HomeMy WebLinkAbout327 21ST ST - Building Permits� � CITY OF COSTA MESA �
B(IILD/NG D/V/S/ON
77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • �wiw.ci.costa-mesa.ca.us
FOR INSPECTIONS CALL: (714) 754-5626
PERMIT TYPE: B COMBO
SUb Type: RES_RRIP
JQB ADDRESS: 327 21 ST ST CM -
APN: 42622128 .� .
Vir,inity: • " �
Zoning: , ,
PERMIT NUMBER: BC08-00302
STATUS: ISSUED
DATE ISSUED: 06/25/2008
ISSUED BY: RMD
SuitelUnit:�
Primary Occ: R3
Const Type: V-B SQ. FT: 360 Valuation: $33,264.00
SCOPE OF WORK: ADD 360 S(]. FT TO A SINGLE STORY SFD - ENLARGE MASTER BEDROOM, ADD WALK-IN CLOSET,
RECONFIGURE BATHROOM, ADD BAY. WINDOW, REPLACE 2 EXIST. WINDOWS. 1 NEW SHOWER, 1 TOILET, 1 WASH BASIN,
8 FIXTURES, 9 OUTLES, 4 SWITCHES; 1 VENT FAN IN BATHROOM.
OWNER: MARLER FAMILY TRUST � � Address: 327 EAST 21ST STREET ., � Unit:
Phone: 949 722-0270 - � City/State/Zip: COSTA MESA, CA � �
APpLICANT: MARLER, LESLIE �
Phone: 949 683-8224 -.
CON7RACTOR: OW IJER-BUILDER
Phone:
Cell:
ARCHITECT: -
ENGINEER: ..
Address:
City/State/zZip:
Adtlress: Unit:
City/State:
License No.
License No.
COMBINATION PERMIT FEE SUMMARY
Building Plan Check: - $31372
Building Fees; � � $482.65
Ela_ctrical Fees: � - $46.60
Mechanical Fees: -` - $30.75
PlUmbing Fees: , , ' � $52.90
SMIP Residentiat: � $3.33
SMIP Commercial: � $0.00
TOTAL FEES: $929.95
"Refer to (ee receipts for all fees paid for project
License No. 000000
Unit:
ZipCode
PHONE:
PHONE:
,::: a
t <,� � ,'
,c
,':
� w:i
�
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: 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
raquired inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this pertnit.
cooer INSPECiIONTPE oa�r innna� C�QD_ES INSPECTIOHTYPE co iNnnai
1616 Fiaed System Pinal Fire Prevention 206 Final Mechanical � J
1266 Pool Spa Final 208 Final Plumbing �
Z�0 Final Re-Roof 210 Final Electncal /�/ C�
201 Final BIaklRetaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site _�__�,��y/��_,
204 Final Dcmolition 250 Final BuildinyOccupancy �!/ wi [(� �
WO'RKERS' COMPENSATION DECLARATIO� -
I hereby aKrm under penalty of peryury one of the following declarations:
❑ I have and vnll maintain a certificate of consent to self-Insure for workers'
compensation, as providetl for by sec[ion 3700 of the Labor Code, for the
peAormance of t�e vrork for which this permit is issuetl.
❑ I have and will maintain workers' wmpensation insurance, as required by
sectbn 3700 of Ihe Labor Code, (or the pedortnance of the w�rk (or which lhis
pertnit is issued. My workers' compensation Insurance carner and policy
number are:
Carrier.
(ihis sett[v' neep nd be cnmqele� Jfhe peiml is raluetl al one hu�rep �,1ars (5100) wless)
Policy Number:
�-� I certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as lo become subject
to the vrorkers' compensation laws of California, and agree tha[ if I should
become subjec[ b the workers' compensation provisions of Section 3700 of
the Lab C de. I 51p11 fo ' h Com ly wilh these provi5ion5.
�/ /2-/�-0�
AOPlicanf Sgna ure — Oale
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNIAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVII FINES UP TO ONE HUNDRED THOUSAND DOLIARS
($700,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEV'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aKrm Ihat I am licensed under provisions of Chapter 9(commencing
with Section 7000) of Division 3 of the Business antl Pro(essions Code, and
my license is in full force and effec[.
