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HomeMy WebLinkAbout169 21ST ST - Building Permits p5�MF CITY OF COSTA MESA 49 BUILDING DIVISION >:r ,,,' . r DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER J. his PERMIT `�o-.��ass B00-01365 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.BUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 169 21ST ST Status: ISSUED Suite: B Applied: 09/05/2000 Vicinity: UNIT B Issued: 09/05/2000 Parcel Number: 42619317 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 889 SQ FT SINGLE FAMILY RESIDENCE-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 2448.46(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 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 sect eed not be complete)1.44e pe 't is valued at one hundred dollars($100)or less.) certify that in the perform:• : of th= •rk 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 of ,Ija ;ores that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these• •vis'• /J /� Applicant Signature:' T / . der WARNING:FAILURE TO SECU-E W• • R COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE(St00.•'•),IN AODR• TO THE COST OFCOMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060F THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm thatlam.licensed under provis• -• : commencing with Section 7000)of Division 3 of.the.Business d Professions Code,and my license is in full force and effect,Lf,1c. • a' "SW—al (Class a /7 Contractors Signature:--- ; (Date` f S–� CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction . .ing 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).): 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 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 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,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 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? IJ 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 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 Califomia Health and Safety Code Section 42303 been made? 0 Yes 0 No certificate of co mp.i..c...o.. e... 8 (If'yes",attach cartificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penally 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 AUTHORIZATION 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 stat: . s. nd city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspec •,•. es.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. I•• ur: e. • s) cifate •rite. uthorized Applicant _ - - -- f Date CODE F INSPECTION TYPE PAIL EIU1ALS POPE. INSPECTIONTYPF DAN IM136L6 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 T D7i 4.74 y 250 Final Building/Occupancy • • ' ' p CITY OF COSTA MESA 4 011ILMBUILDING DIVISION - j � DEVELOPMENT SERVICES DEPARTMENT P MIT NUMBER f jos PERMIT !' '`� B00-00985 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa. �LDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 'BUJob Address: 169 21ST ST Status: ISSUED Suite: B Applied: 06/30/2000 Vicinity: UNIT B Issued: 11/22/2000 Parcel Number: 42619317 Zoning: Applicant: JONES, CLIFTON ISSUED BY: Address: 10945 SOUTH ST#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 : WILKINSON ASSOCIATES Eng: STRUCTURES WEST Address: 17932 SKYPARK CI#A Address: 3430 E FLAMINGO RD#240 Phone: (949)852-8596 Phone: (702)435-1307 IRVINE,CA LAS VEGAS, NEVADA Zip: 92614 License: 89121 License: SCOPE OF PERMIT CONSTRUCT NEW TWO-STORY SINGLE FAMILY RESIDENCE WITH ATTACHED GARAGE FOR"INFINITY HOMES"(UNIT B) -1080 SQ FT 1ST FLR, 1075 SQ FT 2ND FLR,&424 SQ FT GARAGE.ALSO,44 SQ FT FRONT&REAR PORCH. FEE SUMMARY Plan Check: $991.74 Calc Valuation: $194,545.78 Permit: $1,525.75 Claim Valuation: so.00 SMIP Res: $19.46 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $2,536.95 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) / Ed XPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandone 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(600) 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 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: (Thi action need not be completed'� itis valued at one hundred dollars($100)or less.) I certify that In the pert• - .p44 ' ork for which this permit Is issued,I shall not employ any person in any manner so as to become subject to the workers' 'pensatlon laws• al f0,073 gree that should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply.with thes- •rout /A-27 _'c✓ I (Applicant Signature: 4 K. /L.Zi • r _Date: �C/ 1 WARNING:FAILURE TO SECU- WO•v��• 'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL' ENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,..n,IN A•sr ION 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 afirm.t.Uc.#m.licen a u et.prpviyons ofr r g • mencing with Section 7000)of Division 3 of the A-.—. Slid Professions Code,and my license Is In full force and effect.Lie.ft o�6�� klass p-- - ContractoYsSigneture:"- - l D< ate:Cr—It,Z r(fZJ 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 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 properly,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 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 fNe(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? ❑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? ❑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? ❑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? Yes INo (Section 65850.2 of the Califomia 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? ❑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 AUTHORIZATION 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 laws .•• '1 ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection p I a•ree not to occupy or allow occupancy of any building authorized by this permit until final inspection. :gnat ' egal O mer(s Date - � - /7-2 0--cJ n• •r Aulho. -• ••ptican Data POE/ INSPECTION TYPE PASE INTITIAL$ CODE! INSPECTION TYPE PATE REELS 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 250 Final Building/Occupancy C r . . . 3603. NEWPORT-MESA UNIFIED SCHOOL DISTRICT CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES PURSUANT TO AB 1600 AND AB 181 To: ( X) City of Costa Mesa District Receipt No. ( ) City of Newport Beach ( ) County of Orange Plan Check No.00-00985 INFINITY HOMES COSTA MESA Applicant: Address: 10945 SOUTH STREET STE 301, CERRITOS, CA 90703 Telephone Number: 562/ 924-4491 Tract/Parcel and Lot Number(s): TRACT 15995 Location of Project: 169 EAST 21st ST UNIT B , COSTA MESA, CA Number of Square Feet of: Residential Space 1266 SF x $1.84 Total $2329.44 .Commercial and Industrial Space x $ .30 Total Commercial/Industrial Project is: (Check One) Warehouse _ Motel _ Preschool R & D _ Bank _ Auto Repair Movie Theater _ Neighborhood Shops _ Hospital Mini-storage Racquet/Health _ Large Office Heavy Industrial _ Hotel _ Office Bldg. Regional Shops _ Medical Office _ Restaurant Light Industrial _ Office Park _ Fast Food This project is exempt because (his certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Government Code sections 53080 and 65995. The Building Permits for this square footage in this proposed development may now be issued by your jurisdiction. Checks are to be made payable to Newport-Mesa Unified School District. By: BONNIE KUBOTA Authorized Representative The above representation as to square footage is true. Applicant agrees"i at ' later determined that such representations are not true,then this certificate shall automatically terminate and the appro& City/C.unty shall be notified. NOV 22 2888/2:82 PM/1 21671.52 RCPT11:81-8069230 2 - Date: /,2 t' e� 112345 ROBIN B. HAMERS 224 E. 17TH St. SUITE 205 & ASSOCIATES, INC. COSTA MESA. CA 92927 CIVIL ENGINEERS • PLANNERS • SURVEYORS (949)545-1192 FAX(949)549-5516 December 21, 2000 City of Costa Mesa Building Dept. 77 Fair Drive Costa Mesa, CA 92628 RE: 169B 21st. St., Costa Mesa Lot 2, Tract No. 15969 Attention: City Building Inspector This letter is to certify that the foundation forms were surveyed for line and grade on December 18, 2000, and are in substantial conformance with the approved grading plan and site plan for the above project. �/ Qsof ESS/04/4 Robin B Hamers 0:' Cg�N B. Hq�‘,53 c2 R.C.E. 31720 fit' cm RCE31720 D cc. Infinity Homes EXP. 12/31/2004 F OF C AL1�il . ®Printed on Recycled Paper. FINAL GRAZING CERTIFICATION Project Address: 169 21st Street Costa Mesa Lot Number: B • Permit Number: G00-00026 By Civil Engineer: I certify to the satisfactory completion of grading in accordance with the approved plans, specifications, local and state codes. All drainage devices required by the grading permit, grading plan and grading ordinance have been installed. Adequate provisions have been made . for drainage of surface water from each building site. • The minimums are: 2% Fall from structures within 5 feet from exterior walls. 1% Fall for asphalt surfaces and landscaped areas. 0.5% Fall for concrete surfaces to approved disposal areas. The final monuments as shown on the recorded tract map were set. All final grading eleva- tions are within ± 1/10 of the deli a elevations. Supervising Civil Engineer Reg. No. 31720 (Signature) Date 11/19/01 COQ p,of ESS/C4,9! SrczpeS1 B*11411€p lj€p FSG) cc ' 20 rn E „ 17 yam r} ' 4r CIVIL P • T9lFCf CAIIF���\ S'EN.IP and SIGN 8?144 INSULATION CER1 Lr'ICATE IC-1 169-B 21st Street • Costa Mesa Number and Street City Orange Amber Way-#15969 B County Subdivision Lot Number Description of Installation I. ROOF Material Brand Name Thickness(inches) Thermal Resistance(R-Value) 2. CEILING Batt or Blanket Type Batts Brand Name Certainteed Thickness (inches) 10" Thermal Resistance (R-Value) R-30 Loose Fill Type Brand Contractor's min installed weight/ft2 lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance (R-Value) 3. EXTERIOR WALL Frame Type A. Cavity Insulation Material Fiberglass Brand Name Certainteed Thickness(inches) 3 1 /2" Thermal Resistance(R-Value) R_1 B . Exterior Foam Sheathing Material Brand Name Thickness (inches) Thermal Resistance(R-Value) 4. RAISED FLOOR Material Fiberglass Brand Name Certainteed Thickness (inches) 6 1 /4" Thermal Resistance(R-Value) R-1 q 5. SLAB FLOOR/PERIMETER • Material Brand Name Thickness(inches) Thermal Resistance(R-Value) Perimeter Insulation Depth(inches) 6. FOUNDATION WALL Material Brand Name Thickness (inches) Thermal Resistance (R-Value) Declaration I hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficiency Sia .,rds for residential buildings(Title 24, Part 6,California Code of Regulations)as indicated on the Certificate ofCompl •n e, wh rJ- .plic.ble. 04. _%li- Sirs 26/01 OJ Inc ulatinn en Item #s ignature, Date 1 Installing Subcontractor(Co.Name)OR r^� General Contractor(Co. Name)OR Owner Item#s Signature, Date Installing Subcontractor(Co. Name)OR General Contractor(Co.Name)OR Owner Item #s Signature, Date Installing Subcontractor(Co. Name)OR General Contractor(Co.Name)OR Owner Revised March 1, 1996 5111 M CITY OF COSTA MESA \,._ . 4, q BUILDING DIVISION f •�,. t ,r DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 4. 111”i; . PERMIT M01-00168 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No B Applied: 04/02/2001 Issued: 04/02/2001 Vicinity: ��/�,�/�A Parcel Number: 42619317 ISSUED BY: l Applicant: RENZ, RUSS i, - VV\ Address: �'. ��� Phone: 714-577-0771 / ,' i </; • Zip: - ; Owner: //INFINITY-HOMES pm I, LLC • Address:' \CLIFTON'JONES III -' , CERRITOS,CA, Phone: 562 924 4491 i, , 10945 SOUTH STREET,#301 Zip: 90703 � % \.. • Contractor:-_,/SENTRY MECHANICAL, INC. : �� / Address: ' 540 S'JEFFERSON - . CA- - v-Phone: 714-577-0771 - - , `• i PLACENTIA,CA;- , -- Zip: 92870 - , License:631049 • SCOPE OF PERMIT ,\ INSTAL HEATING AND AIR CONDITIONING IN NEW SFR. / , REF:B00-00985.CONTRACTOR IS DOING HEATING AND AIR CONDITIONING ONLY. FEE SUMMARY . < -- - Quantity : - - Quantity-) ISSUE FEE $23.50 -- - - - . Repair/Alt Absorbtion Unit -; ,$0.00 0 . ' Inst FAU"<100 k-BTU ' $0.00. '•0 - •-- ' Repair/Alt Refrigeration Unit % I$0.00 _ 0; Inst FAU>100 k BTU, - $18.20 1 Ventillation System $0.00 0 , ,' ' Repair!Alt Cooling/Heat $0.00. 0 Evaporative Cooler 7 ' $0.00 ;0 �,.: f Inst/Rep. Recess Wall Htr $0.00 0 Commercial Incinerator ,; $0.00.,,0 / Refrig SO<100 k BTU $0.00 0 Domestic Incinerator ///' / '$0,00' 0-,(, / Refrig Sys>100 k-BTU) $0.00 0 - - •-Compressors/Absorption Systems ';'///' i / Gas Piping , / H ' $0.00 0 - Up-to3 hp/100 k BTU `L'/ `woo '0 Factory Fireplace . $0.00 0 -- 3 To"15 hp/500 k BTU .'.% / $0.00 / 0/ Hood w/Mech,Exhaust, ' �� / -$0.00 0 , - 15 To 30 hp/-1,000,k BTU /`i '-,$0.00//b 0' VAV Box /,`� �� \-:-$0S10.,-1-0-‘.,_ 30 To 50 hp/1,780 kBTU •/ H Moor)/0 Vent Fan/Slagle Duct / g $0:00 0 /� Over 50 hp/Over 1 750 BTU! ! $0.00 0 Appliance �c� <777 $0:000,3 ( - • ,Boilers � �� Fire Dampers -$0.00\0��; - Up to 3 hp /� (-2, : j,$0.00 0 Smoke Dampers /�, ,$000-� 0V- `� - , 3 To15hp=-- - ,�\/:,, '$27.15 1 Inst or Relocate Appl Vent-N-7\ �-$0-00---,NO, - ,� 15,10-30 hp "T,A _ 'I..> /,1,7/ $0.00 0 Air Handlers< 10000cfmN, $0.00 0 - 30 to 50 hp - - .- $0.00 0 J/ Air Handlers> 10000cfm \.„,„.\-----"%H.$13‘.06" /0,, Over 50 hp %, ,\ \', �" �j G $0.00 0 Floor Furnace /$0.00 •0 ,- , ' - '-'- Other Mechanical Fee . ,�. Floor or Suspend Heater -$0.00 ,0, - - Investigation Fee-" j / $0.00 . _ - - Plan Check Fee " ' $0.00 Reinspection.Fee'— $0.00 . __-- - TOTAL CALCULATED FEES $68.85 COMMENTS/SPECIAL CONDITIONS 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(6/00) v 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 _work for which this permit is issued. Q—f 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 wo ers'c enation Insurarllc9 carrier and policy number are;, _ _Carrier: ✓1 1 Yt Suva h C QLc--- K C- Pol c Number:.