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Home My WebLink About165 21ST ST - Building Permits Abp • •F CITY OF COSTA MESA BUILDING DIVISION > 4 f•p,.- , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 1 •t PERMIT R` � . B00-01359 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca,usIFfG PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDJob Address: 165 21ST ST Status: ISSUED Suite: Applied: 09/05/2000 Vicinity: Issued: 09/05/2000 Parcel Number: 42619318 Zoning: Applicant: JONES, CLIFTON ISSUED BY: Address: 10945 SOUTH ST UNIT 301 Phone: (562)924-4491 CERRITOS,CA Zip: 90703 Owner: INFINITY HOMES CM, I LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor INTREPID HOMES INC Address: 10945 SOUTH ST UNIT 301 Phone: (562)924-4491 CERRITOS,CA Zip: 90703 License: 779066 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT DEMOLISH EXISTING SINGLE FAMILY RESIDENCE(1094 SQ FT). FEE SUMMARY Plan Check: $0.00 Calc Valuation: $3,500.00 Permit: $97.25 Claim Valuation: $3,500.00 SMIP Res: $0.00 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $97.25 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit FOR INSPECTIONS CALL: (714)754-5626 244648(&00) DECLARATIONS ` WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: O I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the ___w rk or which this permit Is issued. nd will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This se '• need not be completed) f is valued of one hundred dollars WOO)or loss.) ( I 1. hlfy that in the pert• : ork for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation law- . AI• la,, :•-•.g��•.gree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with the - ns. Applicant Signa // - Date: `�-/ WARNING FAILURE TO SE RE WO-f COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(SIM.Is).IN A-1/IT•N TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060F THE LABOR COOE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that.l.am.licens:d un•e p c; to s• ihapteri•mmencing with Section 7000)of Dlvislon3 of.the.Busines d Professions Code,and my license Is In full force and effectLic.N 'Aril Iair i -Classla—� rContmnorsSignature: --- IIT Date:_- q—5'60 r — CONSTRUCTION LENDING AGENCY:. ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement Ls sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. _ Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. 0 Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,I.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: O I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California AdminlstratNe Code). ❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Se-tion 25505 of the California Health and Safely Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one lime during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds.or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Flre Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and SafetyCode been fully complied with? 0 Yes ❑No ._ _. _. _..___...._ _._ _ .r._ .. 5 Does—or will the oast Air u lity Management n bustling o oat y other for the work ontch districtIs the subject age of this applicationYes modification- from Dualityfromair jJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ._ ..ths permit eet_m._._ _._..__....._.- 6 Will any pan of the facility to be constructed under this permit be within 1000 feel from the outer boundaries of a school? ❑Yes 0 No (If'yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ..._ ..is_...._ _._.i......___.. _._..ewo..__.— 7 a permit from the South Coast Air Qualityci ed Management Californiaal or ofcontroldistrictagencyapplication, Health Safety Code Section 42303 been made? LI Yes ❑No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHOR ION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state law `dinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection p 1'a not to occupy or allow occupancy of any building authorized by this permit until final inspection. • nner(s) 9"--X-30 to •�o•r Auth•! p _. Date-- 1 CODE L INSPECTION TYPE Pill IIMIQIELS CODE! INSPECTION TYPE all EMMA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing - 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition £a 4 �T 4)_250 Final Building/Occupancy GREENLEAF DEMO AND GRADE 714 848 0167 P. 02 , e k ';3bOUTH COAST AIR QUALITY MANAGEMENT DISTRICT i NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL • 21865 E.Copley Drive,Diamond Bar,CA 91765-4182 (909)396-2000 i peMD.:' MAIL FORM AND FEE TO SCAQMD,ASBESTOS NOTIFICATIONS,FILE#55841,LOS ANGELES CA 90074.5641 1 �'AQMD USE ONLY SCREEN Bj? RECEIVED POSTMARK ENTERED BY - I NOTIFIcr . I COMPLETED BY i G t_al_COMPANY G ' G PHONE t y t`t�n, cteen rA�. rbotlo” rt. R7x-7b Ss , DATE 9_ y_ O0 CHECK# 17 3 S FEES /t),2. 93 PROJECT# i NOTIFICATION TYPE ORaGlrut� REVISION DATESRensioH OTHER(highlight) CANCELLATION PROJECT TYPE IUFMOLITION ORDERED DEMOLITION RENOVATION(removal) EMERGENCY REMOVAL PLANNED Rsu; SITE INFORMATION SITE NAME j Si LE ADDRESS j G S _ )to 9 2 t -CI SX , CROSS STREET CITY CO3 -}.A Mrs& STATE cei; 4,. ZIP COUNTY /1 --'_- DESCRIBE WORK AND LOCATION BUILDING SIZE(SQ FT) 8 7 9 0 NUMBER OF FLOORS I BUILDING AGE(YEARS) lip NUMBER OF DWELLING J' BLDG PRIOR I PRESENT USE COMMERCIAL HOSPITAL INDUSTRIAL Other OFFICE PUBLIC BLDG. HOUSE SCHOOL SHr •S TE OWNER 'M'I' rr dt Own' f I . ADDRESS 10 9 Ayr S e t.'f 4 J x `rYc » :.1` CITY C.rr•; 'I'vs STATE cZIP 907 03 CONTACT .�- PHONE 9y 9_ t1, dolt 280• ' ` REQUIRED BUILDING ASBESTOS YESN® ASBESTOS YEJS NO ASBESTOS 0, NO BUILDING TO BE INFORMATION PRESENT? SURVEY? • REMOVED? DEMOUSHED? L — If PROJECT DATES START 7_ j y_ 0 p END q_ 2 2 _ o o WORK SHIFTS swing, ASBESTOS AMOUNT TO BE FRIABLE CLASS I CLASS II TOTAL AMOUNT . . REMOVED(in square feel) —•y4 ASBESTOS REMOVAL FROM SURFACES PIPES COMPONENTS ! AMOUNT OF EACH TYPE OF ACOUSTIC CEILING LINOLEUM INSULATION FIRE PROOFING DUCTING STUCCO I • ASBESTOS (in square feet) I r---- FLOOR TILES(VAT) DRY WALL PLASTER TRANSITE ROOFING OTHER 1 (describe) CONTRACTOR INFORMATION CSLB LICENSE# L SS y j 4 OSHA REG# AQMD ID# NAME 6rerhlr&)' 6r2se h*-7 A. ADDRESS 770 2 yL.40A, Dr,_—_ __... CITY��u.•4. Q� STATE Ca 1. Zip g16y8 SITE SVPVR e0 / U 1 PHONE 0.y- . rWASTE TRANSPORTER#1 LANDFILL 'J re C6,^Y04 I ADDRESS ADDRESS 1 CITY STATE ZIP CITY iY v i M t STATE[k I; f, .'I - Asbestos surveys are required prior to Demolition and Renovation Forms.instructions,and the Rule 1403 can be obtained from AQMD web site http:llwww.agmd.gov Page 1 of? Fore 8-30-2000 1 :39PM FRt 3PECTRI.M ABATEMENT 714+771 84i j P. 2 NOTICE OF COMPLETION AUGUST 30,2000 TO: INTREPID HOMES, INC. 10945 SOUTH ST., STE. #301 CERRITOS, CA 90703 PHONE: 562.924.4491 FAX: 562.809.6393 JOB#: 2000634 JOBS1TE: 165-169 2167 ST. COSTA MESA, CA On 08/24/00 thru 08/25/00 Spectrum Abatement performed removal of asbestos containing material at the aforementioned site. • All work was performed in accordance with Federal, State and local regulations. If you have any questions, or need any further assistance,please contact me- Slyv,Aee 7 David E. Fischer ;L•.