Lic. # Class #
Comracbr's Signature Date
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a consWctbn lending agency for the
performance of lhe v.ork ta wfiich this pertnit is issued. (Sec. 3097, Gvil Code).
Lender s Name:
Lentler's Atldress:
Da�e
OWNER-BUILDER DECLARATIONS:
I hereby aKrm Ihat under penalry of perjury ihat I am EXEMPT PROM THE
CONTRACTORS LICENSE LAW for [he following reason (Sec. 7031.5,
Business and Professions Code: Any city or county which requires a permit to
construct, alter, impmve, demolish, or repair any strucWre, prior to its
issuance, also requires Ne applicant for such permit to Ne a signetl statemeM
iha[ he or she is licensed pursuant to Ihe provisions of the Conlractors
License Law (Chapter 9(commencing wi[h Seclion 7000) of Division 3 of the
Business and Pm/essions Code) or that he or she is esempt theretrom and
the basis for [he allegetl exemption. Any violation of Sec[ion 7031.5 by any
applicant for a permit subjects ihe applicant to a civil penaily of not more than
five hundred dollars ($500).):
❑� I, as owner of the property, or my employees with wages as their sole
compensation, WILL DO THE WORK, and the struclure is not intended or
oflered for sale (Sec. 7044, Business and Professions Code: The Contractors
License Law does not apply to an ovmer of pmperty who builds or improves
ihereon, and who does such work himself or herself or through his or her own
employees, providetl that such improvements are not intentled or oflered for
sale. If, however, the building or improvement is sold within one year of
completion, the ovmer-builder will have lhe 6urden of proving ihat he or she�
did not buila or improve for purpose of sale.). ,
❑ I, as'owner of�the'propeky, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to construct the projecl (Sec. 7044, Business and
Pmfessbns Code: The contractors License Law dces not apply �o an owner of
propeAy who builds or improves thereon, and v.ho contracts for such project with
a cmtractor(s) license pursuant ro the Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code (or Ihis reason:
�►!� ��./� li� ; /:
�,
!
Ovmer.ID verified by dnv ense. Yes ❑ No �� �
Driver's License No. �Expires: �3
Verification of Ovmership by (rype of document, i.e. - property tax bill or deed)i
DIVISION OF INDUSTRIAL SAFE7Y PERMIT CERTIFICATION:
❑ I hereby cetlify that no exravation frve (5) or more feet in deptti into wfiich a
person is required to descend, will be made in connection with work auttrorized
by this pertnit, and Ihat no building slrucNre, scaffdtling, falsework, or demolition
or dismantling thereof, will be more than Ihirty-six (36) feet high. (Chap. 32, Grp
2. M 2, Sec. 341, Title 8, Califomia Atlministrative Code).
❑ As owner-builder. I will not employ anyone to do work which woultl
require a permit trom the Division of Industrial Sa(ety, as noted above, unless
such person has a permit to do such work from the division.
Applicanl's SignaWre Date
Division o( Industrial Satety Permi[ Number
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or presenl or fu[ure builtling occupant need to file and
certi(y a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of Ihe Calitornia HeaIN and Safe[y Code requires, wi[h some
exceptions, that a Business Plan be filed with Me Costa Mesa Fire
Department by every business which has at any one lime during a reported
year a quamiry ot hazardous matenals 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 lemperature and pressure).
2. Does or will Ihe applicant or present or fuWre 6uilding occupan[ neetl to file
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Sa(ery Cotle, vnth some
exceptions, requires registration with the Costa Mesa Fire DeparimeN by
each business which al any one time has on hand a quantity of acu[ely
hazardous matenals equal to or greater ihan a weigh� of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
�emperature and pressure).
3. Does or will the applicant or present or (uture building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous matenals)? ❑ Yes ❑ No
(Section 25534 0( the Califomia Health and Safety Code provides that [he
Costa Mesa Fire Department may require the preparation, certification antl
filing wi[h the Fire Department of an RMPP by businesses which are required
to register acutely hazardous malerials with the Fire Department.