--A) C C.)10 -10o - 00 (Thissedtion need not Completed if the permit is valued at one hundred dollars($100)or less.) O 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 to become subject to the workers' compensation I:.s of California nd:•re: t if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with t e ep :visions. - ApplicantSignature:-_ .-Air . i`11�� ba-- y- -3.-O WARNING:FAILURE TO SECURE WORKERS'CO -ENSATION COV -'GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TOTHE 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 thai-l•am licensed underrfpr isions of Chapter 9(commencing with Section 7000)of Division 3 of.the Business and Professions Code,and my license Is in full force and effect..Licrtt )/, /n y !`51( //�(�� (-Class# "l - 7 0 Contractors SignatiJi•eF( ; 'J`l �{ �''p Th '^ _ Date:-----e:--....-L j..3 _cr ) _ CONSTRUCTION LENDING AGENCY: x r \' - O 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). 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).): 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 property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). O 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: ❑ 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 Califomia 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 ❑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 a,p_ermit 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 u 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 ❑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? 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 AND AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Of Legal Owner(s) Date (/P"mrAuthodz:i. •pplicant• • - LDate . _ CODE it INSPECTION TYPE DACE' INTITIALS CODE It INSPECTION TYPE: /� PAIS rtL 1616 Fixed System Final Fire Prevention 206 Final Mechanical I el`t`04 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 250 Final Building/Occupancy 9 CITY OF COSTA MESA ._�' 4 • • BUILDING DIVISION > • tourdeongt ,0 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER J PERMIT '►b,Me.fi` P00-00667 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No B Applied: 12/01/2000 Issued: 12/01/2000 Vicinity: UNIT B Parcel Nunmber: 42619317 ISSUED BY: ' Applicant: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 License: 317026 Arch / Eng : Address: Phone: Zip: License: SCOPE OF PERMIT PLUMBING PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT B). INSTALL 2 BATHTUBS, 1 DISHWASHER, 1 EXPANSION TANK,5 GAS OUTLETS, 1 WASHER, 1 PRESSURE REGULATOR, 1 SHOWER, 1 KITCHEN SINK, UP TO 4 VACUUM BREAKERS,4 WASH BASINS,3 WATER CLOSETS,&1 WATER HEATER. REF:B00-00985 FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $9.80 1 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $19.60 2 Pressure Regulator $9.80 1 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $12.30 1 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $39.20 4 Dishwasher $9.80 1 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $29.40 3 Drain, Roof $0.00 0 Shower $9.80 1 Water Heater/vent $12.30 1 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $9.80 1 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $6.15 1 Sink, kitchen $9.80 1 Water Softener $0.00 0 Gas(Over 4 outlets) $1.10 1 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $202.35 NOTICE: The work authorized by this permit sGGOMMEJ'fliS kaRECciAle QGNJ *TAQWS 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 .7 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(6/00) 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 workfor.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: r LCarrier._Q rJ`�t L-= cy Numbe_r_ i T-I L.r (This section need not be completed it the permit is valued at one hundred dollars($100)or less.) ❑ 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 to become subject to the workers' compensation laws of Califomia and agree that If I ould become subject to the workers'compensation provisions of S ction 700 of the Labor Code,I shall forthwith comply with these•rov'-ions. C., / Applicant Signature:_ A .L d• ' _ .2 L_Date: /1/ no WARNING:FAILURE TO SECURE If KERS'•• TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRI INAL NALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS(5100,000),i ADDITION TO'. T OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060F THE LABOR ODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm Ihat.l.am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect - _ (Class a, Signature: - — (Date:— CONSTRUCTION LENDING A 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). 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 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 ere 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,end who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). O 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,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? ❑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? ❑Yes ❑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? U Yes U No (Section 65850.2 of the California Govemment 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? ❑Yes ❑No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........... it 7 If a permit from the South Coast res Qualityced Management District or other airtpollution ooncontrol district03 or agencyIS 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 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 AND AUTHORIZATION 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. - �Si natur iLegal Owner(s) /7/�k Date /A) n r'Authodzed Applicant - L U `Date _ r// ;ODE P r nl•.TYP. ME INTRIAL$ ;ODES INSPECTION TYPE WI MOM/ 1616 Fixed System Final Fire Prevention _ 206 Final Mechanical �x /� 1266 Pool Spa Final 208 Final Plumbing ID`t,-or U N 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 250 Final Building/Occupancy 44 p5111 MF 9 CITY OF COSTA MESA BUILDING DIVISION >w „ , DEVELOPMENT SERVICES DEPARTMENT P RMIT NUMBER 4. % PERMIT - E01-00331 (714)754-5273` 0•73� �• Fax(714)754-4856 • www.ci-costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No B Applied: 05/01/2001 Vicinity: UNIT B Issued: 05/01/2001 Parcel Nunmber: 42619317 Applicant: INGRAM, STEVEN ISSUED BY: Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: ELITE ELECTRIC Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 License: 418242 SCOPE OF PERMIT ELECTRICAL PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT B). INSTALL NEW ELECTRICAL THROUGHOUT RESIDENCE& 1 LIGHT,2 OUTLETS,& 1 SWITCH IN GARAGE- REF: B00-00985 ' FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $120.68 2155 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $1.10 1 up to 50 kva/kw 50.00 0 Recept Outlets $2.20 .2 up to 100 kva/kw $0.00 '-0 / ' Switches $1.10 1 over 100 kva/kw-' $0.00 0 . , Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 . Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 • Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 .0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $148.58 Intermed Pole $0.00 0 COMMENTS I SPECIAL CONDITIONS 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 y 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 peimit! FOR INSPECTIONS CALL: (714)754-5626 // 2446-48(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 __ ylmli 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: r -Carrier: 2 '['elicit-Number: l ,(T is section need not be completed if r•:permit is valued at one hundred dollars(3100)or less.) ... -- 4011 ❑ I certify that in the ped•,, anc k • : 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 • Cali Al C :gree come subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with Ihes. Drovisio•- ApplicantSignature: a es a-- -`Datei 1 /j`/ -- 0 I I,WARNINO:FAILURE TO SE •- WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND OVIL FINES UP TO ONE HUNDRED THOUSAND Drx m ARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Cha ter 9(commencing with Section 7000)of Division 3 o1 the Business and Professions Code,and my license Is in full force and effect.tc.a \ (Class 0 Contractors Signature: _ ,Date:-� r. / — 0 1 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,CMI 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 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 driver's 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: ❑ I hereby certify that no excavation five(5)or more feel 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 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 yoar 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). .._...___—__..__..__t..._— _ 3 Does or will the applicant or present or .ffuuture 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? ❑Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of thisapplication a ermit for such comodification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes Di 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). .....I.a permit __t....._...__uality__ —_ _.._ alit 7 Ifa a from the South Coast s Quality Management Californiaal or Sr epollution control 3i 3 or agency is required for the work which is the subject of this application,have all of the disclosures prescnbed by Celifoia Health and Safety Code Section 42303 been made? ❑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 AND AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for ins•rction purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. `��� .^"' Date _--��•_- r— i--0-(_ And/Or Authonzed Applicant ..... ',Date—' CODE INSPECTIONTYPE QAIE' VITAS CODE( INSPECmONTYPE QM _____ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing r 200 Final Re-Roof 210 Final Electrical 9-i 2. 201 Final Block/Retaining Weil 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval . 203 Final Sign 222 Final Site 204 Final Demolition - 250 Final Building/Occupancy C F 9 : CITY OF COSTA MESA . -- BUILDING DIVISION r - ).. ,,,,•. ,r $ DEVELOPMENT SERVICES DEPARTMENT PERM T NUMBER t 1 !s t1 PERMIT .4„aonso� M01-00208 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No B Applied: 04/24/2001 Issued: 04/24/2001 Vicinity: UNIT S Parcel Number: 42619317 ISSUED BY: Applicant: PETERS, RANDY Address: 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA Zip: 91702 Owner: INFINITY HOMES CM I, LLC Address: CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 ' Contractor . OJ INSULATION INC Address: 600 S VINCENT AVE " Phone: (626)812-6070 AZUSA,CA Zip: 91702 License:465709 SCOPE OF PERMIT INSTALL MECHANICAL FIREPLACE FOR NEW SINGLE FAMILY RESIDENCE(UNIT B). REF:B00-00985 • • FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00- 0 Repair/.Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 Inst/Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00. 0 Refrig Sys<100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems . Gas Piping $0.00 0 Up to 3 hp/100 k BTU . $0.00 0 Factory Fireplace $10.65 1 3 To 15 hp/500 k BTU $0.00 0 Hood w/Mech Exhaust $0.00 0 15 To 30 hp/1,000 k BTU $0.00 /0 VAV Box $0.00 0 30 To 50 hp/1,750 k BTU $0.00% 0 Vent Fan/Single Duct , ' $0.00 0 _ ' Over 50 hp/Over 1,750 BTU '50.00 0 Appliance , $0.00 '0 Boilers Fire Dampers ,50.00 0 - Up to 3 hp -- ,$0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers< 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers> 10000cfm - $0.00 0 Over 50 hp $0.00 0 Floor Furnace 10.