-• Spectrum Abatement as Clans tia- ---.B um - 7232N6467 2 - `� • Nov 24 99 1O: 22a Ri. and Jackson 94- 33-0556 P- 2 FROM : Pi-COrt NO. : f Nov. 22 1999 05:32Fn P2 :. HI- TECH Environmental and Laboratory Services LABORATORY 3ERYICE3 PIWME 1 SITE ASSESSMENTS ASBESTOS•LEAD WOE BULK SAMPLE ANALYSIS PAT810970 !LAP 12072 NYtAP 8101012 CLIENT: CHARLES JACKSON REPORT NUMBER: 70803 PROJECT: 165-169 2147 STREET REPORT DATE: 11/22/99 COSTA MESA.CA • claw LOCAIIDNOFSPECIMEN SPECIMEN TWE ASBESTOS. SPECIMEN SPECIMEN DESCRIPTION& DETECTED COMPOSITION ID COLOR 165A-0I INTERIOR WALL INTERIOR PLASTER ND VERMICULITE GRAY 5Y MINERALS 50% CALCITE 10% BINDER 35% 165A-02 EXTERIOR WALL EXTERIOR PLASTER CH=<I% VERMICULITE TAN 10% MINERALS 50% BINDER 40% 165A-03 ROOF ROOFING ND CELLULOSE BLACK 10% FIBERGLASS 40% MINERALS 20% BINDE 30%' 16513-01 INTERIOR WALL INTERIOR PLASTER ND MINERALS METE 50% BINDER 50% 165E-0Z EXTERIOR WALL EXTERIOR PLASTER CH=<I% MINERALS .IAN 70% BINDER 30% 165B-03 ROOF ROOFING ND CFI LULOSE BLACK_ 20% FIPFRGLASS 40% MINERALS 20% BINDER 20% 5396 Lincoln Avenue.Suite A • Cypicns,California 90630 (714)827-0693 - Fax (714) 827-0695 • Nov 24 99 10: 22a RI and Jackson 941 63-0556 P, 3 f ROTI : PFOhE ND. : 4 Nov. 22 1999 05:34pti p3 CHARLES JACKSON REPORT 470X03 PAGE 2 1650-01 INTERIOR FLOORING 01=5% MINERALS BROWN 35% CALCITE 30% ELUDER 30% 1650-02 INTERIOR WALL INTERIOR PLASTER C14-<1% CELLULOSE GRAY 10% VERMICULITE 10% Numay LS 40% CALCITE 20% BINDER '20% 165C-03 EXTERIOR WALL EXTERIORPLASTER ND MINERALS TAN '50% CALCITE •20% BINDER -30% 165C-04 ROOF ROOFING ND CFJJ ULOSE BLACK 15% FIBERGLASS 35% MINERALS .20% BINDER 30% 165D-0I INTERIOR WALL DRYWALL CH-CI% CELLULOSE WHITE _40% GYPSUM 30% CALCITE 20% BINDER 10% 165D-02 EXTERIOR WALL EXTERIOR PIASTER ND MINERALS FRAY 70% BINDER 30% 1650-03 ROOF ROOFING NO CELLULOSE BLACK 20% FIBERGLASS MDdHRA1S 20% BINDER 20% • • Nov 24 S9 10: 23a RI, ird Jackson 949 ;3-0556 p. 4 FROM PHOtE 340. . + Nov. 22 1999 06:35PM P4 CHARLLS JACKSON REPORT 470803 PAGE 3 169A-01 INLERIOR FLOORING CH=3% CALCITE BROWN 37% BINDER 60% 169A-02 INTFRIORWALL INTERIOR.PLASTER- CH=<1% ,MINERALS WHITE SOY. CALCITE 30% BINDER 20% L69A-03 EXTERIOR WALL EXTERIOR PLASTER ND VERMICULITE TAN 10% mINERAIS 659'. BINDER 25% 169A-04 ROOF ROOFING ND CELLULOSE BLACK 30% FIBERGLASS '30% MINERALS -25% BINDER 15% 169B-01 INTERIOR FLOORINGCH-$% MINER/LS BROWN -20% CALCITE 3554 BINDER •'. .40% 169B-02 INFERIOR WALL 1NTERIORPLASTER CH-<1% VERMICULITE WHITE .10% MINERALS .50% CALCITE 20% BINDER 20% 169B-03 BX'ITRIOR WALL EXTERIOR PLASTER ND MINERALS TAN 50% CALCrrP 20% BINDER 30% • D • Nov 24 99 1O: 23a Ri and Jackson 949 '13-0556 p. 5 FRO`t : PHp'E NO. + Nov. 22 1993 05;36Pn PS CHARLES JACKSON REPORT 170803 PAGE 4 1693-04 ROOF ROOFING ND CELLULOSE BLACK 40% SYNTH FIBER 10% NUMERALS 20% BINDER _ 30% 1690.01 CEILING ACOUSTIC ND CALCITE 1 WHITE 20% BINDER 50% FOAM 30% IG9C-02 INTERIOR FLOORING CH are; CALCITE WHITE 38% BINDER 60% 169C-03 INTERIOR WALL DRYWALL CH=<1% CELLULOSE WHITE '30% GYPSUM 30% CALCITE 30% BINDER 10% 169C-04 EXTERIOR WALL EXTERIOR PLASTER CH=a% MINERALS TAN 50% CALCITE .30% BINDER 20% 169C-05 ROOF ROOFING ND CELLULOSE A1.MX 20% FIBERGLASS 20% MINERALS ,20% BINDER 40% 169D•01 INTERIOR -- — FLOORING CH=4% tALCTTE BROWN 365E BINDER 60% 169D-02 INTERIOR WALL DRYWALL ND CALCITE WHITE 30% BINDER 70% • • • Nov 24 99 10: 23a R. 'ard Jackson 94: 63-0556 P, 6 FRCM : PHONE N0. • Nov. 22 1999 05:37PM p6 CHARLES JACKSON REPORT 170503 PAGE5 • 169D-03 EXTERIOR WALL PLASTER. CHa<1% MINERALS TAN 60% CALCITE 30% BINDER • 10% 1690.04 ROOF ROOFING ND CELLULOSE 10% FIBERGLASS • 50% MINERALS 20%. DOWER 20% A-SRFFITIS TYU% C1=CI1R75V7J1£ (RarFOCIN JR' Aw n:wi171j . - ✓ -fPffrui" - _1. G - .It ! • ...or sae.! •aaea,l The law*s fwd.Oevc vmat sabmiltel ase•snpaa.f afcrasining sterna Tlx rwbs of analysis sac fm tic maple a stub dilla'atd n 10-TECH Psvoomnrtal And may sal rcpesmthe emistwiaial*vn wbiehtbs ssngle v.utakt& On a ern tivt smolt,the EPAracemmd wee sr man talars Sant •Dstost rnosoUsL avem Wins k I.cmddaataoehms at.ens:Rise Pcaaua wiWp.or*avows ma.damird led.aincer Prfocksksa notwind ogle miaoacoPy ad&Wran asiniuymite MOSH•pprawd Method 1403. This mead is into ddoodint6s EPA 600/1442-020,-1¢letiw Hated fortho DelamMosliea at nil aaiofulk.La.LaaS.mylo.^ Nn*4isbla r4ci.L.such safleactag.attic.asfay..aaLtieSt de sat Law pepping mcaMclapr opo acd m ex ASTM Gamins.-sung sd Maned of Twang Asbaca cculabing®tretsks by Palcvod Linn Microscopy." Trac sastorissla ma waged Sot wly.e by non-doe+n.MW stahod. Umber light microscopy hu tan know to Mn asbafa.m.moll permute sr simple wilm=tab arms. Wops tierce=int foor 6k.eapie with•+p'dvo"nakc w.y-k!halm add teat SOt or Mit .Asbsaoa is tscicuy geaeti6nlntma Aa daft as utbartim uaM:gaa Th:.method iz..0 .s.aisv sty sarfasinp•Sc awe..weave tis Kat.ahn=malarial para in Ow nn,lc at sample lays. This is saaatolhhai by snot oamina:ioo sf bonegm.w Olds rn?wuiwt tuna dsi polarized EPht microscope asch.wplc is Wilily cannon uncles.stew aoamttyc al a mogniLcaim d h so SO tin Mesas Kmaicd%.s e6awvaiaed hand Yvon rooryhologo. Pestes of coal.one&vat andel voila pale a.d L(p*in a Rion micaapt with a Met-+tnw dicfneion wiring itjetSn weds. 100 limn ataci fscs on. Op int hawaiaia otos Gums maaisl way eemaad to Mama.Oa ncaktby.f the fshaa Thu chew)vial dauaadnies ltdada.agje of aninefiaq its Of.lontstsat,and dapreas solani cakes Nene detesW is any s.pNwo&An•thawgh.rods uldfaty gp`gittuu.a.pk pepsreien wdmigxs is amdaded sad so abode,is SNsat.A TM morn ms set ;spry slut so ubcMs it posy* 44 mdnd'r eel capable of maim that daennitca im Rahn.if istplis that tither Alberta is sot;Waft a if it it.i1 i fibaly • "a....:C-..u. MinaretMinaretfirrIVH F-tni�lmcts(..t most to.ai5sd Who l;waced e d rIs red*I.anwame.6r ssnvJac yasvd n ll M r P.I.bnep. WS. N w s pateiNter aYW HOMJILR 10141}. The rsaan ear stun be not 5y 0et earsp en wan sfisMdornes.nt by HYLA?or ver erred dm V t. C-O.erwsstsl.Ali igMeanlice res*t(ahs ibis woodsy N nomittsrr his sin wrwYry t.'Lberth"-One twhwr'.bthms+.tkws.lawn ti. {aysry wdam °;Ot cwtwau�cf "- VOA ta-hetRcafTmpep 6Y.wWwa46t loll wallas gpn.Y sfmis►.rMry. v t One%Hilda,Pmadmt Delo S.gamey Mane)SAO knit Appmwd Stews Avec nil Signahnm • f02 f20j iii HI-TECH ENv;RONMENTAL 6 LABORATORY SERVCEE 04111 M CITY OF COSTA MESA 440,- 11 BUILDING DIVISION >wDEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER t / PERMIT : B00-01360 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.usNG PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDI• Job Address: 165 21ST ST Status: ISSUED Suite: A Applied: 09/05/2000 Vicinity: Issued: 09/05/2000 Parcel Number: 42619318 Zoning: Applicant: JONES, CLIFTON ISSUED BY: Address: 10945 SOUTH ST UNIT 301 Phone: (562)924-4491 CERRITOS, CA Zip: 90703 Owner: INFINITY HOMES CM, I LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: INTREPID HOMES INC Address: 10945 SOUTH ST UNIT 301 Phone: (562)924-4491 CERRITOS,CA Zip: 90703 License: 779066 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT DEMOLISH EXISTING SINGLE FAMILY RESIDENCE(882 SQ FT)-UNIT A. FEE SUMMARY Plan Check: $0.00 Calc Valuation: $3,500.00 Permit: $97.25 Claim Valuation: $3,500.00 SMIP Res: $0.00 SMTP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $97.25 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and a': required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit FOR INSPECTIONS CALL: (714)754-5626 J 2446.4516'00) DECLARATIONS 1 WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. ❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if,: •:rmit:5 valued at one hundred dollars($100)or less.) �� —certify that in the perfo �j 0- for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws o 'alit,. ,• ,• ee that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these• ovist+! ,A-x Ai ^CJ C 'Appll�nt Signature> — l �---Deter—(f—" WARNING:FAILURE •' E.,,,..