4. If an RMPP is presenlly required, has Section 25534 of [he California
Health antl Safety Code been fully complied wilh? ❑ Yes ❑ No
5. Does or will the applicam or present or future building occupant require for
Ihe vrork which is the subjec[ of [his application a pertnit for such construclion
or modifcation (rom the SOWh Coast Air Quality Managemen[ District or (mm
any other air polWtion control tlistrict or agency? ❑ Ves ❑ No
(Section 658502 of the Califomia Govemment Code requires that the requested
information be tumished on applications !a rarnresidential building pertni[s).
6. Will any paA of the faciliry to be cons[ructed under this permit be within
1000 (eet (rom the outer boundaries of a school? ❑ Yes ❑ No
(If'yes", the facility musl meet the requirement ot Sections 25534 and 42303
of the Cali(ornia Health and Safely Code).
7. If a permit (rom the South Coast Air �uality Managemen[ District or other
air polN[ion con[ml disMc[ or agency is required for the work which is the
subject of this application, have all of the disclosures prescribed by California
Heallh antl Safety Cotle Section 42303 been made? ❑ Yes ❑ No
8. (If'yes", attach cenifcate of compliance from ihe appropriate ai� pollution
control oKcer). � � �
CERTIFICATE OF COMPLIANCE: I cei[ify that under penalty of perjury.the
information given above is correcL I agree to compy with all stzte laws antl
city ortlinances regarding Fiazartlous Materials and Emissions. ,�
S�gnaWre Date '
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRV: I
certify under penalty of perjury Ihat I have reatl [his application and sWte lhat
ihe in(ormation given is cortecL I agree to comply with all state laws antl city
ordinances relating to building consWction, and authorize representatives of
the Ciry of Costa Mesa to enter upon the above-described property for
inspectio purposes. I agree nol to occupy or allow occupancy o( any builtling
aut by this p rmi il f fin I i spection. . /� /�' ^�
U
5gnalure of Legal meqs) � Date
AnE/or Au�honzetl Appbwm Dale
Job Address
Inspector's N
' " =CIAL INSPECTOR REGISTRATION �- '
Residence Address � �iiA 14L.4ViU
Number & Street
RawckD SyM� {'NArS GA fLG &P'
City ' ._�t State Zip
Laboratory 'So��14� W�T
Address �►�W �{AM�WciA1. L✓Wy LA'%fM�i} 9B�ii�
Street City iP
All licenses listed below must be currently valid and legible copyls) and must be attached to this registration.
DISCIPLINH � L.A. COUNTY
CONCRETE
DUCTILE MOM@NT
RESISTING FfiqME
REINFORCING STEEL
PRESTRESSING STEEL
WELDING
HIGH STRENGTM $OLTING
5T0.UCTURAL
MASONRV
REINFORCED GVWSUM
CONCRETE
INSULATING CONCRETE
FIIL
SPRA V ED ON P� RE
PROOFING
PILINGS, DRILLED PIERS,
CAISSONS
SPECIAL GRADING�
EXCAVATION OR p�LLING
SPECIAL CASES
UNUSUALHAZqRDS
L.A. CITY � ORANGE COUNTY I OTHER
�
I hereby certify that I am qualified by training and experience to perform the inspections for which I hold
the above listed Special Inspectors licenses, and will provide �II certifications requ;red by the City of Costa Mesa.
I will inspect and certify the following procedures:
I will certify not only to the job conditions but that they are in conformance with the approved plans. If at
any time, progress occurs on the above mentioned job relating to my area(s) of responsibility, without my knowl-
edge or approval,. I will stop the jobs progress immediately with notification in writing to ihe job superintendent
and notify the Building Division of the situation. A record of my tests and/or inspections as agreed to above will
be available upon request by the Building Division. Upon re uest I ill submit a compiete package of testing and
inspection results. A letter certifying satisfactory completio�i will b�provided by me upon completion.
This
(Plan
and app
GMF lO6B-66
by:
(Build(ng
Wnite-Builain9Division: Canary-Soeciailnspector; Pink-Develooer
: •
� r
CITY OF COSTA MESA
BUILDING DIVIS/ON
77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • ww.v.ci.cosla-mesa.ca.