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee 50.00 . Reinspection Fee $0.00 TOTAL CALCULATED FEES $34.15 COMMENTS I SPECIAL CONDITIONS • 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 expiratiortof this permit/ FOR INSPECTIONS CALL: (714)754-5626 2446-46(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 rk for which this permit is issued. '❑ thaw'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. L��My workers' ensatl nsurance carrier and policy number are: _,^ {map2 '(Trios: n�71LoIT 1Ar( �POIIcy Number D'�� l ,(This sect/on need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ 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 to become subject to the workers' compensation law alllom and ag that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply_with.the r spio 7. /` ApplicantSignature: c - Date: -G 7 '0/ WARNING:FAILURE TO SECURE O ERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5/00,000),IN ADDr1ON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that.l.a Ic/6n•:•under'to sions of Chapter 9(commencing with Section 7000)of Division 3 ol.the Bugine 5 and Pro •E Code.and my license Is in full force and effecf,tLIc.P� U I Classy C, Contractor's Signature. res /I�aa Dei:7 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,CMI 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 properly,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 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 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 e permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I 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 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 Safety Code been fully compiled 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 azermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agony? j�Yes 8 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 II 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 prescnbed by California Health and Safety Code Section 42303 been made? 0 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 AUTHORIZATION,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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nl f)wnar c` eel/'c7 a 9� ° And/Or Authorized Applicant-----1 Dates_ CODE# INSPECTION TYPE QhIE' INTIrIALS CQOEt INSPECTION TYPE gdIE MOMS 1618 Fixed System Final Fire Prevention 206 Final Mechanical 1268 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Well / ��j 212 Final Fire Prevention 202 Final Factory Fire Place (2.6.0/ tl N - 220 Final Planning Approval • 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy • CITY OF COSTA MESA 01"ut9 BUILDINGDIVISION )., 11 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us v. Ogroofi FOR INSPECTIONS CALL: (714)754-5626 PERMIT NUMBER: P11-00005 PERMIT TYPE PLUM STATUS: ISSUED APN: 42619317 DATE ISSUED: 01/14/2011 ISSUED BY: KJB JOB ADDRESS: 16 9`H"21ST S�T_CM""• " � Suite/Unit: H Vicinity: SCOPE OF WORK: WATER HEATER CHANGE OUT OWNER: MATYEAR,IAN Address: 169 E 21 ST ST PHONE: 949-646-3042 City/State/Zip: COSTA MESA,CA APPLICANT: ATANASOV,STOIL • Address: PHONE: 866-692-5273 City/State/zZip: CONTRACTOR: CALIFORNIA DELTA MECHANICAL INC License No. 811114 Address: 1235 GRAND AVENUE PHONE: 800-898-0008 City/State: SPRING VALLEY,CA ZipCode: 91977 CELL: 866-692-5273 ARCHITECT: License No. PHONE: ENGINEER: License No. PHONE: PLUMBING PERMIT FEE SUMMARY PLAN CHECK FEE: $0.00 PERMIT FEE: $35.80 TOTAL FEES: $35.80 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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE I. INSPECTION TYPE DATE INTRIALS CODED INSPECTION TYPE DATE INITi1ALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical -T 1266 Pool Spa Final 208 Final Plumbing f-2B 1rn 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 250 Final Building/Occupancy 1111 w WORKERS'COMPENSATION DECLARATION: Owner ID verified by driver's license. ❑Yes ❑No I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires: O I have and will maintain a certificate of consent to self-Insure for workers'. Verification of Ownership by(type of document,i.e.-property tax bill or deed): 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 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: permit is issued. My workers' compensation Insurance carrier and policy 0 I hereby certify that no excavation five(5)or more feet in depth into which a number are: .I}- person is required to descend,will be made in connection with work authorized S1-a I p /� by this permit,and that no building structure,scaffolding,falsework,or demolition Carrier u or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp (This section need not be completedd the permit is valued al one hundred dollars($100)or less) 2,Art 2,Sec.341,Title B,California Administrative Code). Policy Number: l 6 -1 7 g.23 0 As owner-builder, I will not employ anyone to do work which would O I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless issued. I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of Applicant's Signature Date the Labor Cod , shall orthwith comply with these provisions. Ii9 1/I Division of Industrial Safety Permit Number: A pllcant's Signature ate HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes ❑No ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST.AND exceptions. that a Business Plan be filed with the Costa Mesa Fire ATTORNEY'S FEES. 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 LICENSED CONTRACTORS DECLARATION: 500 pounds, or a volume of 55 gallons,or 200 cubic feet of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure). with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file my license is in full force and effect. a registration form for acutely hazardous materials? ❑Yes 0 No Lic.# 8 ( l I '17 Class# 3' (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by 7�L/('p�-q}}� each business which at any one time has on hand a quantity of acutely ontractor's Signature r-te 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 CONSTRUCTION LENDING AGENCY: temperature and pressure). ❑ 1 hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Lender's Address: 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. Signature Date 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑Yes ❑No I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. the work which is the subject of this application a permit for such construction Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? ❑Yes ❑ No issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Govemment Code requires that the requested That he or she is licensed pursuant to the provisions of the Contractors information be fumished on applications for ran-residential building permits). 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 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes ❑ No applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes", the facility must meet the requirement of Sections 25534 and 42303 five hundred dollars($500).): of the California Health and Safety Code). ❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the offered for sale(Sec.7044,Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? ❑Yes ❑ No thereon,and who does such work himself or herself or through his or her own 8 (If"yes", attach certificate of compliance from the appropriate air pollution employees, provided that such improvements are not intended or offered for control officer). 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 CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions. LICENSED CONTRACTORS to construct the project(Sec.7044.Business and Professions Code: The contractors License Law does not apply to an owner of Signature Date property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that 0 I am exempt under sec. the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig .0 re of L al Ownegs) Date Signature Date / '/ 3057-46(3107) 2/ A for Authorized Applicant Oat • f LI-aQ00S .'ciiij}triii: OI (:'i,n;pIi's;;::c: t_i;sidesriigi 1t'i.t' -itiRtirit "'.if-.l!).:.it.t •r .•f.r:,: -----_ Climate 2.onc: trate: i ..•:. . , ...r, -:n.r:m4•seed jar nitrrnlimr atadditionof renter hraltug.rLr[ems. V:,1'1'(;1; HEATING -- -- ----�-•_.___._._._. . :. .c.n,-, ilatocrs and boilers for both domestic hot water(DHI.1T)heaters and hydropic space heating. Individual dwelling. - •-. ur:crt be gas or propane fired, and mrry not exceed 50 gallons. Hot water pipe insulation from the DHifi heater is .nisi and on all underground hot waterpipes is required in all component packages in oll climate zones. - l ' Energy Factor or r1:dei-Id co ler Type/ Distribution Type Number of Tank Capacity Thermal External'Jai! f )tact types (Standard)' System (gal) Efficiency Insulation Y.-c:;i• '{ 1 Standard I'M-pp TO 6_ T�s 4 6z._ zlat_--- I '.-:::dr.::nc7)pe(Storage Gas,Heat Pump,In tanlaneouj eta) ----- f • 1 'tit dub tong siren serving multiple dwelling units shall meet the recirculation requirements of 150(n). The Prr✓eriptive requirement, C.,.f I.._ __ i a• , tria the illatatntian a(ncir1E hEa reeard11 )Vater riE alrStCHi far sine diV _.& hglunits 7'in-water boating tank andpiper shall be insulated to meet the requirements 07500. t nntrncurr(3ocunientation Author's I sponsible Designer's Declaration Statement) ,_ • t,:ufity that this Certificate of Compliance documentation is accurate and complete. { 1• I ameligible under Division 3 of the California Business andProfessions Code to accept.responsibility for the building design identified n;. ! tali:Certificate of Compliance. 2 ,:•:r t it)'that the energy features and performance specifications for the building design identified on this Certificate of Compliance concern- i.,tile',allurements of Title 24,Pads 1 and 6 of the California Code of Regulations. • I tic building design features identified on this Certificate of Compliance are consistent with the information led to document thts ! by lid'IT g design on the other applicable compliance forms,worksheets,calculations,"plana andafaceifiCaliadkifiZiritted to the aitbrcemenl I n;_rn se 1 gevfer ay roval with tbisbuildm; . ..'t•..litatiom. 4 tut., f 4g. ,.,1 ,. i Signature: �cj/ /f I' ' }.'California Delta Mechanical Date n„11/ig/ --___ "'! j •'I'i"'4`.!i056 E. Baseline Rd.,#155 License:Si 1114- —'--`--- I • ... :c,':irp-(xler . ti7. 85206 • Phene;c .692..557.3 hfamt+10-+:' • • I INSTALLATION CERTIFICATE CF-OR-M}X'H-01 Dv)mestieH0t Water(DHW) , (Page 1 oft) Site Address::/V ( r h/',/tL /f t:jrn;.ement .a Permit No rn her: 7V/ •///� Ci6 KJ� I. WATER HEATING SYSTEMS: Disuibution Rated CLC Type If 5 of ("Pm(kW Tank Standby Neater Certified Mfr Name&Model (Std.Point-of. Recirculation, Identical Or Volume Efficiency Loss Type Number Use,etc) Contra)Type Systems Bruila)t (gallons)/ (EF,R``E)t Tal (%)7 jeks 5�5b11Z6< / q16 9-1-61 ''� D 5.‘ S� D.6Z„ Note I:For small gas storage(rated input less than or equal to 75,000 Btu/hr), electric resistance and heat pump water heaters,list Energy Factor(EF). For large gas storage water heaters(rated input of greater than 75,000 lbu/hr), list Recovery Efficiency(RE), Thermal Efficiency,Standby Loss and Rated Input For instantaneous gas water heaters,list the Thermal Efficiency and Rated Input. 2. Mandatory Measures TO COMPLY - ALL BOXES MUST BE CHECKED §1104113: Water heaters,showerhead and faucets are certified by the California Energy Commission. §150(j): Water System Pipe and Tank Insulation. And Cooling Line Insulation `. Storage tank insulation A. Storage gas water heaters rated with an Energy Factor no greater than the federal minimal standard arc externally wrapped with insulation having an installed thermal resistance of P.-I2 or greater:and .t tri i iii :d•ituril_3 tanks er diner indirect nut water farlk9 ha... I!-:1 ';..,et1:.'ti i ti\:3li,ttem i:: R-tri iii::r ,.,. a 'o:ul:Pin2 'Ther:. 'be :n:::r....; i.. at:di:to V .d -. 'Nater piping and cooling system line n ulation thickness and conductivity 'Ns (-7;.., .'cit Otho( and cosi:;rater fuses clr:'i >t it `.vale-ifierier tart, Iicn-:ecireuiatin systolic..and entire e,t'v.ia It .' aI ei t• n ,'1 a �r_< :ire 1 tial i '•.: ill r t tin i ,fl f anti Pipe !rt uiai1cd. for.-ie n7 hvii hill heating systems or hilt water systems - I. psi,meets the reel irenlems of Standards Table 123-A. Insulation is protected from damage, including that due to sunlight, moisture, equipment maintenance,and wind. fi' §IS1(f)8D: If indicated on the CF-1R,all hot water piping that runs from the hot water source to the kitchen fixtures is insulated per Standards Table 150$. r 2008 Residential Compliance Forms August 2009 • I INSTALLATION CERTIFICATE CF-612-MECf1-01 Domestic Hot Water (DHW) (Page 2 of 2) Site A6dress: /t Ent'66-3-0, 3-0,ent. ency: i Permit Number: �/ 3. Central Water Heating in Buildings with Multiple Dwelling Units(required for prescriptive) ATO COMPLY - ALL BOXES MUST BE CHECKED . All hot water piping in main circulating loop is insulated to requirements of§150(j) (19 Central hot water systems serving six or fewer dwelling units which have(I)less than 25' of distribution piping outdoors;(2)zero distribution piping underground;(3)no recirculation pump;and(4)insulation on distribution \ _ piping that meets the requirements of Section 150(j) ?[5 Central hot water systems serving more than 6 dwelling units-presence of either a time control or a time/temperature control • • • DECLARATION STATEMENT • I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and correct. • 1 ant eligible under Division 3 of the Business:and Professions Code to accept responsibility for cdnstruci ion,or an authorized representative of the person responsible for construction(responsible person). .:>:iii:i!?pli�titi^Coil:':lnP�rao iatlia:i. ; ni+ iwoalaittn conAisiei?:',v;tlt 41+^ia:?i anti rneeitic '.:rs rrove.ih ;nnali ln:i. __pi; :.. • I (-viewed a copy ai the Certificate of Compliance(CT-IRI firm approved by ilrt enloreement agency that identines the specilla tcte.•;uiriarainic for thy. installation. t r ertift rIm:the rcq,irei enh detnilad .. rhos r'F!P. ha.apply toi i ,rs'a11.:fpm h avc been mei t wilt ensure that a completed,signed cop;of this installation Certificate;hall he pasted,pr made pva iiahie with the building permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand !tat a cig'red copy of Ih is Ims tailatioa Cer:itiesse is r:,rrairrd? to y. included :-nh the::orr:m:.,Ctntin:;iL. Earn(:kr pr::SJ,trc to the building owner at occupancy. i Company Nae: I Installing S ibconlractor or General f.ontractnr or RRudder/Owner)! — — -- i elIa /� i lQ/lefitI - Responsible Person's Name: r ResponsblePc n's i:nature: /1/ a r�+ j CSI,13I.icutse: � 1II Date Signed: t� Position With Corpanyl(Title): I � 7id/�V Per>rtP1 L10.Y• 2008 Residential Compliance Forms August 2009 S CITY OF COSTA MESA 4x010 BUILDING DIVISION Iw b,,' TA DEVELOPMENT SERVICES DEPARTMENT ERMIT NUMBER PERMIT omo.mso F00-00287 (714)754-5273 • Fax(714)754-4856 • www.ci.costa- FIREaSUPRESSION PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 169 21ST ST Status: ISSUED • Suite: G Applied: 11/02/2000 Vicinity: UNIT G Issued: 04/11/2001 Parcel Number: 42619317 Zoning: ISSUED BY: Hcf___ Applicant: MARTINEZ, MONA LISA Address: 1787 POMONA RD SUITES D&E Phone: (800)915-3473 CORONA,CA Zip: 91720 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor FIRE SPRINKLER SYSTEMS Address: 1787 POMONA RD SUITES D&E Phone: (800)915-3473 CORONA,CA Zip: 91720 License: 684600 SCOPE OF PERMIT FIRE SPRINKLER PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT G). INSTALL 26 FIRE SPRINKLER HEADS. REF: B00-00991 FEE SUMMARY Plan Check: $39.07 Calc Valuation: $1,700.00 Permit: $60.10 Claimed Valuation: $1,700.00, Other $0.00 Total: $99.17 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(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 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 carder raapd policy number are: Cartier: :�I ; Y1CJl Policy Numbef LO�-�-(.)L7 1241 I-t& (fXZX (This section need not be completed It the permit is lued at one hundred dollars(5100)or less.) ---- ❑ I certify that in the pertormance of the work 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 of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these p • '-ions. �_ Applicant Signature: BatUY i /A -- '—Date: -4/// WARNNO:.FAILURE TO SECURE W• f'COMPENSATION COVERA r5 UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE(S100,000),IN ADDITION TO THE COST OF COMP' .