• ORKE-.,COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE WOO.' IN ALM''• TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTOR • LARATION: - I hereby affirmthat am.licenss@d u (letor v io•--• commencing with Section 7000)of Division 3 of.the-Burin nd Professions Code,and my license is in full force and efect..Lic..q__-.' 6)ZY CClass.N. e-— Contractor's Signature: _',QA_ Date:.-----e7--_) —c_) CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construct'', " •ng agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of properly who builds or Improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Gm 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the Califomia Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this.application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? D Yes D No (Section 65850,2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Duality Management District or other air pollution control district or agency is required for the work which Is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE�: I• ' ••- RIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to Comply wit�a.II/-tate laws •nd city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described proper? tion pu•ises.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. lour ••1 Le al O ner(s) y'�`�'C -. : ( , ( Dates---_ _ COPE I IIISPFCTI' PATE MiAe CODEC INSPECTION TYPE MI II0IIIALS 1616 Fixed Sys nal Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 6/Q. �g>:L�2Cr0 Final Building/Occupancy pwA CITY OF COSTA MESA 4 BUILDING DIVISION >4._ ,r DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER r._: r te PERMIT A` oaarw fp" B00 -01361 (714) 754-5273 • Fax(714)754-4856 • www.ci.cosfa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 165 21ST ST Status: ISSUED Suite: B Applied: 09/05/2000 Vicinity: UNIT B Issued: 09/05/2000 Parcel Number: 42619318 Zoning: Applicant: JONES, CLIFTON ISSUED BY: Address: 10945 SOUTH ST UNIT 301 Phone: (562)924-4491 CERRITOS, CA Zip: 90703 Owner: INFINITY HOMES CM, I LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: INTREPID HOMES INC Address: 10945 SOUTH ST UNIT 301 Phone: (562)924-4491 CERRITOS,CA Zip: 90703 License: 779066 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT DEMOLISH EXISTING SINGLE FAMILY RESIDENCE(882 SQ FT)-UNIT B. FEE SUMMARY Plan Check: $0.00 Calc Valuation: $3,500.00 Permit: $97.25 Claim Valuation: $3,500.00 SMIP Res: $0.00 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $97.25 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 • NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(WOO) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: 0 I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. O I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This$ lion need not be completed i/th: .erm',is valued at one hundred dollars($100)or less.) be-I certify that in the perform-.:: for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' sensation laws of o „Jr- that If 1 should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these pr••Ilio �• Appll a t Sig - Titer IDate:9-'S WARNING:FAILURE TO SECURE ' ORK • ' •MPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TOCRIMINAL PENALTIES MID CAVIL FiNES UP TO ONE HUNDRED THOUSAND DOLURE($100,000)'N AD. I•'TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: 1 hereby affirm(ihat.l.am.licens id vier'rovi of •.•er 9(commencing with Section 7000)of Division 3 of the Buslnegr�Id Professions Code,and my license Is in full force and effe ttL Uc p. ._-"— (Cla fl •Q Contractors-Signature: --- .44/10.? �'��4l, _ `Date:— ./ S'"Cr CONSTRUCTION LENDING AG .CY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant fore permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): O I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of properly who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,This 8,California Administrative Code). ❑ As owner-builder, I wit not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (if'yes",the facility must meet the requirement of Sections 25534 and 42303 of the Catifomia Health and Safety Code). 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑No 8 (If yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTH•= ON OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state I...-4001, ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspectii., . gree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sy4+-:Of n:r( �I.Datte • / !; .(s .And/Or'•.•'•�ed'App l :nt---- ._ _ Date CODE It, INSPECTION TYPE PATE INTRIALS CODES INSPECTION TYPE PATE INTRIAL$ 1616 Fixed System Final Fire Prevention _ 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing - 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site �Q-(eL� �ilrrft[� 204 Final Demolition 4//1401.-- 250 Final Building/Occupancy 6 CITY OF COSTA MESA J/ BUILDING DIVISION DEV f , ELOPMENT SERVICES DEPARTMENT PERMIT NUMBER � t R'it 111 PERMIT • BOO-01362 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.BUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 165 21ST ST Status: ISSUED Suite: C Applied: 09/05/2000 Vicinity: UNIT C Issued: 09/05/2000. Parcel Number: 42619318 Zoning: Applicant: JONES, CLIFTON ISSUED BY: Address: 10945 SOUTH ST UNIT 301 Phone: (562)924-4491 CERRITOS,CA Zip: 90703 Owner: INFINITY HOMES CM, I LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: INTREPID HOMES INC Address: 10945 SOUTH ST UNIT 301 Phone: (562)924-4491 CERRITOS, CA Zip: 90703 License: 779066 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT DEMOLISH EXISTING SINGLE FAMILY RESIDENCE(1104 SO FT)-UNIT C. FEE SUMMARY Plan Check: $0.00 Calc Valuation: $3,500.00 Permit: $97.25 - Claim Valuation: $3,500.00 SMIP Res: $0.00 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $97.25 PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existinq: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 244646(6/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the _ work hich this permit isk issued. / ave and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. My workers'compensation Insurance carrier and policy number are: Policy Number: ` a need not be complete•c�th.'e pe it is valued et one hundred dollars($100)or less.) _ certify that in the parlor nce hie w• k for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' — —compensation laws• 7I(7•� la, :id a•, ee that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these • ons. J Applicant S _��f!