FOR INSPECTIONS CALL: (714) 754-5626
PERMIT NUMBER. P08-00179
PERMIT TYPE PLUM
APN: 42622128
JOB ADDRESS: 327 21ST ST CM
vicinity:
STATUS:
DATE ISSUED:
ISSUED BY:
Suite/Unit:
ISSUED
08I0612008
YH
SCOPE OF WORK: REPAIR MAIN SEWER LINE (APPROX. 10') - ALL WORK ON PRIVATE LOT.
OWNER: MARLER, BIL� D TRUST
PHONE: g49683-8224
APPLICANT: THOMISON, JEREMY
PHONE: 714 641-1545
Address: 327 E 2iST S7
City/State/Zip: COSTA MESA, CA
Address: .
Ciry/State/zZip:
CONTRACTOR: C AND R DRAINS INC License No. 531746
Address: 1525 MAC ARTHUR BL. PHONE: 714-641-1545
City/State: COSTA MESA, CA ZipCode: 92626 CELL:
ARCH17EC7: License No. PHONE:
ENGINEER: License No. PHONE:
PLUMBING PERMIT FEE SUMMARY
PLAN CHECK FEE:
PERMIT FEE:
TOTAL FEES:
50.00
$48.'I S
$48.15
�'� i 79
NO710E: The work authorized by this permil shall wmply with all applicable handicap access requirements under Califomia sfatutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS; In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspeetions and flnal approval must be obtained. Failure to obtain inspeclions and final approval will resull in the expiration of this permit.
CODE t. INSPECTION TYPE Q� $ M � �� INSVECPOM TYVE 0� INTI7UL5
1818 Fixed SyStem Final Fire Prevention 208 Final Mechanical � J���= ,._ �
1288 Pool Spa Final . 208 Final Plumbing P�A' 1Lw ifK�
200 Final Re-Roof 210 Final Electrical
' (J
201 Final Blotk/ReWining Wall 212 Final Fire Prevenlion
202 Final Factory Fire Place 220 final Planning Approval
203 Final Sign 222 Final Site
204 Final Deqqlition 250 Final Building/Occupancy
, �
WORKERS' COMPENSATION DECLARATIO
I heraby affirtn under penalry of perjury one of lhe ollowing decla2tions:
❑ I have antl will maintain a certificate of consent to self-Insure for workers'
compensation, as providetl (or by section 3700 of the LaDor Cotle, for Ihe
peAortnance of the work !or which this permit is issued.
❑ I have antl will maintain workers' wmpensation insurance, as required by
sectbn 3700 of the Labor Code, for the peRormance of the work fa which this
pertnit is issued.�AA�rke�s' compensation In rance wrrier an{� policy
numberare: �`.��� \ 1 ,y/ � �
Cartier: ✓ `'�� 1
(iM155oUimneetlndGe /Ne �'a�.yada n ars ss)
!
Polity Number: � ll
❑ I certify I�at in Ihe peAormance of the work for which this pertnil is
I55ueC, I shall not employ any person in any manner so as to bewme subject
to tha vrorkers' compensation laws ot Calitomia, and agree that if I should
betome subject la the warkers' wmpensation provisions of Section 3700 of
lhe Labor de. I shall forthwith 'th these provisions.
— '�—(v — O�
omnt§ Sipnawre Da�e
WARNING: FAILURE TO SECURE WORKERS' CAMPENSP.TION COVERAGE
IS UNLP.WFUL AND SHALL SUBJECT AN EMPLOVER TO CRIMINAL
PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND DOLLAF2S
($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 here0y aKrm tha� I am licensetl under provisions o( ChaD�er 9(commencing
with Section 7000) ot Division 3 ot the Business and Protessions Cotle, anA
my license is in uW *� an eHe .
Lic. # Class # �
� C`�—% `��f
a s Si a re. �ate
CONSTRUCTION LENDING AGENCY:
❑ I hereby affmn tha� Ihe2 is a constructbn leriding agency (or the
peAormance of the v.ork fa wfiich tNs permit is issued. (Sec. 3097. Civil Code�.