•110N,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: s I hereby affirm that I am Ilc¢nsed and prprovisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business§}id Pr I ss;ons Code,and my license is in full force and effect.1.1c:4- (1�L�t"lP ' _/ ) Class N C "I Contractors Signature: ,d// Date: '> 4I/;/0/ e 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). 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.). ❑ 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: ❑ 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,Califomia 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 end 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 end 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 requiretl.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 a ermit for such construction or modification from the South Coast Air Ouallty Management District or from any other air pollution control district or agency? Yes No (Section 65850.2 of the California Govemment 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 Califomia 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 Califomia Health and Safety Code Section 42303 been made? ❑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 COMPUANCE AND AUTHORIZATIONOF 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. x Sign tufa Of Le a�ner(s) Da a' /7 41-10/1 4/11 -O_ cAn Or Auth• ,•Applicant ate-/- ODE 0 INSPECTION TYPE TT INALOOD S E. INSPECTION TYPE RAN RII1Dd15 1616 Fixed System Final Fire Prevention I -b"d) W}\. 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 I'-12-0I ( 3 202 Final Factory Fire Place 220 Final Planning Approval . 203 Final Sign 222 Final Site 204 Final Demolition • 250 Final Building/Occupancy �� S CITY OF COSTA MESA 449 BUILDING DIVISION L $. ,r DEVELOPMENT SERVICES DEPARTMENT 1 /PERMIT NUMBER 1 •••r+. 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 ork for which this permit is issued. have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Cede,for the performance of the work for which this permit is issued. My worker 'co pensati nsuranca carrier and policy number are: 6��g -Carder: --- IV U( Policy.Number-1 -(This section need not be completed if the pppbbbrmit/s valued at one hundred dollars($1 00)or less.) ❑ 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 to become subject to the workers' compensation laws• -lifomia,a agree t t if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these ions. CApplicant Signature: -Date:--may WARNING:FAILURE TO SEC 'E WO 'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER O CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($10O,OW),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm thathaL a�Tlicf ��'/ji���ff yyn /pjTO°O(y' ions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Pr Ions Code,and my license is in full force and r -Sig atureJ !! �gesss b 5i2t' Cont ractorsSrlgn_ature: ,'/A� Date 54-70—eV 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). 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 toils 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).): ❑ 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 driver's 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,faisework,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? ❑Yes ❑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 0 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? ❑Yes ❑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 Duality Management District or from any other air pollution control district or agency? Yes 8 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? ❑Yes ❑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 AUTHORIZATION.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 com4ply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes,I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ion e Of Leal Owner(s) �7(�/,Da°te And/Or AutfiorizedApplica_t LDat�� CODE I INSPECTION TYPE CHIS' INTRIALS CODE I INSPECTIONTYPE LAZE INIRIALS 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 1-3,02— /�n N- 4' 220 Final Planning Approval 203 Final Sign •n fj-- 222 Final Site 204 Final Demolition • 250 Final Building/Occupancy CITY OF COSTA MESA 4 . ,►q@ BUILDING DIVISION >•4 ,,,,, r t.g DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER Fek t his lir PERMIT *Iberia re r n s 0#. / M01-00173 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No G Applied: 04/02/2001 Issued: 04/02/2001 Vicinity: ' Parcel Number 42619317 ISSUED BY: C - V Applicant: RENZ, RUSS , Address: - / Phone: 714-577-0771 - Zip: Owner 'INFINITY'HOMES CMI, LLC . Address:/ ,CLIFTON JONES III ' CERRITOS,CA, ' Phone: 562 924 4491 ' 10945 SOUTH STREET• ,#301 Zip: 90703 - � '. Contractor:-„ SENTRY MECHANICAL, INC. : - • Address: ' 540 S JEFFERSONr 1 CA -Phone: 714-577-0771 " PLACENTIA,CA Zip: 92870 . License:631049 - SCOPE OF PERMIT . ' ' INSTAL HEATING AND AIR CONDITIONING IN NEW SFR. 7 '\ 1 REF:800-00991.CONTRACTOR IS DOING HEATING AND AIR CONDITIONING ONLY. ' FEE SUMMARY Quantity - Quantity ISSUE FEE $23.50. - - --- - ' Repair/Alt Absorbtion Unit J $0.00 0• Inst F,AU <100 k BTU $0.00 "-0 - . - Repair/Alt Refrigeration Unit '' ' $0.00 Oi Inst AU>100 k BTU $18.20 1 Ventillation System ,//,' .$0.00 0 Repair/Alt Cooling/Heat $0.00. 0 Evaporative Cooler Inst/Rep.Recess:Wall Htr $0.00 0 Commercial Incinerator $0.00. 0 it Refri Sys<100 k BTU $0.00 0 Domestic Incinerator _ ' 9 Y •/4//� $0.00 / 0/ i Refrig'Sys>100 k-BTU $0.00 0 .. • - Compressors/Absorption Systems / e I / Gas Piping ',, i" - - $0.00 0 Up to3 hp/100 k BTU , '� -$0;00 ,'0 Factory Fireplace ` - $0.00 0 - , 3 To 15'hp/500 k BTU $0.00 /.0/ Hood w/Mech Exhaust, `. $0.00 0 - 15 To 30 hp/1,000k BTU '/ ,$0.00//' 0 VAV Box ,�v `‘,1:'$0 C 00. -0 • . ,.30 To 50 hp/1,7501(131/U' /71,/ • v $0.00:/ 0 Vent Fan/Single Duct � �� $0.00 ., 0 ' - >Over 50 hp/Over"4,750 BTU '- $0410 0 Appliance A, V/ $000. 0, Boilers %- � Fire Dampers ,,A ,./ , $0 00- 0. ; , ‘ Up to 3 hp .:.>7 /,$0:00 0 Smoke Dampers �:,., ,,///10.90,_- 0- 3 To 15 hp- , - 7 = 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 for which this permit is issued. y work r wilt maintain workers'compensation insurance,as be r ar by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My_workers' pensatlon Insuraose carrier and policy number are: Carrier:. Nr'N yr, N I h S (d v C C-C `-Lx (PolicyNumber: NIA-) C p! Q7QO —0 (This section need not be completed if the permit is valued at one hundred dollars($700)or less.) ❑ 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 to become subject to the workers' compensation I of Califoml and ggreet 'f I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,1 shall forthwith comply with th s p sions. ,� -Applicant Signature: \) (//� rDate: ('I I'\ I G WARNING:.FAILURE TO SECURE WORKERS'COATPENSATION RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED �TFIOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that am li n d under e r¢yision5 of Chapter 9(commencing with Section 7000)of Division 3 of the.Business and Professions Code,and my license is in full force and effec(Lic.q, / / 0 l '1 (Class a— !C — Zp Contractors-Signature:—ure:— - L6q->,�/V.,1��� 7t" (-Date_ 9 - % - 0 ( CONSTRUCTION LENDING AGENCY: O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,CMI Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT'FROy1 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�theq 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 7a�eo).): ❑ 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 property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). O 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 Drivers License No. Expires: Verification of Ownership by(type of document,I.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CffRTIFICATION: ❑ 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,faisework,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 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? ❑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 wit 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 en RMPP is presently required,has Section 25534 of the California Health end Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present Dr future building occupant require for the work which is tit-IS-subject of this application aaermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes U No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑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? 0 Yes 0 No 8 (If yes",attach certificate of compliance horn-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 AUTHORIZATION_OFENTRY: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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ccaImo, ` Ig t e Of Legal Owner(s) Date And/Or Autho d Applicant `Date,_ ;ODE I INSPECTION TYPE ;ATF' UIIIIIALS CODE I INSPECTION TYPE PAIS 1618 Fixed System Final Fire Prevention _ 206 Final Mechanical } 3-Op. iV 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 __ - 250 Final Building/Occupancy Sii CITY OF COSTA MESA 401 IBUILDING DIVISION F1 _____ DEVELOPMENT SERVICES DEPARTMENT PERMI NUMBER J•.1,, PERMIT °0PoRmso`. 00-00673 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No G Applied: 12/01/2000 Issued: 12/01/2000 Vicinity: UNIT G • Parcel Nunmber: 42619317 ISSUED BY: Applicant: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 . Contractor: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 License: 317026 Arch / Eng: Address: Phone: Zip: License: SCOPE OF PERMIT PLUMBING PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT G). INSTALL 3 BATHTUBS, 1 DISWASHER, 1 EXPANSION TANK,5 GAS OUTLETS, 1 WASHER, 1 PRESSURE REGULATOR, 1 SHOWER, 1 KITCHEN SINK, UP TO 4 VACUUM BREAKERS,4 WASH BASINS, 3 WATER CLOSETS,&1 WATER HEATER. REF: B00-00991 FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $9.80 1 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $29.40 3 Pressure Regulator $9.80 1 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $12.30 1 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $39.20 4 Dishwasher $9.80 1 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $29.40 3 Drain, Roof $0.00 0 Shower $9.80 1 Water Heater I vent $12.30 1 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $9.80 1 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $6.15 1 Sink,kitchen $9.80 1 Water Softener $0.00 0 Gas(Over 4 outlets) $1.10 1 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $212.15 NOTICE: The work authorized by this permit sC4DMME$ES/aSBEOkfble 60NQjTiQNS 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 C - 2446-46(6/00) DECLARATIONS '3' 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. ON- F I t-et- Policy Number: O J F/L C -(This section-need not be completed i/the permit Is valued at one hundred dollars($100)or less.) O 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 to become subject to the workers' compensation laws of California,and a e that if I should become subject to the workers'compensation provisions of Sectio 3700 of the Labor Code,I shall forthwith comply with thes• •r vi iona: Applicant I' ppl`nLAG.' Ir_! c„.-Date:-l�. 800 WARNING:FAILURE TO SECU- ORKE- ENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TOC PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND COLLARE(6100,i IN ADDRI- THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE R WDE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that.l.am licensed under provisions of Chapter 9(commencing with Section 7000)of Dlvision3 of the•Busine and Professions Code,and my license Is in full force and effect.Uc.a-- %, __.._- LClass•k- - ConiraMor'sSignature:_ -0, 1 Date: .fol. � ob • CONSTRUCTION LENDING A ' CV: fr ❑ 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). 