fmm the South Coast Air Quali[y Management Distnct or other air pollution control disMcl or agency is required for the vrork which is the subject of �his application, have all of the disclosures prescribed by California Health antl Salety Cotle Section 42303 been matle? ❑ Yes ❑ No 8. Q('yes", altach certificate ofcompliance irom-lhe appropriate air polWtion control offcer). � CERTIFICATE OF COMPLIANCE: I�certify Ihat under penalty of-perjury Ihe information given above is correct. I agree to comply with all state laws and city ordinances regarding HazarUous Matenals and Emissions. . - SignaWre Dare CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penally of perjury that I have read t�is application and slate that Ihe infortnation given is covecl I agree to wmpty with all s[ate laws and city ortlinances relating to building construction, and au[horize repre5entatives o! the City of Costa Mesa [o enter upon the aboveEescribed property for inspection purposes. I agree not lo occupy or allow occupancy of any building authorized by this pertnit umil final inspection. SiB�aWreo �egalOvmer�s) �--- AnE/O! AUNOlIxCG AOOIiCdnl � COUN'I'Y OF ORANGE BUILDING DEPT. 636 No. Broadway Santa Ana� Cali(omia Phone: KI 2-6211 / 1. OWNER'S 2. 3. 4. 5. MAILING A � � Application for Building Permit AND FOR A Certificate of Use and Occupancy Permit No.. 3_'5�.:3,� /� ` ' ' l/� S s 9 n,te....---�� - �-. G/-�� ............. . v �- �..�-�- � � .. ........_..- -S - ................ ........../..�....�...'-----� - - -- - PHONE:....-----� -- ...--------..... ... .... �� .�� U '- �i��.r .....-.<.........'_.......--- -- - .. CITY.C`-"'- "��.�� - - -- -- ....... .. �--...-- ��-- .... � amc.............._..........""--..-."'--------•----..._..---........----""-'......---- (Architcct or Engincer) Address - - -- -- - � — - --- ...... C:cy .---- - ........--� - -1--� - - State Lic. No.....---._.....-------------------- ��h4ne..._:.--. . Name...........................-._..----- -"'----.......... - ----...........-'----- - ��- —(C�po �[ra�t r _ ...... ..... Address... ............�(.,N -.....:..._......_........ .__----------- City Statc Lic. 1 PROPOSED USE:��..-... __... �,. .l�,�...�.�..�.. r - �� -^.... JOB LOCATION-------�.�._. �� "' .�LO � r C'�Y� ---�---- --- --------" ..............'---"--...---.._...`--'-------- (House ho.) �� / (Name�( reet�) �L � LEGAL DESCRIPTION: Lot---- ----------G. .... . .. .--�--Bl�cll _._----------------- (Metes and Bounds De<crip[� —Use revcrse :ide (orm CORNER LOT (�INTERIOR LOT ( ) THROUGH LOT ( SIZE OF BLDG.:.._L �.11.��.....rIREA :................................SIZE OF LOT:._ � (Town or School District) � ---'----`-......-`- Tract----.�..%.�..._._......_...-- SLOPE OF LOT { ) 6. HEIGHT OF BLDG.:------------..._.......-----------CEILING HEIGHT :..............----...--------..NO. OF STORIES---------------------•--..... 7. NO. FAMILIES._...._..._ ... ..............__.._Size of Smalleet 8. EXTERIOR WALL CONSTRUCTIOIQ:_...._ .............................. (Frame, S[ucco, Etc,) 9. SETBACKS: Fronc Yard From Center Line of Strcet .............. Size of WALL COVERING........--------------- --. . ._. ' (Pl�steyDrywa� Etc.) � � �'S� . /�T�- _ ii n i iit.. i_ . Ncarest Side Yard.._ ....................Rcar Yard...._..__..............Distancc in Feet Bctween Bldgs. on Same 10. A COMPLETE PLOT PLAN IS REQUIRED, SHOWING ALL STRUCTURES AND USE OF EACH. 11. For Acce�sory Bldgs. and Similar Structures: (a) Footing (b) Size of (c) Sizc o[ (d) Sizc of of Wall ...............----........... 12. VALUATION OF PROPOSED WOR}:�Induding all ]abor, plumbing, electrical wiring, heating, fire =prinklers, painting and sewage disposal $------------------J.�. ',��.-"."-.V.j„_ 13. I HEREBY CERTIFY THAT TO THE BEST OF MY KI�'OWLEDGE AND BELIEF THE INFORMATION IN THIS APPLICATION IS CORRECT AI�'D THAT THE CONSTRUCTION V�LORK WILL CONFORM TO ALL LAWS OF �COUNTY OF ORAIQGE AND THE STATE OF CALIFORNIA�AP ICABLE THERETO. �PlL ` r / lL✓ SignedC.......�.......- --- - �-��(i(_�._. .....------...-------------�-�---- � /� (Owuet) - Plans Filed:�..��.�._.- -- c1- � -,-..:- S'. -" --'- FEES: �j Bldg. Permit • $-..----.--i.� �� - Plan Check - �....._..........�S.D. Tot;il . . , 5-----�---- � �-- -- Q Reccipt No. • �...5 . .... Paid to • ' -- ' -' ---'----.. D;�te ..................::...........�.�ll�..S1.--- By:. ARTMENTAL USE ONLY GROUP...... ..�. . TYPE...--�......._. DIST. � MAP- .........�.-:... -- SHEET Ir'0......GDr.�..`.1. .-- DATE..--.�_- ..l.I..�.J...1-... - - (Authorized Agent) Cri " G BY APPLICATI . EALTH__......_....._._......... ZONING .. ... --.---.--- FIRE I'LANS AND MARSHAL ......................... SPEC'S ..........--------....... STATE --- ---...--- ..... CORRECTIONS ENGINEER UNTY BUI II: �PcCTf ��.� � �1��i� �/r-:Ii�I �v�—/' / '.. .. / ��