Lender's Name:
Lentler's Atltlress:
Da�e
OWNER-BUILDER DECLARATIONS:
I hereby aHirm that untler penalty ot perjury that I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW tor me following reason (Sec. 7031.5,
Businass and Prolessions Code: Any city or counry which require5 a permit to
conswct, alter, improve, demolish, or repair any sWcwre, prior to its
issuance, also requires the applicant tor suc� permit to file a signed stalemenl
��at he or s�e is licensed Dursuant to the provisions af ihe Conlractors
License Law (Chapler 9(cOmmenting wi�h Set�on 7000) of Division 3 ol the
Bu5ine5s and Professions Code) or that he or she is exempt Ihere(rom and
Ihe basis (or the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty ol nol more Ihan
five hundred dollars (5500).):
❑ I, as ovmer of lhe property, or my employees with wages as their sole
CAmpensation, WILL DO TME WORK, and the sWcture is not intended or
offeretl for sale (Sec. 7044, Business and Professions CoCe: Tha Contractors
License Law dces not apply to an ovmer of property who buiids or improves
thereon, and who dces such work himself or herself or ihrough his or her own
employees, provided that such improvements are not intentleC or ofterea for
sale. If, however, the buildinq or improvement is sold wiNin one year of
wmpletion, lhe ownerbuilder will have lhe burden of proving that he or she
tlid not builC or improve for purpose ol sale.).
❑ I, as ovmer ot the property, am EXCLUSIVELV CONTRACTING WITH
LJCENSED CONTRACTORS to conswct the project (Sec. 7044. Business and
Protessions Code: The contractors License law dces rrot appy to an ovmer o(
propeny who builds or improves thereon, and wiw cont2cts fa such project with
a contracta(s) license pursuant to the Cont2ctors Ucense Laws.).
❑ I am exempt under sec.
Business and Professions Cotle for this reason:
Sgnawre Date
]OS)<61101)
F \
Owner ID veri(ietl by tln ice ❑ Yes ❑ No
Driver's License No. E�cpires:
Venfication of Ovmership by (type of document, i.e. - property tax bill or deetl):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby ceAify that no exwvation frve (5) a mpe leet in depth inro wfiich a
person is required to descend, will be made in connectbn with work author¢etl
by ��is permi�, and lhal no building struclure, scaHdtlirg, falsev.ork, or demdition
or dismantling thereof, will be more than thiAy-sa (36) feet hgb. (Chap. 3.2, Grp
2, Art 2, Sec. 341, Title B, CalifOmia Administra�ive Code).
❑ As owner-builder, I will not employ anyone ro Ao vrork which wou10
require a pertnil lrom the Division of Intlustrial Safery, as notetl above, unless
such person has a permit to do such vroAc from lhe division.
Ap01iron1's S�gnalure Da1e
Division o( Industrial Safely Pertnit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or fuWre building occupant naed to fila and
certify a Business Plan for emergency response to release or threa�eneE
release of a hazartlous material? � Yes ❑ No
(Section 25505 of lhe Califomia Health and Sa(ey Code requires, wiN some
exceptions, that a Business Plan be filed with the CosW Mesa Fire
Department by every Dusiness which has at any one time during a reporte0
year a quantiry of hazartlous materials equal ro or greater lhan a weight of
500 pounds, or a volume of 55 gallons. or 200 cuDic teet ol compressetl gas
al standard temperature and pressure).
2. Does or will the applicant or preseN or fuWre builtling occupant need to !le
a registration lorm for acutely hazardous matenals7 ❑ Yes ❑ No
(Seclion 25533 of the Califomia Health and Sa(ety Code, with some
exceptions, requires regisl2lion with lhe Costa Mesa Fire DepatlmeN by
each business which at any one lime has on hand a quantity of acutely
hazardous malerials equal lo or greater Ihan a weight of 500 pountls, or a
volume of 55 gallons, or 200 cubic (eet o( compressed gas at standartl
temperature and pressure).
3. Does or will the applicanl or present or fuNre building occupant need to
prepare an RMPP (Risk Management anG Prevention Program for acu[ely
hazartlous materials)? ❑ Yes ❑ No
(Section 25534 of Ihe Cali(ornia Heallh and Safety Code provides that the
Costa Mesa Fire Departmenl may require lhe preparation, certification and
filing with �he Fire Depariment of an RMPP by businesses which are requiretl
to register acutey hazardous matenals vrilh the fire Depariment.