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.). ❑ 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 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: 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 then 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? ❑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 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 appermit 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 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? ❑Yes ❑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 end city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. A tahit jigna ': Of Legal Owner(s) _ /2/C/e) Date d/Or Authorized Applicant. -- - (-Date _ v. CODE t ftrEcnoN TYPE OE INTTAL$ CODE( INSPECTION TYPE PETE REAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing I-2-o a. R N 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 250 Final Building/Occupancy , ' '4o CITY OF COSTA MESA 4q BUILDING DIVISION .. F i :144,271. DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER 4 PERMIT E01-00336 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No G Applied: 05/01/2001 Vicinity: UNIT G Issued: 05/01/2001 Parcel Nunmber: 42619317 Applicant: INGRAM, STEVEN ISSUED BY: Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor • ELITE ELECTRIC . Address: ' 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 License: 418242 SCOPE OF PERMIT ELECTRICAL PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT G). ' INSTALL NEW ELECTRICAL THROUGHOUT HOUSE,AND INSTALL 1 LIGHT,2 OUTLETS,&1 SWITCH IN GARAGE. REF:B00-00991 , . FEE SUMMARY • Quantity Quantity. ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 - Busway/100 ft $0.00 0' Res. a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $137.09 2448 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 '0 Transformers up to 1 kva/kw $0.00 - 0 . Pool/Spa $0.00 .0 up to 10 kva/kw $0.00 0 Lighting Fixts $1.10 1 up to 50 kva/kw $0.00 - 0 Recept Outlets ` `'` ' - $2.20 '.2 - up to 100 kva/kw- $0.00 '0 / Switches $1.10 '1 over 100 kva/kw - $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 . 0, , Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a , $0.00 ' 0 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00' 0 Motors to 1 hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 .0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $164.99 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS 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'eli% required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration.of this permi/ FOR INSPECTIONS CALL: (714)754-5626 / �/ 2446-46(6/001 ll 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 �work for which this permit is issued. 'i 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: Carrer: -1 Tr -Policy Number: 1 -(ThIssection need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performant of the work 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 of Califo an• :.r:,:that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these • Applicant Signature: (—Date:- 7['- C WARNING:FAILURE TO SECURE •• r RS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(8103,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under v !e commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.•N 2 Class A•-) _ ContractoesSlgriature: (—Date:" 3 - I - O( - 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). • 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 fore 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.). ❑ 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.). O 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,An 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? ❑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 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 apgermit for such construction or modification from the South Coast Air Qualify Management District or from any other air pollution control district or agency? PI 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? ❑Yes ❑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 AUTHORIZATION.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 laws end city ordinances relating to building construction,end authorize representatives of the City of Costa Mesa to enter upon the above-described props or inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. -' i..,... . • e:a •..:- . - Date And/Or Authorized Applicant-' / Date CODE F INSPECTION TYPF DATE INTITIALS CODER INSPECTION TYPE PA1E INTITIAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing p /� 200 Final Re-Roof 210 Final Electrical /—u/ "'f2 y TY- 3,- 201 Final Block/Retaining Wall 212 Final Fire Prevention 7 202 Final Factory Fire Place - 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy �� CITY OF COSTA MESA 49@ BUILDING DIVISION >• „„,. 4r'$ DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER t *IA 4 BO -00991 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.BUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 169 21ST ST Status: ISSUED Suite: G Applied: 06/30/2000 Vicinity: UNIT G Issued: 11/22/2000 Parcel Number: 42619317 Zoning: Applicant: JONES, CLIFTON ISSUED BY: Address: 10945 SOUTH ST#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 : WILKINSON ASSOCIATES Eng: STRUCTURES WEST Address: 17932 SKYPARK CI#A Address: 3430 E FLAMINGO RD#240 Phone: (949)852-8596 Phone: (702)435-1307 IRVINE,CA LAS VEGAS, NEVADA Zip: 92614 License: 89121 License: SCOPE OF PERMIT CONSTRUCT NEW 2-STORY SINGLE FAMILY RESIDENCE WITH ATTACHED GARAGE FOR"INFINITY HOMES”(UNIT G)- 1268 SQ FT 1ST FLR, 1180 SQ FT 2ND FLR,&442 SO FT GARAGE.ALSO,44 SO FT OF FRONT&REAR PORCH. FEE SUMMARY Plan Check: $1,082.74 Calc Valuation: 5219,764.84 Permit: $1,665.75 Claim Valuation: $0.00 SMIP Res: $21.98 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $2,770.47 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 fora 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, andle I 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)7545626 v 2446-46(6/00) 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 Insuran . -- , •nd policy number are: Carrier: - Policy Number: (This se ' need not be complet:• I ;o permit is •lued at one hundred dollars($100)or less.) n I certify thatthe pen• e work is which this•:mai is Issued,I shall not employ any person In any manner so as to become subject to the workers' compensation laws Carr .agr:: hat if I - y bject to the workers'compensation provisions of Section 3700 of thg Labor Code,I shall forthwith comply with rhes, •rovi ty� u-• ��� lC/�vl Applicant'Slgnalur - �e /Dale: 0 • - WARNINO:FAILURE - .%'E WORKERS' • PENSATION COVERAGE I5 UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL FIBNALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,.••),IN ADDITI*. /O THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR WOE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTOR" CLARATION: / + I hereby affirn-thol i•am ilc d Tdqr 99 sion • C • ( • mencing with Section 7000)of Division 3 of-the Busir d Professions Code,and my license is in full force and effect:Lc..#. / rl6 ,s Class a Contractors-Signature: - - - C ( Date: // •JT'cC CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a conslructio lending =.envy 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(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 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 sate.). ❑ I,as owner of the properly,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 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: ❑ 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 B,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 end 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 Firo 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 01 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? ❑Yes 0 No 5 Does or will the applicant or present or future building o cupant require for the work which Wilier 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? U Yes LI 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 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? 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 AND AUTHORIZATION 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 - s and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for,tion pu •• es.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ,1111- 'nature d eQQ•//al mer /j Z Date harz t _ - - CDate — ;ODEA ' 140y PAIL QLd4i B ;ODE( INSPECTIONTYPE PETE =al1616 Fixed S -al 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 250 Final Building/Occupancy (� 3608. NEWPORT-MESA UNIFIED SCHOOL DISTRICT CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES PURSUANT TO AB 1600 AND AB 181 To: (X ) City of Costa Mesa District Receipt No. ( ) City of Newport Beach ( ) County of Orange Plan Check No.1300-00991 Applicant: INFINITY HOMES COSTA MESA Address: 10945 SOUTH STREET STE 301, CERRITOS, CA 90703 Telephone Number: 562/ 924-4491 Tract/Parcel and Lot Number(s): TRACT 15995 Location of Project: 169 FAST 2 Lot ST UNIT G, COSTA MESA. CA Number of Square Feet of: Residential Space 1566 SF x $1.84 Total $2881.44 Commercial and Industrial Space x $ .30 Total Commercial/Industrial Project is: (Check One) Warehouse _____ Motel _ Preschool R & D _ Bank _ Auto Repair Movie Theater _ Neighborhood Shops _ Hospital Mini-storage Racquet/Health _ Large Office Heavy Industrial _ Hotel _ Office Bldg. Regional Shops _ Medical Office _ Restaurant Light Industrial _ Office Park _ Fast Food This project is exempt because i his certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Government Code sections 53080 and 65995. The Building Permits for this square footage in this proposed development may now be issued by your jurisdiction. Checks are to be made payable to Newport-Mesa Unified School District. By: BONNIE KUBOTA Authorized Representative The above representation as to square footage is true. Applicant agrees that i later 'etermned that such representations are not true,then this certificate shall automatically terminate and the appy oun hall be noh{� NOV ��28 8 0 /2:82 PM/f 21671.52 RLPTk:81-0869238 Date: /Al2 �CJ / , 112345 Applies / D ROBIN B. HAMERS 234 E. 17TH ST, SUITE 205 6 ASSOCIATES, INC. COSTA MESA,CA 82627 CIVIL ENGINEERS • PLANNERS • SURVEYORS (849)548-1192 FAX(948]546-5516 December21, 2000 City of Costa Mesa Building Dept. 77 Fair Drive Costa Mesa, CA 92628 RE: 169G 21st. St., Costa Mesa Lot 7, Tract No. 15969 • Attention: City Building Inspector This letter is to certify that the foundation forms were surveyed for line and grade on December 18, 2000, and are in substantial conformance with the approved grading plan • and site plan for the above project. 1 NZGLIf Robin B. Hamers R.C.E. 31720 cc. Infinity Homes QRpFESS/p 0.c m op -c 1RCE31720 = EXP. 12/31/2004 erlCMI �Q' ® Printed on Recycled Paper. . FINAL GRACING CERTIFICATION Project Address: 169 21st Street Costa Mesa Lot Number: G Permit Number: G00-00026 By Civil Engineer: 1 certify to the satisfactory completion of grading in accordance with the approved plans, specifications, local and state codes. All drainage devices required by the grading permit, grading plan and grading ordinance have been installed. Adequate provisions have been made for drainage of surface water from each building site. The minimums are: • 2% Fall from structures within 5 feet from exterior walls. I% Fall for asphalt surfaces and landscaped areas. 0.5% Fall for concrete surfaces to approved disposal areas. • The final monuments as shown on the recorded tract map were set. All final grading eleva- tions are within ± 1/10 of the desi ne elevations. Supervising Civil Engineer Reg. No. 31720 . (Signature) • Date 11/19/01 QRofEss4: ::--N\\\\ X00\C1 yje Fpm Lu cc R 31 20 m CPI 2004 �IF�P� STkIP and SIGN i09s 46 INSULATION CER. ICATE J IC-1 169-G 21st Street Costa Mesa Number and Street City Orange Amber Way—#15969 G County Subdivision Lot Number Description of Installation I. ROOF Material Brand Name Thickness(inches) Thermal Resistance(R-Value) 2. CEILING Batt or Blanket Type Batts Brand Name Certainteed Thickness (inches) 10" Thermal Resistance (R-Value) R-30 Loose Fill Type Brand Contractor's min installed weight/ft2 lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance (R-Value) 3. EXTERIOR WALL Frame Type A. Cavity Insulation Material Fiberglass Brand Name Certainteed Thickness(inches) 3 1 /2" Thermal Resistance (R-Value) R-13 • B . Exterior Foam Sheathing Material Brand Name Thickness(inches) Thermal Resistance (R-Value) 4. RAISED FLOOR Material Fiberglass Brand Name Certainteed Thickness (inches) 6 1 /4" Thermal Resistance(R-Value) R-19 5. SLAB FLOOR/PERIMETER Material Brand Name Thickness (inches) Thermal Resistance(R-Value) Perimeter Insulation Depth (inches) 6. FOUNDATION WALL Material Brand Name Thickness(inches) Thermal Resistance (R-Value) Declaration I hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficiency S : ••ards for residential buildings(Title 24, Part 6, California Code of Regulations)as indicated on the Certificate of Com• ce, w r• app ica. e. OeifI.!