� Date:7,_ S WARNING:FAILURE TO SE...". -_,..e;'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER-TO—CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,ur ••' TION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am.licensed under provisio sof••:•! • mencing with Section 7000)of Division 3 of the Business Professions Code,and my license is in full force and effect. IcLIcL .N 1 t a ...Arr. Class qm3/J ontr idlor's Signe es �I Tee — � Date: < 9"----5.--CV CONSTRUCTION LENDING AGENCY: O I hereby affirm that there is a constructio . ding agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). O I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes ❑No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes ❑No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature end pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑yes ❑No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes LJ No (Section 65850.2 of the Califomia Government Code requires that the requested information be fumished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑No 8 (If"yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND A r-•-IZATON OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct.I agree to comply with all sta�,=/P1111,y d city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspe w6" s.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. rI O .-. ) te ��• Authorized Applicant ,,,- - , Data ;ODE It . HI•. I'a g ltd CODE! INSPECTION TYPE PSIS MALI 1616 Fixed System Ina Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign ``` .. 222 Final Site 204 Final Demolition �6 I- 1.--- 7" �� 4r,Y•"'�JJ',� 250 Final Building/Occupancy ADDRESS OF MIMING: 165 21ST ST DIT: 0 CITY OF COSTA MESA - BUILDING PERMIT CWNEWSNMIEIFIDIOAM:MR, & MRS . NED JACOBY PERM NO: P 080296 *3°4553: 375 23RD STREET NEWPORT BEACH, CA. 92660 1a - r PERMIT NO: P 080296 PLAN CHECK NO: N GOVT: N SUPP: N 714 /631-6686 APPL.MAILING ADORES& CONSTRUCTION TYPE: V-N PERMIT TYPE: PLU PURPOSE: OTH OR IHC.NO.: JOB DESCRIPTION : REPLACE GAS LINE TO RESIDENCE SQ FT: ARCM.OR EN0.1 ADDRESS: Wit: CLAIM VALUE: CALC-VALUE: GROUP OCC : R-3 / CONTRACTORSNANE:C AND R DRAINS INCORPORAT ( 714 ) 754-1762 CdGNACTOWSMMUNG 1525 MACARTHUR BL COMMENTS: NO BUILDING PERMIT ASOOCIATED WITH THIS WORK ADDRESS:COSTA MESA CA ucNO.: 531746 ********4+e***N*RE*** '**Rt RE*x-RLRE+FiE********* -Ric' 'RE*REQ- '*iE*+ERE* '*Rc'*****AEx'********+t'*RE*RE*** 92626 DIr: 11 Z ONING REQUIREMENTS LICENSED CONTRACTORS DECLARATION:I hereby affirm under penally of perjury that I em licensed under provisions of Chapter 9 SETBACKS (commenting with Section 7000)of Division 3 of the Business and Professions Code.and my license is in full force and effect. CRY GC.NO.:045014 uc.cuss: C 36 LIC.NO.: 531746 EXP: 05/97 MAIN BUILDING ACCESSORY BUILDING FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN Dme:y —y`9G Centred L- 6..V....;:` LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN OWNER BUILDER DECLARATION:I hereby affirm under of perjury that I am exempt from the Contractors License Law for the following reason(Section 70315 Business and Profession Code:Any city or minty which requires a Penn§to construct alter,improve, PARKING REQ: P RO V: PARCEL : 42619318 Z N E: REF NO: 'mofah,or repair any structure,prior to Es issuance,also requires the applicant fa such Penne to fere a signed Statement that he or she 'steed pursuant to the provisions of the Contractors License Law(Chapter 9(mnmendrg with Section 7000)of Weikel 3 of the PLANNING NOTES> l Tress and Professions Code]or that he or she is exempt therefrom and the basis for the alleged exemption.My violation of Section > ,031.5 by any appirent for a permit subjects the applicant toe civil penalty of not more then We hundred dolled ISSW]l. ******************************************************************************* ❑ I.as owneroftheponodyormyemployeeslhwagesmtheirsolemnpensation.wOdothework.andtheatroctureinetiMended DEVELOPMENT SERVICES REQUIREMENTS or offered for sale(Section 7044,Business and Professions Code:The Contractors License Law does not appy to an Owner ot property who builds or improves thereon,and who does such work Iimseff or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.M.however.the building or lmpmrement is sold within One year of completion,the ZONING APPROVED BY DATE: ownerbuitder will have the burden of proving he or she did not build or improve for the purpose of sale). ❑ I.as owner of the property,am exclusively contracting with licensed contractors to construct the protect(Section 7044.Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon and who BUILDING APPROVED BY : _ DATE: contracts for such projects with a mtractor(s)licensed pursuant to the Contractors License Law). ❑ lam exempt under Section: B.AP.D.,for this recon: APPLICATION ISSUED BY: 142575 DATE: / ******************************************************************* ** Dale: Owner: LEGALIZATION;N F E E SUMMARY STRUCTURAL SEGMENT:N I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505.25533.and 25534,and that I or any future building occupant will/will not(date one)need to comply with said state codes end the requirements for e permit tormutructionor modification Irma the Ar Quality Management Oidrid.Reeidemilmmouctioneppkaiau are exempt honetese BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING Provisions. PERMIT 8 , 75 Date: Awaken!: 25% • SMIP/NON-RES WORKER'S COMPENSATION DECLARATION:I hereby adhnn under penalty of perjury one of the hollowing declarations: PLANISSUE FEE . 00 • O I have and wit maintain a certificate of consent to salt-insure for workers'compensations, provided for bySection 3700 of the Labor BUILDING-DIV-> PERMIT 22 ISSUE PLAN-CHECK TOTAL PAID DUE Code.for the performance of the work for wNch this permit is issued. TOTALS----> 8 . 75 22 . 00 - 0 . 00 30 . 75 30 . 75 . 00 -I l I have and wit maintain workers'compensation insurance,as required by Section 3700 d the Labor Code,for the performance of the }� work for which this permit is issued.My workers'compensation insurance anter and policy number are: Cartier TRUCK INS EXC EXPIRES REVENUE DIVISION TOTALS--> COLLECTED: 30 . 75 OVER/SHORT: . 00 Policy Number; 1OR5640-96 02 /01 /97 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN-CHECK S section need not be completed iI the permit is for one hundred dollars js100)or east 30 . 