4. I( an RMPP is presently required, has Section 25534 of Ihe Califomia
Health antl Safety Code been fully wmplietl vrith? ❑ Yes ❑ No
5. �oas or will tha applicant or present or tuture building occupam require for
ihe work which is the subject of this aOC�icalion a permit lor such con5truclion
or modifica�ion from the South Coast Air �uality Manaqement Oistrict or Irom
any other air pollution conlrol Oislrict or a9ency7 ❑ Ves ❑ No
(Sectbn 65850.2 of the Califomia Govemment Code requires tha� the requested
informalbn be fumished on applicalions (a norrresitlential buildirg permits).
6. Will any part of the faciliry to be conswcted untler t�is pertnit be within
1000 feet from the outer boundanes of a school? ❑ Yes ❑ No
Q('yes", the lacilily must meet the requirement ol SecGons 25534 and 42303
of the Calilomia Health and Salety Code�.
7. If a pertnil Irom Ihe South Coast Air Qualiry Management Districl or other
air polluGon coNrol disMct or agency is required for the work whith is the
suDject of I�is application, have all of Ihe disclosures prescribed by Calilomia
Health and Salety Code Sectian 42303 been maCe? ❑ Yes ❑ No
8. (If yes', atfach cenificate of wmpliance from the appropriate air polluuon
control officer).
CERTIFICATE OF COMPLIANCE: I certify that untler Denally ol perjury Ne
infortnation given above is correcl. I agree to wmply wilh all state lav5�and
ciry ordinances regarding Hazardous Materials and Emissions.
Signnlure Oale
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalty of perjury Ihat I have read this application and sUte thal
the infortnation given is covect I aqree lo comply with all s[ate laws and ciry
ordinances relating to building wnsWction, and authorize representatives ot
the Ciry of Costa Mesa to enter upon the abovedescribed property tor
inspection purposes. I agree not to occupy or allow occupancy of any Duildinq
authorizetl by lhis permit unlil final inspection.
Signalure ol Legal Ovmtt�s) Da�e
�? � �-�� 8"-ffl - d'2�
or itiorizeE AOPLranl ' Dale
REPORT OF INVESTIGATION
Variances: Assigned to:
� Building Division
C.U.P.'s: ❑ Planning Division
❑ Joint Investigation
Case No.: SyL%
Assigned to: SCO%%
/j Date: ��/�/g3
` i���
Received by:,�, �D'"-� �� ��- "'� - /�
ac� 9 -�,'�-/d>S 3�7 �. �� ��S'.� -
ComplaMt (Prinq Cpmpleint Addr055
M�2 /�t'��S �+ii�c ��or� U,v%T�A�
Complaintant (Signatuw.. � Date � Name ot Tenent (if eppliCeble)
�/ % �li `����� cS.� 7%�,��,-.� .�cLi i ��3 -��J-c—�cr�
� fl;(/�LA�OwN
Aadress Name of Propeny Ownar Te�ephone
(o SO - /X / � �1Nr-�-�
7eiepnona Numoer „ Owner's Residential Address
Nature of Complaint: -� // c
Investigation by: S Co I I y( i P�1 P�
InspeCtor
Building Permit Files Reviewed:
Initial and Date
Assessor's Parcel No.
Violation of C.M.M.C. Section (s�:
Findings: �� � S a �
�� le C
NOTICES:
1st Given:
Date
2nd Notice:
�' �
����Y
R Fr-��c
Time of Day (if applicable)
Zoning Files Reviewed:
Initial and Date
_ Map No.
f,S YIO� 1 !�I � � � Ci
- i L, �nu,n l �. �
r7 ciosed
��-e s y eo � �
c!°���i W�
Tirg� Allotted for Correction
�
5•day maximum time
Date
Certified letter advising that if violations are not corrected, the complaint and all supporting data will be forwarded
to the City Attorney's office with request for prosecution.
Date Mailed Date Received 7Cay recheck of site
Files forwarded to City Attorney's office with request:
CMF 0829-30 rev. 4/83
Initial and Date