`\ I6/26/01 OJ Insulation Co. , Inc. Item #s Signature, Da Installing Subcontractor(Co.Name)OR General Contractor(Co. Name)OR Owner Item #s Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item #5 Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Revised March 1, 1996 f tti r - 1 O 4\ CITY OF COSTA MESA 4 BUILDING DIVISION f „_' ,I DEVELOPMENT SERVICES DEPARTMENT PER NUMBER �' PERMIT °„ B00-00989 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.usNG PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDIJob Address: 169 21ST ST Status: ISSUED Suite: E Applied: 06/30/2000 Vicinity: UNITE Issued: 11/22/2000 Parcel Number: 42619317 Zoning: ( Applicant: JONES, CLIFTON ISSUED BY: A Address: 10945 SOUTH ST#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: Address: Phone: Zip: License: Arch : WILKINSON ASSOCIATES Eng: STRUCTURES WEST Address: 17932 SKYPARK CI#A Address: 3430 E FLAMINGO RD#240 Phone: (949)852-8596 Phone: (702)435-1307 IRVINE,CA LAS VEGAS, NEVADA Zip: 92614 License: 89121 License: SCOPE OF PERMIT CONSTRUCT NEW 2-STORY SINGLE FAMILY RESIDENCE WITH ATTACHED GARAGE FOR"INFINITY HOMES"(UNIT E)- 1268 SQ FT 1ST FLR, 1180 SQ FT 2ND FLR, &442 SQ FT GARAGE.ALSO,44 SQ FT FRONT&REAR PORCHES. . FEE SUMMARY Plan Check: $1,082.74 Calc Valuation: $219,958.28 Permit: $1,665.75 Claim Valuation: $0.00 SMIP Res: $22.00 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $2,770.49 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, andall 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 /v/ 2446-46(WOO) ` DECLARATIONS 'r 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 - er and policy number are: Carrier: Policy Number: (This 5:- on need not be completed a permit i'valued of one hundred dollars($100)or less.) L•_I.cem that in the pe•.rma.A. e wo or which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation law •f C.' •v •agr e that If I s subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall fonhwIth _comply.with.the-.pr.•si.• _._ 1 Applicant Signature: -..."/ t e SrDate: // Z Z rc/`l T WARNING:FAILURETO( SECURE ADI<E--. r• PEN OST O COMPENSATION, TION,DAMAGES A SHALL SUBJECT I AN EEMPLOYER 7 6O CRIMINALHOR CODE, AND CIVIL ODES rUPO N ONE HUNDRED. THOUSAND DOLLARE(5100,0(10), NAD. ON •THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirmjthat'l•am lice. :• ridyr�,Prgv1slop• (commencing with Section 7000)of Division 3 of•the•Busine and Professions Code,and my license Is In full force and effect.Lie.A ULo(,9 —.�• - �Ctass p. ^'�� i•-. 666 -PJC) Cantrectgnelure: - iv/ Date:, Z� CONSTRUCTION LENDING AGENCY: �/ ❑ I hereby affirm that there is a constnicti•• - ding 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 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. 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: ❑ 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,The 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: I 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 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 a ppermit 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 California Government Code requires that the requested information be furnished on applications for non-residential building permits). 8 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer b0undaries 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 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 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 Hazard0us Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION 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 -•s and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for i pu .•-es.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. -•. ature O eget Oyna' //1-2eData -"Co •//� bdzed Applicant----- -- _ _ f Date - ;ODE 0 . 14. E' / DAM =la SOH 1 INSPECTIONTYPE DAM MBA 1616 Fixed S •• Val 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 250 Final Building/Occupancy /-2-, /(J-aZ " - 4 • - 3606 NEWPORT-MESA UNIFIED SCHOOL DISTRICT CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES PURSUANT TO AB 1600 AND AB 181 To: ( X) City of Costa Mesa District Receipt No. ( ) City of Newport Beach ( ) County of Orange Plan Check No.B00-00989 Applicant: INFINITY HOMES COSTA MESA Address: 10945 SOUTH STREET STE 301, CERRITOS, CA 90703 Telephone Number: 562/ 924-4491 Tract/Parcel and Lot Number(s): TRACT 15995 Location of Project: 169 EAST 21st ST UNIT E, COSTA MESA, CA Number of Square Feet of: Residential Space 1415 SF x $1.84 Total $2603.60 Commercial and Industrial Space x $ .30 Total CommerciaVlndustrial Project is: (Check One) Warehouse _ Motel _ Preschool R & D _ Bank _ Auto Repair Movie Theater _ Neighborhood Shops _ Hospital Mini-storage Racquet/Health _ Large Office Heavy Industrial _ Hotel _ Office Bldg. Regional Shops _ Medical Office _ Restaurant Light Industrial _ Office Park _ Fast Food This project is exempt because Phis certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Government Code sections 53080 and 65995. The Building Permits for this square footage in this proposed development may now be issued by your jurisdiction. Checks are to be made payable to Newport-Mesa Unified School District. By: BONNIE KUBOTA Authorized Representative The above representation as to square footage is true. Applicant agrees at if I • later determined that such representations are not true,then this certificate shall automatically terminate and the appr ' t: • /e•unty shall be notified. /J NOV 22 2888/2:82 PM/f 21671.52 / RLPT8:81-8865230 Date: !/�Z 112345 INSULATION CERI__'ICATE IC-1 169-E 21st Street Costa Mesa Number and Street City Orange Amber Way—#15969 E County Subdivision Lot Number Description of Installation 1. ROOF Material Brand Name Thickness(inches) Thermal Resistance(R-Value) 2. CEILING Batt or Blanket Type Batts Brand Name Certainteed Thickness (inches) 1 0" Thermal Resistance(R-Value) R-30 Loose Fill Type Brand Contractor's min installed weight/ft2 lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance(R-Value) 3. EXTERIOR WALL Frame Type A. Cavity Insulation Material Fiberglass Brand Name Certainteed Thickness (inches) 3 1 /2" Thermal Resistance(R-Value) R-13 B . Exterior Foam Sheathing Material Brand Name Thickness (inches) Thermal Resistance(R-Value) 4. RAISED FLOOR Material Fiberglass Brand Name Certi anteed Thickness (inches) 6 1 /4" Thermal Resistance(R-Value) R 1 9 5. SLAB FLOOR/PERIMETER Material Brand Name Thickness (inches) Thermal Resistance(R-Value) Perimeter Insulation Depth (inches) 6. FOUNDATION WALL Material Brand Name Thickness (inches) Thermal Resistance(R-Value) Declaration I hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficiency Stan-.rdr for residential buildings(Title 24, Part 6, California Code of Regulations)as indicated on the Certificate of Oomph ilk. wh ,e ..pile•bl ' EC'1i1�;_.t_.� 6 26/01 nJ InGulation Co. , Inc. Item#s igna re, Dae Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item #5 Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item #5 Signature, Date Installing Subcontractor(Co. Name)OR General Contractor(Co.Name)OR Owner Revised March 1, 1996 ROBIN B. HAMERS 234 E. 7TH ST., SUITE 205 & ASSOCIATES, INC. COSTA MESA. CA 92627 CIVIL ENGINEERS • PLANNERS • SURVEYORS (949) 546-1192 FAX(949) 546-6516 December 21, 2000 City of Costa Mesa Building Dept. 77 Fair Drive Costa Mesa, CA 92628 RE: 169E 21St. St., Costa Mesa Lot 5, Tract No. 15969 Attention: City Building Inspector This letter is to certify that the foundation forms were surveyed for line and grade on December 18, 2000, and are in substantial conformance with the approved grading plan and site plan for the above project. // i2.-t Robin B. Hamers R.C.E. 31720 oRpFESS/py�� cc. Infinity Homes <Q`��O�Ng. HA-,e44, ro m RCE31720 r`1 JD cc EXP. 12/31/2004 1 ig Jr `Pl CMI 4Q 11 - q`F=Alf% 0 Printed on Recycled Paper. FINAL GRATING CERTIFICATION Project Address: 160 21st Street Costa Mesa Lot Number: E Permit Number: G00-00026 By Civil Engineer: • I certify to the satisfactory completion of grading in accordance with the approved plans, specifications, local and state codes. All drainage devices required by the grading permit, grading plan and grading ordinance have been installed. Adequate provisions have been made for drainage of surface water from each building site. The minimums are: 2% Fall from structures within 5 feet from exterior walls. 1% Fall for asphalt surfaces and landscaped areas. 0.5% Fall for concrete surfaces to approved disposal areas. The final monuments as shown on the recorded tract map were set. All final grading eleva- tions are within ± 1/10 of the desig eelevations. Supervising Civil Engineer -I Irlh^{ Reg. No. 31720 (Signature) 11/19/01 Dale QROFESS/04, 1/40%N B. Hgyk��l�yZ C • STAMP and SIGN Iagu6 6111 Ms CITY OF COSTA MESA :4.4ft BUILDING DIVISION f ,1 DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER V PERMIT E01-00334 ,se (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No E Applied: 05/01/2001 Vicinity: UNIT E Issued: 05/01/2001 Parcel Nunmber: 42619317 y Applicant: INGRAM, STEVEN ISSUED BY: Address: 9415 BELLEGRAVE AVE. Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 Owner: ' INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: • ELITE ELECTRIC Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 License: 418242 SCOPE OF PERMIT ELECTRICAL PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT E). INSTALL NEW ELECTRICAL THROUGHOUT RESIDENCE&1 LIGHT,2 OUTLETS,&1 SWITCH IN GARAGE. REF: 800-00989 FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 i Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) • $137.09 2448 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 ' Lighting Fixts $1.10 1 up to 50 kva/kw $0.00 0 , Recept Outlets ' ' $2.20 . .2 up to 100 kva/kw $0.00 0 , / Switches V ' $1.10 ,1 - over 100 kva/kw ' $0.00 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 . 0 Res Appl ' ' $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00" 0 Motors to 1 hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 .0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $164.99 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS 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- 7 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 for which this permit is issued. I give 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. hi _—My workers'compensation Insurance carrier and policy number are: .Carrier: .� PolicyNumber: `• (This section need not be completed if the pe 'f Is valued at one hundred dollars($100)or less.) -- ❑ I certify that in the performance ofk 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 of Ca': ; dee that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these prov' Applicant Signature: _ -. r-Date:. f 5- - / - 01 .WARNING:.FAILURETO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND OOLLARE($100,000).IN ADDRION 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 provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. k.4 'I �2 Class. ' .- - ContractorsSignature:- ��`��� I Dater"r / -- 0 f 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). 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 end 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 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 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 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 ❑No (Section 25533 of the California Health end 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 TitureillIcling occupant require for the work which is the subject of this a plication apPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes U 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 ❑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 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 AND AUTHORIZATION.OF ENTRY:I certify under penalty of perjury that I have read this application end state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property •r inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. •. .Owner - D to And/Or,Auth0� /Date' ;ODE# INSPECTION TYPE PATE' INTTULS CODER INSPECTION TYPE PATE !IITMAL5 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 - 250 Final Building/Occupancy 5111 CITY OF COSTA MESA . fratp BUILDING DIVISION F4 -1 DEVELOPMENT SERVICES DEPARTMENT PERMIT UMBER PERMIT J M01-00211 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No E Applied: 04/24/2001 Issued: 04/24/2001 Vicinity: UNIT E Parcel Number: 42619317 ISSUED BY: • Applicant: PETERS, RANDY Address: 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA Zip: 91702 Owner: INFINITY HOMES CM I, LLC Address: CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: . OJ INSULATION INC Address: ' 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA - Zip: 91702 License:465709 ' SCOPE OF PERMIT INSTALL MECHANICAL FIREPLACE FOR NEW SINGLE FAMILY RESIDENCE(UNIT E). REF:B00-00989 . FEE SUMMARY • Quantity - Quantity • ISSUE FEE $23.50 • Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit ", $0.00 0 Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 ' Inst/Rep. Recess Wall Htr $0.00 0 Commercial Incinerator - . :$0.00- 0 Refrig Sys<100 k BTU; $0.00 0 . Domestic Incinerator $0.00 " 0 ' Refrig Sys>100 k BTU $0.00 0 ' - Compressors/Absorption Systems Gas Piping ; $0.00 0Up to 3 hp/100 k BTU , $0.00 ' 0 Factory Fireplace - $10.65. 1 3 To 15 hp/500 k BTU $0.00. 0 Hood w/Meeh Exhaust ' $0.00 015 To 30 hp/1,000 k BTU . $0.00' 70 VAV Box $0.00 0 30 To 50 hp/1,750 k BTU $0.00 0 Vent Fan/Single Duct, / i/ "" $0.00= 0 ,. . Over 50 hp/Over 1,750 BTU /$0:00 0 Appliance $0.00 0 Boilers " �' / Fire Dampers - " $0.00 0 _ Up to 3 hp Smoke Dampers $0.00 0 3 To 15 hp /' $0.00 0 Inst or Relocate Appl Vent $0.00 015 to 30 hp $0.00 0 Air Handlers< 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers> 10000cfm $0.00 0 Over 50 hp . , $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $34.15 COMMENTS/SPECIAL CONDITIONS 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" 7 required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration.of this per / FOR INSPECTIONS CALL: (714)754-5626 2446-46(6/00) V DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have end 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 k for which this permit is issued. r— I Have end 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 work o enation surance ca ler and policy number are: ,, �/}^�r� -Carriac\ �i �Bdicy-Number?DY6 tctt/J C/6 J _(This.sedtion need not be completed if the is valued at one hundred dollars($100)or less.) ❑ 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 to become subject to the workers' compensation laws alifo • d agree t at If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with the r sion (AppanC licSignature: L�Date:�L/(/� !!