75 O I certify that in the performance of the work for which this permit is issue!,I shall not employ any penin in any manner so as to become abject to the workers'mnpenaafan laws of California.and epee that M I should become abject to the workers' ******************************************************************************* compensation/ provisionsprof Section 3700 of the Labor Code,I forthwith py ' /%qj/Jif/ane/ I N D I V I D U A L" F E E B R E A K D O W N XDate: // —u APPlicam: d. %rs /`i Warning:Failure b secureswan'compensation cow 'unlawful,and shall subject an employer to MMrW prude and TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST chill fines up to one hundred thousand defiers($100. In eddldon to the cost of compensation,damages as provided for In Section 3705 of the Labor Code,interest and atfomers fees. • PLU 1 GAS SERVICE a- 8 . 75 8 . 75 CONSTRUCTION LENDING AGENCY: I hereby allure under penalty et perjury that there isa construction Wiling agency for the END OF FEES performance of the work for which this pent is issued(Section 3097,Civ.C), LENDER'S NAME: LENDER'S ADDRESS: .- I certify that I have read this application and state that the above information is correct.I agree to campy with all dry end county ordinances A and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property - 1 for inspection purposes. JOHN MELROSE \ Print ht DATE: 11/04/95 TIME: 16:14 7411(111 "e/A /e 01 00218533-00213538 TOT 30.75 O /L� Date: Signature of OwergenVAppfanV onlrada � , (5151e5.WP) White-Suildig b Soley:Green-Fe:Caney-Appiant;Pink-Revenue:Goldenrod-Assessor • CONSTRUCTION AND PLANNING - POOL "' SPA APPROVALS Permit# Date Inspector APPROVALS Pe,..an Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location" 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding • 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE r. 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd-,Test • 9. Water Pipe-Undrgrnd. - 60. Backwash Lines, P-Trap, -Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK , 11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final 12. Sewer Cap 63. Heater& Vent-Final 13. Roof Drains • 64. Plumbing System - Final ' , 14. Rough Plumbing _4 65. Electrical-Final 15. Rough Electrical-Conduit 66. Solar System-Final 16. Rough Electric Wiring • 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating& Air Conditioning FIRE DEPT. REQUIREMENT 20. Rough Factory Fireplace APPROVALS Permit# 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd.Storage Tank ❑Gas ❑Oil 25. Roof Sheathing 74. Overhead Hydro 26. T'Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing& Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED C n 33. Final Electric Notes: 11-6-%Gas LINE FIWALIZEO 111L 34. Final Heating & Air Conditioning . 35. Final Gas Pipe-Test 11,b„c?6 K 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service-Final 40. Gas Service-Final 41. Solar Domestic-Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System • 45. Sound Attenuation - 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 46. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No Date • PROJECT ADDRESS: 165 21ST ST UNIT: 0 CITY OF COSTA MESA - BUILDING PERMIT PERM NO: P 049283 OWNER'S NAME MR. & MRS . NED JACOBY ADDRESS: 375 23RD STREET PERMIT NO: P 049283 PLAN CHECK NO: N GOVT: N SUPP: N NEWPORT BEACH, CA. 92660 CONSTRUCTION TYPE: PERMIT TYPE: PLU PURPOSE: OTH 714/631-6686 ARCHIENGINEER: REO.NO.: JOB DESCRIPTION : REPAIR SEWER LINE SQ FT: ADDRESS: UNIT: CLAIM VALUE: CALL-VALUE: GROUP OCC: / PERMITTEE: C & R DRAINS ( 714 ) 641-1545 ADDRESS: 1525 W MACARTHUR COMMENTS: NO STRUCTURAL WORK BEING DONE CM CA 92626 +E*+e************ at*at***** *yE*****atxitet** *****aEaret**+eat+Era*et*yt*****+tat*St********aE**** UCENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z ONING REQUIREMENTS 7000)of Division 3 of the Business and Professions Code,and my license is in fall force and effect. SETBACKS cm/uc.: 450140 STATE uC.:317 4 6 cuss: —6 r Dale "3 -7D Signature: — ji4io/-'— MAIN BUILDING ACCESSORY BUILDING WORKERS'COMPENSATION DECLARATION: Ihereby that)have acertficate of consent to self-insure or a certificate of Workers' FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN CompensationA cjy rifled ctionWOO,Lab. ) LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN POLICY NO.: v c+��crtEXP.DATE: L)2/01 /91 CDMPANY: STATE PARKING REQ; PROV: PARCEL : 42619318 ZNE: REF NO: ' 1 Certified copy is hereby furnished. N Certified copy is filed with the city Budding Division. PLANNING NOTES> n ----rater /0 -- ?-10 Applicant.--III �_ ._ ******************************************************************************* EXEMPTION FROM WORMERS'COMPENSATION DECLARA)f This section need not be completed if the permit is for one hundred 15100)or less). DEVELOPMENT SERVICES - : REQUIREMENTS I certify that In the performance of the work for which Is permit Is issued,I shall not employ any person in any manner so as to become t -. subject to the Workers'Compensation Laws of California. ZONING APPROVED BY : DATE: Date: Signature: NOTICE:If,after making this declaration,you should become subject to the Workers'Compensation provisions of the Labor BUILDING APPROVED BY DATE: Code,U you must forthG comply I ith such provisionshaa this permit shall be deemed revoked.f CONSTRUCTION LENDING AGENCY: hereby affirm that there Is a construction lending agency for the performance of the work for APPLICATION ISSUED BY; V{ iF/UE which this permit is issued(Section 3097,Dv.C). ********************************************* ' ***************** ** * * LENDER: ******************************************************************************* ADDRESS: LEGALIZATION;N F E E SUMMARY STRUCTURAL SEGMENT:N OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from theContractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish,or PERMIT 5 . 00 repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed 2 5% pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business PLAN SMIP/NON-RES and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). ISSUE FEE 3 . 00 I I, as owner of the property or my employees with wages as their sole compensation, wiu do the work, and the BUILDING-DIV-> PERMIT ISSUE PLAN-CHECK TOTAL PAID DUE structure is not intended or offered for sale(Section 7044.Business and Professional Code: The Contractors'State License Law TOTAL S----> 5 .00 3 .00 0 . 00 8 .00 8 . 0 0 , 0 0 does not apply to an owner of a property who builds or improves thereon,and who does such work himsell/herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If.however the building or REVENUE DIVISION TOTALS––> COLLECTED • 8 .00 OVER/SHORT• 0 0 improvement is sold within one year of completion,the owner will have the burden of proving he/she did not build or improve for the purpose of sale). BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN-CHECK I as owner of the property,am exclusively contracting with licensed contractors to construct the project Section 7014,Business 8 . 00 ❑ and Professions Code: The Contractors'State License Law does not apply to an owner of property who bt ds or improves thereon and who contracts for such projectsrth acontractor(s)license pursuant to the Contractors State License Law).I am aware ******************************************************************************* that proof of their Worker's Compenszlion insurance should be provided to me. INDIVIDUAL F E E BREAKDOWN ❑ I am exempt under Section: B.