�_h/ WARNING:'FAILURE TO SECURE WORK S'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRItdINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND OOLLARE($100,000),IN (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!am.lic: :. n.er prov'Isions of Chapter 9(commencing with Section 7000)of Division 3 of.the Busin�S5 nd Prgtyssions Code,and my license is in full force and effect.Lk.# 7 _e 'l 1 [Class#1 (1 ici Contractor's Sig; �a�Ti [Class 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). 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.). ❑ 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 ❑No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bili 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: I 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? ❑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? ❑Yes ❑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? ❑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 Ll 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 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 . ..t. .prop... 8 (If yes",attach certificate of compliance from theeappropriate 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 AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ignature .gal Owner(s) / .Late - A r Authorize kant, LDateee CODE S INSPECTIONTYPE RALE' INTITIAL5 CODE}, INSPECTION TYPE O� 1616 Fixed System Final Fire Prevention 206 Final Mechanical .1kZAtert 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 - -- 250 Final Building/Occupancy ,5111 p 9 CITY OF COSTA MESA 4 • BUILDING DIVISION >Ate"-.v DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F 1 �ws� r ' r/� PERMIT 'k~1.ryaertN le M01-00171 (714)754-5273 • Fax(714)754-4856 • www.ci-costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No E Applied: 04/02/2001 Issued: 04/02/2001 Vicinity: C. Parcel Number: 42619317 ISSUED BY: �i Applicant: RENZ, RUSS Address: ' • Phone: 714-577-0771 , Zip: _ - _ Owner: INFINITYHOMESCM I, LLC �" Address:/ CLIFTON JONES 111 - , CERRITOS,CA,. Phone: 562 924 4491 , 10945 SOUTH STREET,#301 Zip: 90703 V \ / Contractor:-_,,'SENTRY MECHANICAL, INC. - �" ��� .1 Address: ' 540 S JEFFERSON - / CA Phone: 714-577-0771 • i PLACENTIA,CA ' . Zip: 92870 . • License:631049 • SCOPE OF PERMIT ` - . , INSTAL HEATING ANDAIR CONDITIONING IN NEW SFR. • / REF:B00-00989.CONTRACTOR IS DOING HEATING AND AIR CONDITONING ONLY. FEE SUMMARY r - Quantity-- ; Quantity ISSUE FEE $23.50 . - - . Repair/Alt Absorbtion Unit 40.00 0 . Inst FAU<100 k BTU $0.00. -0 ' Repair/Alt Refrigeration Unit ' $0.00 0; � ' Inst FAU>100 k BTU . $18.20 1 Ventillation System ''„ $0.00 0 Repair/Alt Cooling/Heat $0.00. 0 Evaporative Cooler / $0.00 ,0 j,,, Inst/Rep. RecessWall Htr $0.00 0 Commercial Incinerator $0.00. 0 . Refrig Sys<100 k BTU A $0.00 0 Domestic Incinerator 7i' ' $0.00'- 0 i. Refrig'Sys>100 k BTU: $0.00 0 , - Compressors/Absorption Systems "%i ' i/ , ' Gas Piping - $0.00 0 - Up to3 hp/100 k BTU - x$0.00 0 Factory Fireplace $0.00 0 3 To 15 hp/500 k BTU $0.00 1 o,' Hood w/Meth-Exhaust „ $0.00 0 -:.15 To 30 hp/1,000 k BTU `/ 7 ,$0.00� 0 VAV Box `, ;�A i $0.00- 0 -. .30 To 50 hp/1,7501k BTU // ' C, 50.001 /0 Vent Fan/Single Duct ' `$0.00. 0N Over 50 hp/Over 1,750 BTU,/ / _ $0.00 0 Appliance \� G// /� $8.0E0,9,..„, _, Boilers )� Fire Dampers , , (/ 7/750.00\l'0.- Up to 3 hp // K. `</ 50.00 0 Smoke Dampers N //$0.00 '0-C--1-:----1,';-- > -3 To 15 hp': -�.'' .„ ,/� $27.15 1 Inst or Relocate Appl Vent.--A x$0.00 0, - - ' ,15 to 30 hp - cvV'-„A /"7/ $0.00 0 Air Handlers< 10000cfm� N $OAO 1/0 30 to 50 hp ' ' $0.00 0 Air Handlers> 10000cfm 7.$0.00 //b.--'�' Over 50 hp % /, / / $0.00 0 Floor Furnace ��$0.00 �0 )- - -� Other Mechanical Fee / -' Floor or Suspend Heater `-$6.06-�0 ' - Investigation.Fee " ,i ....-----/ $0.00 _ Plan Check Fee '" $0.00 Reinspection"Fee $0.00 TOTAL CALCULATED FEES $68.85 COMMENTS/SPECIAL CONDITIONS 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 21 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(6100) 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 for which this permit is issued. 41---1 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 w,,o..I(kkets'yc^yensation Insurance carder and policy number are: �� ( carder. h0(.r1lVe1Gh l—Ak( & Cr, PalcyNumbar,LJ(-UC niOi00 —O() (This section need not be cornets: it the panni*is valued at one hundred dollars(5100)or less.) ❑ 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 to become subject to the workers' compensation laws of California,and agree t t if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with the 4 slons. /�11 App ant Signature: J !A T Date:--'-- -3 -0 WARNING:FAILURE TO SECURE WORKERS'COM _NSATION COVE E IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TOONE HUNDRED THOUSAND DOLLARE ISIP0,003),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST.AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that.Lam.lic•n d under.r.vlr`'ons of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect fLic..0-- f 0 -I JClasa a� C. -j_O Contractors Signature: . I . Date: C-__3--C) 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: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of pert ury 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 Profession 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 properly who builds or improves thereon,and who does such work himself or herself or through his of 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 properly,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 em 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: ❑ 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 6,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 gallon, 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 lime 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 a pllcation aEermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 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 ❑No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .t_ pollution _---_ _..__ 7 a permit than the South Coast res Quality cri edManagementCaliforniaDistrictHor other airgold tion ooncontrol district3 agency is required forthe work which is the subject of this application,have all of the disclosures prescribed by CalifoHealth and Safety Code Section 42303 been made? 0 Yes ❑No 6 (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 AUTHORQATION 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 1I re Of LegalDate �' Owner(s) 9 And/Or Auih ori Applicant Date---- COPE I INSPECRON TYPE GALE' ILLS CODE It INSPECTIONTYPE DEE 1616 Fixed System Final Fire Prevention 206 Final Mechanical -3"Ori _61L 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 250 Final Building/Occupancy `, 9 CITY OF COSTA MESA 4 BUILDING DIVISION i DEVELOPMENT SERVICES DEPARTMENT PERM NUMBER PERMIT %aaaR4' P00-00671 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No E Applied: 12/01/2000 Issued: 12/01/2000 Vicinity: UNITE MN Parcel Nunmber: 42619317 ISSUED BY: 1 JV Applicant: GOLDEN WEST PLUMBING INC IVB Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 License: 317026 Arch / Eng: Address: Phone: Zip: License: SCOPE OF PERMIT PLUMBING PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT E). INSTALL 3 BATHTUBS, 1 DISWASHER, 1 EXPANSION TANK, 5 GAS OUTLETS, 1 WASHER, 1 PRESSURE REGULATOR, 1 SHOWER, 1 KITCHEN SINK,UP TO 4 VACUUM BREAKERS,4 WASH BASINS,3 WATER CLOSETS,8 1 WATER HEATER. REF: B00-00989 FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub I Washer $9.80 1 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $29.40 3 Pressure Regulator $9.80 1 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $12.30 1 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $39.20 4 Dishwasher $9.80 1 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain,Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $29.40 3 Drain, Roof $0.00 0 Shower $9.80 1 Water Heater/vent $12.30 1 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $9.80 1 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $6.15 1 Sink,kitchen $9.80 1 Water Softener $0.00 0 Gas(Over 4 outlets) $1.10 1 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $212.15 NOTICE: The work authorized by this permit sCilDMMENTS/aSPEClittla COWW4ONS requirements under California statutes and related regulations. (Ord.No.92-28,§ 1,12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all J required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permi FOR INSPECTIONS CALL: (714)754-5626 2448-48(6/00) rillailMilillilliMIPIII WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. raI:have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. lrMyivorkers'compensation Insurance carrier and policy number are: Carrier:5P FIL.0 r Polity Number: Qu -Fit-LT.- __/Carrier: need not be completed if the permit is valued at one hundred dollars($f00)or less.) l�- -- ❑ 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 to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 700 of the Labor Code,I shall forthwith comply with these pro;sions. _—^ __' �� r -Applicant.Signaturey A. t jt_' aad 4th Date: /2� 7' n0 Lx� _THOUSAND DOLIA E( SECURE •' ERS' T•I COSI ON COVERAGE IS UNLAWFUL, AMAG AND SHALL PROVIDED FOR I ANEMPLOVER OY37 TO FTI NAL R COOS,INTEREST,AND CIVIL FINES TP TO ATTORNEY'S HUNDRED. THOUSAND DOLIARE IS10m,eW),p ADDITION TOS COST OF COMPENSATION,DAMAGES AS FOR IN SECTION 3706 OF THE LABOR CODE, ANDATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that under revisions of Chapter 9(commencing with Section 7000)of Division 3 of the Businessrand Professions Code,and my license is in full force and effect Lic.a, . - Class p Contractors Signature: Date:-/7 Ir fX) C 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). 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.IL 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 driver's license. ❑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,talsework,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 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 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 apconstruction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65050.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 8 WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑No (If'ryes",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? 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 AND AUTHORIZATION 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit unfit final inspection. _i Legal Owner(s) 7 ^T Date Ar Authorized.Applicant—. - - -IIRIDate - CODE M 4 P. PATE TIA15 ;ODE INSPECTION TYPE DATE nS 1616 Fixed System Final Fire Prevention 206 Final Mechanical q �T � 1266 Pool Spa Final 208 Final Plumbing 1` J -n a 47 ry 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 250 Final Building/Occupancy f CITY OF COSTA MESA 440111F BUILDING DIVISION > f' • ,: , DEVELOPMENT SERVICES DEPARTMENT PER NUMBER In I t '"" ce PERMIT J, et F00-00285 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 FIRE SUPRESSION PERMIT Job Address: 169 21ST ST Status: ISSUED • Suite: E Applied: 11/02/2000 Vicinity: UNITE Issued: 04/11/2001 Parcel Number: 42619317 Zoning: ISSUED BY: /! Applicant: MARTINEZ, MONA LISAII Address: 1787 POMONA RD SUITES D,&E Phone: (800)915-3473 CORONA,CA Zip: 91720 Owner INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA - Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor FIRE SPRINKLER SYSTEMS Address: 1787 POMONA RD SUITES D&E Phone: (800)915-3473 . . ' ' CORONA, CA Zip: 91720 • License: 684600 SCOPE OF PERMIT FIRE SPRINKLER PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT E). ' INSTALL 26 FIRE SPRINKLER HEADS. , REF: B00-00989 , FEE SUMMARY Plan Check: $39.07 Calc Valuation: $1,700.00, Permit: $60.10 Claimed Valuation: $1,700.00- Other: $0.00 Total: $99.17 ' , A /. , / 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 244846(8/00) 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 for which this permit is issued. xI 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 worker 'compe sation Insurance carrier and policy number are: _ _ .e.--- . - 0 i Illta C/i�YV Carder:-' - ■ t s af/I �Policy Numbe.. '(This section need no be completed if the permit i valued at one hundred dollars($100)or less.) , - ❑ 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 to become subject to the workers' ' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these�jrroo�isions. / Applicant Signature: ///rfl'YY/ r Dale: i'/ !!