&P.C. for this reason: TYPE QTY DESCRIPTION UNIT COST TOTAL COST Date: Owner: PLU 1 SEWER, CONNECTION TO BUILDING EACH 5 .00 5 . 00 I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505,25533,and END OF FEES ' 25534 and that I or any future building occupant will/will not(circle one)need to comply with said state codes and the requirements for a permit for construction or modification from the Air uality Management District.Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and state that the above Information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. -�h/ 01 C0071030-00071030 TC 4 c. jO—� l O signature: t../�� !. - 'L. - DATE: 10/C3/90 ,TIflE: C?+21 Driver's License or Social Security 0: • 1641-46 White—Building:Green—Code Enforcement;Canary—Applicant;Pink—Revenue;Goldenrod—Assessor 1 • - CONSTRUCTION AND PLANNING SPA . APPROVALS Permit# Date Inspector APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole '; 52. Pool & Equipment Location •2. Soil Pn ipe-Undrgrnd ��, zr 53. Steel Reinforcement . 3-Electrical Conduii: Utility-Undrgrnd. 54. Forms 4'. Electrical Conduit-Undrgrnd. 55. Electrical Bonding • 5'-'Steel Reinforcement 'C 56. Rough Plumbing & Pressure Test 0 - 6.`t-',Electrical UF Eli Grnd. ,� 57. APPROVAL TO COVER-GUNITE 6 '7!.?Footings - - 58. Electrical Conduit-Undrgrnd. 8.'Foundation 59. Gas Pipe, 0 Undrgrnd.,Test 9'. Water Pipe-Undrgrnd. 60. Backwash Lines,P-Trap, 0 Undrgrnd, 10. StYuctural Floor System61. APPROVAL TO DECK 11. Property Sewer Line& House Connection 62. Backwash & Receptor-Final 12. Sewer Cap i =' • 63. Heater & Vent-Final 13. Roof Drains . c,. 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical-Final • 15. Rough Electrics`;-Conduit 66. Solar System-Final 16. Rough Electric-Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19..Rough Heating &Air Conditiopjng .9 ; * ,.FIRE.DERT. REQUIREMENT 20.t:Rough Factor& Fireplace S:^ c:.% . ; --i5..- c• • 'APPROVA ES:.-,E-Permit# 21.-Duct's, in Structure' - •' �: + " C "` 4: ` • '- �." -ro ti g F-, , p :i es:* 70. Undergrounds Hyd, X 22._Duas, Ventilating .. . = 'G ;) Z-:g G71. Product-Piping OGas rip' 23. Gas,Pi e-Rou h & Test • MI. 'I- ••' S n* ' o& A. P rg :r M J` .. c s * _.72. Undergroup d.Flusfi' - . v 24. Roof Framing - - P, r - > X ,-i:-- • --73.- e T Undergrnd.Storagank 0 Gas 0 Oil 25. Roof Sheathing _ h w ' -1 D Cl"' ,- 74,--Overhead Hydro.- ' 26.!T-Bat Ceiling ;Structural) &1Nonocoat x O n J O+-9. r 75:Dry Chemical 27.--Frame and Flashin Cp:X _ ' ,=' - xa: x '-� " •-' 9'; _n „a. 76. Dry Standpipe 4 s. - - �28. Lathing& Siding--<> i 7 � T . ',WI-, O • + a: 77�-F IXED SY'STEMW:INA Lit - ri 29. Insulation :y m ?; . ! - * 78.'-�,FI,RE PREV. FINAL :- „ ' - 3 30. Drywall Nailing -• ra 'y 01..: cHEALTHtDEPT=REQUIREMENT C31. Plaster BrownCoa`i ; `m 1,! x '79. 'FINAL INNN1 JCTION y , , c x x tP y32.=Electrical;Power Meter-Final , * l I x n 80.E-FOOD CERTIFICATE ISSUED r. ._. -.33.=Finals Electric, h: r C # +Notes: y .r.:1 7 O n LiC ;34.:FinahHeating.& Air,Condr itioning' 4' I 1* ;-..1m -y _` , '1 " 35./Final Gas Pipe-Test' Os •• n ;' Y -3 t. O-i ' -.. is A r: '1 , 2' ii: 36. Hood or Canopy •-,• 4: " f: . r :co ^' `37. Final•Factory Fireplace '= ----4 6 a. - ' '38. Final Plumbing x :-� 4�lti¢o' j LIEl.5?7, -• 't ,x -39. Water Service-Final, sc I ' h' >+ = ' r'40. Gas Service-Final ' : <:”r- " 7-1 1* 1. ,) " G I. ,.41. Solar Domestic-Final to i I * fi _ • -▪ -• ` - -• 42. Backflow Preventer'• r" - :1Z •. II , l -1 a 1. sr. ,T C., r•-s. .. 43. Backflow Irrigation - r t -- * " c' - ' -' rr^- _ G A. ?44. -Landscape Irrigation System7"'.: cc - '' 0 r-T � ``� • i s . . .45.;Sound Attenuations ,s m h .mrs 4 - - -' y: I--- C46. Handicap-Regulations ' j �� = s 47. 'FINAL STRUCTURE & BUI'LDING • c. `+ •• ' •V '= , . . • ... I CO t: - . - ? 48. FIN'A'L PLANNING, "`' • '" r�- "' e `' .49. Eledtr?ic Release to Edison a 1 , 4 r •c': x 50. :Gas;.Release to Southern California:Gas Co ; ',.;,• '' -' - - c t-_ "1: f- - -51. CERTIFICATE OF OCCUPANCY - ' • - - No Date QD 17 OP OOH La C 2rioLa V � �LaL2LLJELI u OP C �3� .�; 7 • 2803 Royal Palm Drive — Phone 549-1111 Notice issued to Lir. A. Varrin Date 19 11 7969 On premises of 165 & 169 E. 21st. Street CityCosta Mesa , Calif. Address Rt.#4 Box 333-A Moosa Canyon Road Calif.CityEsco^,dido, YOUR ATTENTION IS CALLED TO the Uniform Fire Code. 1967 Edition. Sections 27.05 and 33.27. Th- condition of this frotarty is an extreme fire heznrd andmust he corrected vitini•n the time limit Liven beim:. If you have any questions concerning: this matter. please call me at 834-5425• • JOHN MARSHALL, Fire Chief December 29_ 69 Kenneth Blakkan � � SJ40 fire Inspector FORM FO.17-2 M-8.66 HP • `l CITY OF COSTA MESA PLANNING _EPARTMENT • , • !UG 25-72M001796Ro�Yu*�140.00 [NSA A.P. No. ii CSt 2 : 22 Bldg. Permit No. PARK AND RECREATIONAL FEES - Apartment Developments • Fee Payment Receipt Project Address 16(1 gArt 21St. fret, C. Owner's Name M iaAnc/ !acvky Bachelor or 1 - Bedroom Units @ $25.00 = 2 - Bedroom Units 1 @ $40.00 = °40.00 3 - Bedroom Units @ $55.00 = 4 - Bedroom Units @ $70.00 = 5 - or more Units @ $75.00 = Total Number of Dwelling Units 1 Total Fee 540.00 Planning Department Approval Date 9_15 n /) Park Area No. By H.L.O. Bob Applicant's Signature (kat( T ID {J625-72fi 001796Ro****40.00 CITY OF COSTA MESA PLANNING DEPARTMENT "s'' A.P. No. 11R-06r.._pi r Bldg. Permit No. PARK AND RECREATIONAL FEES - Apartment Developments Fee Payment Receipt Project Address 165 Fact plc L Street r tt Owner's Name H Jear1c/Jarnhy Bachelor or 1 - Bedroom Units @ $25.00 = 2 - Bedroom Units 1 @ $40.00 = 40 CO 3 - Bedroom Units @ $55.00 = 4 - Bedroom Units @ $70.00 = 5 - or more Units @ $75.00 = Total Number of Dwelling Units 1 Total Fee $40.00 Planning Department Approval Date o_95-72 Park Area No. 0 Bylq.L.U. Bob Applicant's Signature (/. -c-C OWNER HENMEPIDINGER, Richard - SOLIDER, Morris & Marie DATE 11-11-57 _ JOB ADDRESS 165-B E. 21st St. BUILDING PERMIT NO. 5967 .GENFQRaL CONTRACTOR Romar JBldrs. VALUE $ 7,536.00 "Al?. No.x"1 LOT 2112 TRACT Re...FIRE ZONE DESCRIPTION OF WORK Residence W/att gar. C-nUP I & J TYPE V ZONE Rh PLAN NO. 59119 • INaPECTIONS DATE PERMITS ISSUED SUBCONTRACTOR DATE NUMBER Trenches Forms Steel .:-MT1�IEQFal Floor System Steel Reinforce �Chimney Re-Rod �j��j�� Bett Beam fC4-1 rriS ina Frame and Flashing Ira] Lathing, In /„y. Out W J �� An Plaster, brow( coat ala.:21/2210151 Underground soil/104S W/ Pipe Top Out /tag"67 Furnace A'S E &_ - - /.2./0 4/- Gas Gas Vmta S stew. ,. .2 - - y, /42 ,S Rough Plumbing HS a-1 - . `P ' •i - a e li- Cesspool Septic Tank sisissimiarra Prop. Swr. Line House Corr St. Swr. =rrr� -. 7- �� i' Sprinkling System Heating Final /hcggitiZifi F.- bin; Fixtures Final MI#-r -' EMINIII e . Gas Test / -- MAtc- -)v-s-8 l alt construct,. 'ole --1lilialV Underground Power �� Ar��v Rough Wiring 1111•ramem�s,�s/� "p ' E';Ll IAuarii- Fixtures, Final s3 ' , OCCUPANCY MN-S 2.-/t!-S Form 210–.5M-1-57 rO1t7 5949 FEE RECEIVC-D ,COSTA •MESA BUILDING DEPARTMENT 10 Z ' P.O.BOX 3I� FINANCE DEPT COSTA MESA. CALIFORNIA CITY OF COSTA MESA FOR APPLICANT TO FILL IN APPLICATION FOR PERMIT ADDRESS BUILDING /g.573. F2/Srsr BUILDING • COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY y� g RECEIPT NO. T_I{O._ OWNER Richard Hemmendin er-Morris & Marie Souder (�///7 � ADDRESS 2510 Westminister Ave. RECEIVED BY /ODiTE RECEIVED !DAT ISS F Costa / a�-s / Ys CITY Costa Mesa TNO. AD // ` Fi l 2 r4 LI 8-8335 SUILDIADDRESS (C� JJ ARCHITECT INE LIG. OR I- .ICTER C. COSTA MESA. CALIFORNIA FIRE 3 ADDnc55 ZONE ZON PLAN .•M fy.Pr GROUP III CONTRACTOR Romar Builder`sY NO. 6336 "°NS 5 - ADDRESS 2430 Newport Blvdwo. L 8-9386APPR0 ED ..."' w`-•CIE 11// ,, LEGAL LOT renwnretraists. DESCRIPTION NO. 24/2. '] BLOCKS} T le ( �(,'�{] }��'�!' ,{yiA.P.NO.//tel �DSO, / / ,'��/I PPR \�/I fu'!yJ . SIZE ` ' / ND.GP RL OT IC OF Cos A' mtsA OF LOT/75 3o O,/J NOW ON LOT [i�_ JJ'..��\ " USEXOF SU�.JE6BIcv13� I)E£PI':REF•. EXISTING BLDG. SETBACKLINE FROM - / r'_ _ //� \/'� CENTER S OF $E PEEST 7.6 REAR YARD N2-r // SIDE TARO RIGHT J LEFT 7 PLAN TECH:- , DESCRIPTION OF WORC NEW X_ ALTERATION I ADDITION • REPA1H MOVING DEMOLISH BUILDING NO.OF SIZE ROOMS STORIES/ EXTERIOR WALL ROOF COVERING COVERING USE • BUILDDINFGEW 1 Two Bedroom Dwelling w_th 12 x 20 Att. Garage 8/ ad,�— J 02 ,70 ° , ,e7 . I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ASQVE 15 %;E AND AGREE TO COMPLY WITH ALL CITY ORDINANCES d`D 5 REG EATINGEl'/• G CONSTRUC. TION. VALUATION t� SIGN ATU- •F �/ _ PERMIT FEE '� PERMITTE �'W</ • $ s 36 ' r AUTHORIZED AGENT TOTAL FEE $ -3C, No-ur i OWNER HEMMENDINGER, Richard -- DODDER, Morris & Marie DATE 11-4-57 JOB ADDRESS 165-A E. 21st St. BUILDING PERMIT NO. 5946 GE ERAL CONTRACTOR Roman _drs. VALUE $ 7,536.00 118A- ?n,17 LOT 242 TRACT la.FIRE ZONE DESCRIPTION OF WORK Residence w/att gar. GROUP I & J TYPE V ZONE R4 PLAN NO. 5948 PERMITS ISSUED I ECTIONS DATE SUBCONTRACTOR G DATE NUMBER Trenches Forms Steel j - ' J/-2.�-I( Floor System Steel Reinforce-/ Chimney Re-Rod Be e1i.-.b Era//./St Frame and Flashing v�/� /'/% 6 Lathing, In Out q;4 ht/so/S7 Plaster, brow coat J /7-.37 • Underground soi1M//c W/G Pipe Test I Top Out //-'4/-57 _ Furnace .f 9 //—Li 5-7 /2/03 1.---- Gas Gas Vents System I,/-9N- .2_//- /,2,I-,/.f ✓ Rough Plumbing `� if:nig ni //-if-57 /S2/Al ✓ _ Cesspool Septic Tank ,,,, Prop. Swr. Ling,. House Coir St. Swr. 0 t)/y-� 5e.j-- 1. 1-13(1 rl I S O i7 Sprinkling System r I Heating Final 4/HS/HMS 2--/Y-Sr t X/UJ Plumbing Fixtures, FinalMS .-iNS- P' F Gas Test /e- M AM"1-/w--rfri 1 / C1...truction Pole ,` / Underground Power rr''-� q Rough Wiring 71j�'f /2-(p_1 I0 &Lk r&4-. d� Co. ft-as---5-7 :5 773 — l Fixtures, Final 7r id-V ' U OCCUPANCY MIfS j^/Y-Srl Form 210-5M-1-51 5946 -OWNER REMMFNDINGER, Richard - SOUDER, Morris & MarieDATE 1141-57 JOB ADDRESS 165 E. 21st St. BUILDING PERMIT NO. 5945 GE ERAL CONTRACTOR Romar Bldrs. VALUE $ 9,264.00 IP.No. LOT 242 TRACT Ih.FIRE ZONE DESCRIPTION OP WORK Residence with att. war. COUP I & J TYPE V ZONE R4 PLAN NO. 5946 I..-PECTIONS DATE SUBCONTRACTOR PERMITS ISSUED -� DATE NUMBER Trenches Forms Steel r,Li-^f-1�Z'�." Floor System 11.1Steel Reinforce Chimney Re-Rod ,fl Bond Beam • :. EilariZg •rt Frame and Flashin, �• ' .1®ry �[r MEM. Lathing, In 1- ? Out '•-L--j--2 -6 IMMINAIMMII n Plaster, browcoat di </ Underground soil/W4, W/G Pipe Test I Top Out II`-°t I Furnace nillnInjN-/ - / bt/C r ✓ Gas Kenes S stem, ir „ --. 25- ✓ Rough Plumbing _ 1 -�_ �_ - -jr /SINES i Cesspool Septic Tank �� a - 1 Prop. Swr. Line House Con.L St. Swr._ �Jt miung .�flin 13 0 Mr A Sprinkling System Mal MMINIMIltabir Heating Final _ MBMW —w P bin. Fixtures Final • -/ -,56 MISIIIIIC Gas Test / T Al hi .-/d.q if Construction 'ole , nritna, Underground Power --MIl'tt (' Rough Wiring - - -., C1. . - -i _.ec . r'�I►7I�' Fixtures, Final - �_ �./�,' OCCUPANCY kiht-S 2-/y- • — Form 210-5M-1-57 59,lq 5946 - FEE RECEIVED . _ !COSTA MESA BUILDING DEPARTMENT it_ 24 —' P.O.AFINANCE DEPT. 4 COSTA MESA,. CALIFORNIAL T MESA FOR APPLICANT TO FILL IN APECIRCIRTgf N FOR PERMIT AD BUIDRESLDINS /(oG �erg ...2/ sr sr BUILDING COSTA MESA, CALIFORNIA FOR OFFICE USE ONLY RECEIPT NO. I]• ND. OWNERRichard Heffinendinger-Morris@M: is Souder (��'•U MAIL RECEIVED BY DATE RECEIVED O JE 5V i ADDRESS 2510 Westmini seer Ave_-Min • :#c n--r' /D '� "7 � 5 TEL. BUILDING /) ,Z CITY CnstA MASA NO.T.T R-P33S ADDRESS ! c ."2.-/ - ARCHITECT LIC. OR ENGINEER No. COSTA MESA. CALIFORNIA FIRE ADD,....S ZONE CITY LIC. AI--rar / I CONTRACTOR 22nn is C - NO.• •� ADDRESS 2430 Newp Or Blvd. •NO T__�9. • �� 'LEGAL LOT • CORRECTIONS DESCRIPTION NO.O242 BLOCK T-A y/ • . I, • / /) A.P.NO. // -_O ('6 -/ 7 111111.71;iiL(13!! SIZE1i a f.r NO.OFBLOT OFLOT / , NOWONLOT aOF ye` i,er • I EXSISETING BLDG. / ' .i rl. y W ` U la SETBACK LINE FROMI - ^) i 1p -�� CENTER OF STREET 4� REAR YARD ✓ SUB ■ -�'I i ,111 SIDE YARD RIGHT LEFT :nitO DESCRIPTION OF WORK NEW X.ALTERATION ADDITION REPA... MOVING DEMOLISH BUILDING/ NO.OF / SIZE / Q ROOMS 6 STORIES EXTERIOR WALL RODE /,�/ COVERING COVERING /( USE OF NE "`---TTT / ' / BUILDING - c • • •1I t ; • • • :.ii_.4t. 3�__ ?gee J.' a•u;¢.U!¢ ,Ii:u.0 dI,Qb.e;(_.k. gr. •5ili. . :Y.: A1 02. o .' I HEREBY FCKNOW LEDGE THAT 1 VE READ THISAttI CATION AIS STATE THAT THE ABOVE IS y.�.II•ECT AND AGREE TO COMPLY WITH ALL TCITY ION.ORDINANCES A D >.1110. 5 GULATIN BUILDING CONSTRUC- TION. VALUATION -/- PERMIT FEE S PIGNATOR= O' /� r• PERMITTEE t a ✓[.(,�cr lll!!!��- ��- PLAN CHECK S /0? fi AUTHORIZED AGENT TOTAL FEE 5 3 6 — "i'"• . C .. 5948 FEE RECEIVED COSTA MESA BUILDING DEPARTMENT P.O. BOX FINANCE DEPT. 31] COSTA MESA, CALIFORNIA �ITy OF COSTA MESA FOR APPLICANT TO FILL IN APPLICATION FOR PERMIT ABUILDINGDDRESS ASA.F' 2/ ,�TS,T B U I LD I N G COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY RECEIPT NO. MIT N OWNER Richard Hemmendinger-Morris & Masie Souder y MAIL RECEIVED BY DATE RECEIVED DATE SSU ADDRESST2510 Westminiater Ave. -T7o/, coo PrP-J7 //�// .i J , CITY �O Sia Mesa TNE.O. G AID)Da-RDE IS$G /V / r 27" LI 8-£?33 ARCHITECT LIC. COSTA MESA. CALIFORNIA OR 'INEER NO. FIRE 3 ADDRESS ZONE "NC NO.OF TYPE GROVP Builders' LIC. PLANS ff'_ �/ CONTRACTOR��iiROmar Builders' NO. 6338 / v P ADORE5�4r,JO Newport Blvd. NO. 8-938E BY Om.,IA /"GATE // 5 LEGAL LOT ��^^�� ``QR /// DESCRIPTION NO. 2 BLOCK // �T RR/AL-977 % A.P.NO. J / 8" _.�. D & ! ^ / / --// APPROVED I SRE 'tip B OF LOT / 3 x 3a))�,f NOWNO.OF ON LOTLDGS. CITY OF COSTA MI:.T USE OF PL ` (� V1 : EXISTING BLDG. SUBJECT ,. I�40-A.i t • SETBACK LINE FROM CENTER OF STREET /1` REAR YARD/O �i/ Y' (� SIDE YARD RIGHT LEFT 77 RY -6, Ong /_ �� DESCRIPTION OF WORK rtt,li. NEV XII ALTERATION ADDITION REPAIR IryAI MOVING DEMOLISH BUILDING 767 NO.OF SIZE (J (J 2„.... NO. STORIES /1 EXTERIOR WALL ROOF COVERING rtrttt,Cc ) COVERING . USE OF N BUILDINGEW 1 Two Bedroom Dwelling with 12 x 20 Att. Garage A I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE �A. CT AND AGREE TO COMPLY WITH ALL CITY ORDINANCE$ O A��y .ULATING BUILDING CONSTRUC- ' TION. / VALUATION ��Z` ., / PERMIT FEE $ O SIGNATUR% OF PERMITTE _ _ �f/-� C`� / (o — PLAN CHECK $ Q S l AUTHORIZED AGENT TOTAL FEE 5 3 o ...' OWNER _JEANES/JACOBY DATE 8-25-72 JOB ADDRESS 165 East 21st Street BUILDING PERMIT.NO. 35244 _GENERAL CONTRACTOR Atlas Bldrs. DESCRIPTION of WORK Res. , Att. gar. & stor. fu. \,.3,,, lo. 118-066-21-jT par 242 TRACT FIRE ZONE VALUE $ 16,800,00 r\ INaPECTIONS Si nature I Date GROUP I & J TYPE 5 ZONE R2 � t� N SOIL /` ' 17/2'7 SUBCONTRACTOR - PERMITS ISSUED I� GAS "Sr' J /%577 i Date Number I Signature WATER /J ♦ / J IShiir* ROUGH PLUMBING •N. PROP. SWR. LINE HOUSE CON: eslut SPRINKLING SYSTEM MISCELLANEOUS ROUGH HEATING AND AIR CONDITIONING [4r.. t o/fcf7 ' TEMPORARY SERVICE OR POLE UNDERGROUND 0 POWER ❑ ROUGH WIRINGa e t-'7' ,I//� He;tin• and Vent._ _ TRENCHES fl FORMS ❑ STEEL REINF. r;,% • - L' I ��1 / .3Q3 Pr EM FLOOREAM I. '3'' /, �, � BOND BEAM � STEEL REINFORCE SHEATHING FRAME AND FLASHIN ,jkp� /y„02 d -2.- .y LATHING - IN OUT I,��/A "Cet�Z4-�J✓!./ P. -STER. BROWN COAT TA -e /. -9- 7 RURAL, FINAL L /nJ .yF 1yQ�`trig HEATING, VENT., REFRIG. AND A.C.. FINAL /C / Z/�//y/'7z 17�, YY/J d,- /O/•f' gre 7.R PLUMBING, FINAL AND GAS TEST n /fT'//p Z•' 7L ••77c /{/,J^-`/tL(/. /Ol/ 7/7,x( `,1I7/3 ELECTRIC, FINAL 6 J' 2- 7 BUILDING, FINAL .. •A I /r Z'//-7 I I • 35244 u; 25-77Pai8 I 001797* ****98.68 C195' COSTA MESA BUILDING-SAFETY DEPARTMENT •P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 APPLICATION FOR BUILDING PERMIT For Applicant to Fill in Completely RE BV D° PRECIVED E ISSUED BUADILDING DRESS %GSfid /`fir Sr i F, 7 �1Z.T-y�2 // Q'O GC- 1-/• L PC7 t7 nO7,/ OWNER 1r77/1/C'S /lA-GO/3 Y A.P.NO. MAIL f��T BUILDING 1SIS C. aI s.rS-- AODRESSZOO �• /5.4.4_4V ADDRESS y� Zw ill /AJ�/ /� r� 12 al BLOCK CLO CITY'/(/Lz✓•oui[.T iSc•7Fc R/ NO.6.7.;'4.3/ TRACT LOT Z2 Q CONSTRUCTION �� / ADD I ALTER REPAIIIMOVING DEMOLISH O N LENDER - BRANCH OWNER .M _1 E.A sy f-ic/ J � 7 QADDRESS P..1✓S IbGNCC 0�t'`J) ALUE/� //J ARCHITECT __ TEL. USE Ar'T T r.Att..AC PCT /K ('`/f 1 `t OR ENGINEER N . O V) Q FIRE • �/y WCC ADDRESS — ZONE TVP ROVP [/ p-W �Q APPRO BSD '�/r JO CONTRACTOR .4.et3 /Sc.,/c_.0 C`.ts BY ✓ C�414/iC °Ae-- i/1„/ CO J cc ADDRESS -2. 4 3 2 / Cw Pc.).t T,SL-do W W ZONE NO.OF USE OF NEW OS)OknGt- O r COTR Ater TEL. 'nit r pLANS z BUILDING z� CITY C� /-/c.�� NO. 9'¢ ¢3 h� iJ,19 JT 6ACiE N0 STATE .., ..../n CITY �/•• YARDS APPROVED YARDS APPROVED CC LIC. NO.2./? -7.--r-r- LIC. NO. Ni c r•- MAIN BUILDING ACCESSORY BUILDING r 0 t (FROM C/L STREET)SIZE OF LOT //3 x 340. /.1C INOW ON LONO.OF BLS G FROM �p 3� FT. d-y4.L71 FT. USE OF EXISTING BLDG. .FdS/.o civ G '--' R SIDE 5 FT. FT. I- SIZE OFNO.OF ' � Z NEW BLDG. 1 /t 007 ROOMS g- STORIES L.SIDE �� FT. FT. Q EXTERIOR WALL ROOF V_ COVERING 57-U0 CO COVERING gO CM.• REAR 5S1--FT. FT. J USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. ...-)a_ BET.MAIN& i MAIN BLDGS. * ACCESS.BLDGS. . • VAR.# DATE 0 e-s I /J c-N �d t •/TI G /L-/z cC.U.P.# APPROVED I- APPROVED ,I (�3 U) s7-0 of.../�-Ce P..d-a ... . ,. AP_EtY W L.L) DATE V/�'�r ZO SIP, b 7�'1a I hereby acknowledge that I have read this application and state SPECIAL \fr. �a ( e Dthat the above information is correct and agree to comply with %i1 xEcIAL / ' CC all laws regulating building construction, and I shall not employ W 1"V I- any person in violation of the workman's compensation laws of j h the State of California. Z , /VC �4-� m [/� to z I hereby certify that I am properly licensed as a contractor under OO SQ. FT. ) o the State of California Business and Professions Code, Division 3. THE AMOUNT SHOWN UNDER VALUATION IS FOR 5 Chapter 9. and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: li am exempt from the provisions of the State of California Business VALUATION i� and Professions C dej Division 3,Cha ter 9. m ..4-..$ / c S / .YO -9ERMIT"FEE -$ D Signature of _ U 1 f/rp:� 5� E Permittee . / $/ PLAN CHECK $� `o Authorized Agent TOTAL FEE $9 �// u" UWNtN .12.13/411b, MID. UAIt o-I-I`t JOB ADDRESS 165 B. 21st St. BUILDING PERMIT NO. 38515 GENERAL CONTRACTOR 'te Go•' uys DESCRIPTION of WORK `=t o Cover A' lo. 118-062-22 LOT TRACT FIRE ZONE VALUE $200.00 II £CTIONS Signature Date TYPE V GROUP J ZONE R2 soIL PERMITS ISSUED GAS SUBCONTRACTOR Date I Number I Signature WATER Plumbing ROUGH PLUMBING LJ PROP. SWR. LINE HOUSE CON. LI SPRINKLING SYSTEM MISCELLANEOUS ROUGH HEATING AND AIR CONDITIONING TEMPORARY SERVICE OR POLE UNDERGROUND Q POWER 0 ROUGH WIRINGRd �� Heating and Vent. TRENCHES ( � ID /] FORMS STEEL REINF. r FLOOR SYSTEM BOND BEAM I] STEEL REINFORCE in SHEATHING FRAME AND FLASHING LATHING - IN n OUT n PLASTER, BROWN COAT 'TURAL, FINAL Electric H. ,NG, VENT., REFRIG. AND A,C., FINAL PLUMBING. FINAL AND GAS TEST n ELECTRIC, FINAL BUILDING, FINAL Sei/-9e.--7L` A :IN -7-71c—Ht- L ***.id:5 00 soy 50 38515 • COSTA MESA BUILDING-SAFETY DEPARTMENT • P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 For Applicant to Fill in Completely APPLICATION FOR BUILDING PERMIT R ECF,IE{p�By'V/ DATEDECEIVED DATE ISSUED BUILDING /6SErs)/S'` 5freet C ff r / 77 x -7-75` ADDRESS OWNER grid, (-Tea"5- A.P. NO. / r 042- Z 2 PERMIT 515 MAIL (9/514' 5.±.. BUILDING ADDRESS /4 rr6Si ADDRESS 765 Zal . L U CITY CQsteSa TNOL64z4017 TRAC�� f?oT p2112. BLOCK 1-Z Z Q CONSTRUCTION NEW ADO ALTER REPAIR MOVING f1FMOLISH O y LENDER 2< am J D BRANCH �J n +G - CO OWNER /�,RS1. \ 44'S CADDRESS / {/, ////�� ) VALUE A/ ' J. ARCHITECT TEL. USE LQ'/I4 %oose- $ ,2 " OR ENGINEER N . N acFIRE W cc ADDRESS ZONE TYPE GROUP d LII /� APPROVED /JJJ////(rte// J Z CONTRACTOR T� C-ree,D 71 BY "✓"// DATE G _ ,- mZ •Jcc ADDRESS /y 2y,2_ IJi l sH r rte. W W ZONE NO.OFUSE OF NEW Cr r TEL PLANS �/f BUILDING douse_ Z1- CITY to 1A. AMA NO.(55(7JJ.x R.2. T L � U STATE [� CITV GG '2 YARDS APPROVED YARDS APPROVED N W LIC. NO. a��$�l l LIC. NO.(I��J ✓ MAIN BUILDING ACCESSORY BUILDING _ U SIZE "'lll NO.OF BLDGS. (FROM C/L SS�T//BEET OF LOT I NOW ON LOT FRONT aye FT. USE OF ,�^ jyli/f, ''p EXISTING BLDG. R SIDE �] FT. /(_ FT, I- SIZE OFNO.OF 2 NEW BLDG. IX / Z ROOMS STORIES L.SIDE 33 S. 7[1 FT. __ C.) EXTERIOR WALL ROOF 4- COVERING J COVERING REAR ct fl. L FT. J J USE OF BVAR.# DATE UILDING AND WORK TO BE PERFORMED DISTANCE BET he ,BET.MAIN& [/ nT �/ MAIN BLOC'S. ACCESS.BLOGS. 0 /`n/� er�rE Mj/Q Ci�_CU.P.# p,�� APPROVED I- 'I APPROVED f1'•� / 70 to ABY DATE {!/ _ 7 J Z 0 . $TA 1� V I hereby acknowledge that I have read this application and state p that the above information is correct and agree to comply with 7//ff CC all laws regulating building construction, and I shall not employ I- any person in violation of the workman's compensation laws of Nthe State of California. ,� / 50m z lC/ L/J 9 I hereby certify that I am properly licensed as a contractor under . FT. o the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: CC am exempt from the provisions ;the State of California Business VALUATION and Professions Cooe, Div n 3,Chapter 9 to (\�.� J //77 PERMIT FEE $ „� O 0Signature ot` // �t E Permittee/ t(�.` $ eaye PLAN CHECK $ r Authorized/Agent u TOTAL FEE $