/�� t WARNING:.FAILURE TO SECURE W E S'COMPENSATION COVE E IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PEN LTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE 15100.000),IN DATION TO THE CART OF P SATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. r LICENSED CONTRACTORS DECLARATION: }}} rrr}}}��� I hereby affirm that I am licensed •.er�p°vi ion•'o Ch-.t: 9(commencing with Section 7000)of Division 3 of the Business an ,ProfesCode,and my license is in full force and effect.Lic.4 -D /". /' -1 e 4 'Class# 1 t� — / Contractor's Signature: - � g -{� ! r ,� �� >`Date: ¢ // 6 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency forth. +erformance 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.). ❑ 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 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,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 Califomia 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 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? ❑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? 0 Yes El 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 AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ie,,n, Signature°lisp!Ow �/ / Date r/GF�i I�GICY/Apa 7 /J/X ✓ And/Or Authorized APPA' nt /` 4) Date., - r CODE# INSPECTION TYPE, I8TITIAL$ CODE 4 INSPECTION TYPE DATE JNTITIALS 1616 Fixed System Final Fire Prevention U- b-0 I '(�. 206 Final Mechanical 1266 Pool Spa Final _ . 208 Final Plumbing 200 Final Re-Roof - _ 210 Final Electrical I' 201 Final Block/Retaining Wall _ _ 212 Final Fire Prevention U '4' ',, ( I 202 Final Factory Fire Place _ 220 Final Planning Approval 203 Final Sign _ 222 Final Site - 204 Final Demolition - 250 Final Building/Occupancy O4 g CITY OF COSTA MESA • :40111BUILDING DIVISION w DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER t arra I PERMIT • 00-00984 Sc'erot (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ccaUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 169 21ST ST Status: 'ISSUED Suite: A Applied: 06/30/2000 Vicinity: UNIT A Issued: 11/22/2000 Parcel Number: 42619317 Zoning: Applicant: JONES, CLIFTON ISSUED BY: Address: 10945 SOUTH ST#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 : WILKINSON ASSOCIATES Eng: STRUCTURES WEST Address: 17932 SKYPARK CI#A Address: 3430 E FLAMINGO RD#240 Phone: (949)852-8596 Phone: (702)435-1307 IRVINE,CA LAS VEGAS, NEVADA Zip: 92614 License: 89121 License: SCOPE OF PERMIT CONSTRUCT NEW TWO STORY SINGLE FAMILY RESIDENCE&ATTACHED GARAGE FOR"INFINITY HOMES"-UNIT A (1080 SQ FT 1ST FLR, 1075 SQ FT 2ND FLR,424 SO FT GARAGE).ALSO,44 SQ FT FRONT&REAR PORCHES. FEE SUMMARY Plan Check: $991.74 Calc Valuation: 5194,545.78 Permit: $1,525.75 Claim Valuation: So.00 SMIP Res: $19.46 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $2,536.95 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 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 1\ 2440-46(WOO) . • • 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 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 carder and policy number are: Carder: Policy Number: (This on need not be completz.• ' e permit is valued et one hundred dollars($100)or less.) - -1'cartify;that in the perto ,4 y work 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 .agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with the�• / Applicant Slgnatu :v'/,/moi./ Date: // 2,Z rr� �_ _ W-THOUSAND FAILURE TE( RE WO*RS'CO E COST O COVERAGE IIS UN,DWFUL AMAGES D SMALL SUBFOR I N EMPSECTION ON37 TO FTHE AL PENALTIES AND FINES UP N ONE HUNDRED, T/IIXISAND OOLURE(st•1,000),I �tr• ON TO THE COST OF ODMPENSATION,DAMAGES AS PROVIDED FOR IN 31080E THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm thallem.11%ned 99cA provi Ions • •(commencing with Section 7000)of Division 3 of.the.Busine d Professions Code,and my license is In full force and effect.Lic.e, ',/,1/Y �/ CamsCamss p. Con4actor'e Slgnatu_. -- - . 6 T Date:e //c Z -cel CONSTRUCTION LENDING AGENCY: � ❑ I hereby affirm that there is a construction I. • g 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 end 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 o1 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).): ❑ 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 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,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder,I will not employ anyone to do Mork 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: I Will the applicant or present or future building occupant need to file and sanity 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? ❑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 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? 0 Yes - ❑No Does or tutu; —.ire for._ _ on_ .._i _. 5 Does he willSo the oast Air ou present art emebuilding occupant at require for the work which districtis the or agency?this a Yeseation a0 Nnit for such wnstruction or modification from the South Coast Air Quality Management District or from any other air pollution control or � LU 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? ❑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 ell of the disclosures prescribed by California Health and Safety Code Section 42303 been made? CI Yes 0 No 8 (If yes',attach certificate of compliance from the appropriate air pollution control officer). Y 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 'TION 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 staff ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for ins tip -• :gree not tto occupy or allow occupancy of any building authorized by this permit until final inspection. . . 0 Owner 5)/, //-2z Dateaty � r � Vv And/Or A •rind Applicant _ __---- - _ (Date - _- BODE A INSPECTION TYPE `L. IIS CODE( INSPECTION TYPE RATE IIfImMLS 1816 Fixed System Final Fire Prevention 208 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 250 Final Building/Occupancy )21- (O C✓+A— 3602 NEWPORT-MESA UNIFIED SCHOOL DISTRICT CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES PURSUANT TO AB 1600 AND AB 181 • To: ( X) City of Costa Mesa District Receipt No. ( ) City of Newport Beach ( ) County of Orange Plan Check No. B00-00984 Applicant: INFINITY HOMES COSTA MESA Address: 10945 SOUTH STREET STE 301, CERRITOS, CA 90703 Telephone Number: 562! 924-4491 Tract/Parcel and Lot Number(s): TRACT 15.995 Location of Project: 169 EAST 21st ST UNIT A , COSTA MESA, CA Number of Square Feet of: Residential Space 1266 SF x $1.84 Total $2329.44k Commercial and Industrial Space - x $ .30 Total Commercial/Industrial Project is: (Check One) Warehouse _ Motel _ Preschool R 8 D _ Bank _ Auto Repair Movie Theater _ Neighborhood Shops _ Hospital Mini-storage Racquet/Health _ Large Office Heavy Industrial _ Hotel _ Office Bldg. Regional Shops _ Medical Office _ Restaurant Light Industrial _ Office Park _ Fast Food This project is exempt because i his certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Government Code sections 53080 and 65995. The Building Permits for this square footage in this proposed development may now be issued by your jurisdiction. Checks are to be made payable to Newport-Mesa Unified School District. By: BONNIE KUBOTA Authorized Representative The above representation as to square footage is true. Applicant agrees- t 's later determined that such representations are not true,then this certificate shall automatically terminate and the appy. . ? e City ounty shall be notified. NOV 22 2880/2:02 PM/1 21671.52 ROM:01-0069230 Date: N-2 Z- f 112345 ROBIN B. HAMERS 234 E. 17TH ST., SUITE 205 & ASSOCIATES, INC. COSTA MESA, CA 92627 CIVIL ENGINEERS • PLANNERS • SURVEYORS (949)546-1192 FAX(949) 546-6516 December 21, 2000 City of Costa Mesa Building Dept. 77 Fair Drive Costa Mesa, CA 92628 RE: 169A 21w. St., Costa Mesa Lot 1, Tract No. 15969 Attention: City Building Inspector This letter is to certify that the foundation forms were surveyed for line and grade on December 18, 2000, and are in substantial conformance with the approved grading plan ,, and site plan for the above project. CC Robin B. Hamers R.C.E. 31720 rf ESS/py9cc. Infinity Homes B. HAMFf' ac Z RCE31720 Do EXP. 12/31/2004 `rI�CIVII../C ;7 y� Printed on Recycled Paper. • ' INSULATION CERT ;CATE IC-1 169—A 21st Street Costa Mesa Number and Street City Orange Amber Way—#15969 A County Subdivision Lot Number Description of Installation 1. ROOF Material Brand Name Thickness (inches) Thermal Resistance(R-Value) 2. CEILING Batt or Blanket Type Batts Brand Name Certainteed Thickness(inches) 10" Thermal Resistance (R-Value) R-30 Loose Fill Type Brand Contractor's min installed weight/ft' lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance(R-Value) 3. EXTERIOR WALL Frame Type A. Cavity Insulation Material Fiberglass Brand Name Certainteed Thickness(inches) 3 1 /2" Thermal Resistance (R-Value) R-1 3 • B . Exterior Foam Sheathing Material Brand Name Thickness(inches) Thermal Resistance (R-Value) 4. RAISED FLOOR Material Fiberglass Brand Name Certainteed Thickness(inches) 6 1 /4" Thermal Resistance(R-Value) R-19 5. SLAB FLOOR/PERIMETER • Material Brand Name Thickness (inches) Thermal Resistance (R-Value) Perimeter Insulation Depth(inches) 6. FOUNDATION WALL Material Brand Name Thickness(inches) Thermal Resistance (R-Value) Declaration 1 hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficiency Stan ;rdr for residential buildings(Title 24, Part 6,California Code of Regulations)as indicated on the Certificate of Compli where T. icab ►1 • — 6/26/01 OJ Insulation Co. Inc. Item #s ignature, Dae — r Installing Subcontractor(Co.Name)OR General Contractor(Co. Name)OR Owner Item #s Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item Us Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Revised March 1, 1996 • • INSULATION CERT. CATE IC-1 169—J 21st Street Costa Mesa Number and Street City Orange Amber Way—#15969 J County Subdivision Lot Number Description of Installation 1. ROOF Material Brand Name Thickness (inches) Thermal Resistance (R-Value) 2. CEILING Batt or Blanket Type Batts Brand Name Certainteed • Thickness (inches) 1 0" Thermal Resistance(R-Value) R-30 Loose Fill Type Brand Contractor's min installed weight/ft' lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance (R-Value) 3. EXTERIOR WALL Frame Type A. Cavity Insulation Material Fiberglas Brand Name Certainteed Thickness (inches) 3 1 /2" Thermal Resistance (R-Value) R-1 3 • 13 . Exterior Foam Sheathing Material Brand Name Thickness (inches) Thermal Resistance(R-Value) 4. RAISED FLOOR Material Fiberglass Brand Name Certainteed Thickness (inches) 6 1 /4" Thermal Resistance(R-Value) R-19 5. SLAB FLOOR/PERIMETER • Material Brand Name Thickness(inches) Thermal Resistance(R-Value) — Perimeter Insulation Depth (inches) 6. FOUNDATION WALL Material Brand Name Thickness (inches) Thermal Resistance (R-Value) Declaration I hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficiency Standards for residential buildings(Title 24, Part 6,California Code of Regulations)as indicated on the Certificate ofComplia e where a•p icabl.. I 26/01 OJ Insulation Co. , Inc. Item #s ignatur , f ate Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item #s Signature, Date Installing Subcontractor(Co. Name)OR General Contractor(Co.Name)OR Owner Item #s Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Revised March 1, 1996 �c CITY OF COSTA MESA 4. . BUILDING DIVISION , DEVELOPMENT SERVICES DEPARTMENT PER T NUMBER �a1 0 r PERMIT ittrita M01-00207 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No A Applied: 04/24/2001 Issued: 04/24/2001 Vicinity: UNIT A Parcel Number: 42619317 ISSUED BY: Applicant: PETERS, RANDY Address: 600 S VINCENT AVE • Phone: (626)812-6070 AZUSA,CA Zip: 91702 Owner: INFINITY HOMES CM I, LLC Address: CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: . OJ INSULATION INC Address: 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA Zip: 91702 License:465709 SCOPE OF PERMIT INSTALL MECHANICAL FIREPLACE FOR NEW SINGLE FAMILY RESIDENCE(UNIT A). REF:B00-00984 FEE SUMMARY -Quantity Quantity , ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU , $0.00 0 Ventillation System $0.00 -0 Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 Inst/Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 / Refrig Sys<100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys>100k BTU $0.00 0 Compressors/Absorption Systems Gas Piping $0.00 0 Up to 3 hp/100 k BTU $0.00 0. Factory Fireplace $10.65 1 3 To 15 hp/500 k BTU $0.00 0 Hood w/Mech Exhaust $0.00 0 15 To 30 hp/1,000 k BTU $0.00 ,70 VAV Box $0.00 0 30 To 50 hp/1,750 k BTU $0.00/ 0 Vent Fan/Single Duct , , $0.00 0 Over 50 hp/Over 1,750 BTU $0.00 0 Appliance / $0.00 0 y Boilers - Fire Dampers $0.00 0 Up to 3 hp /$0.00 0 Smoke Dampers $0.00 0 3 To 15 hp ,/ $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers< 10000cfm •$0.00 0 30 to 50 hp $0.00 0 Air Handlers> 10000cfm $0:00 0 Over 50 hp $0.00 0 Floor Furnace - -$0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $34.15 COMMENTS/SPECIAL CONDITIONS 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(6/X) i( 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 wo for which this permit is issued. I-hve 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 work gLs'rco r salion Irprance card and policy number are: p�V /y -Garner: ��lldh,not C7 LPolicy.Numbecr(/ J 3 (This-sedtion nee not be completed if the permit s valued at one hundred dollars(5100)or less.) O 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 to become subject to the workers' compensation law " Califon' ,and gree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with th:., ••.visir . Applicant Signature._A' r Dated y`2,61-0/ L -WARNING:FILURE TO ECUR*It•KERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5100.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm thabbemd' --. •: p '.ns of Chapter 9(commencing with Section 7000)of Division 3 of.the Basinjagsd Pr f s' ns Code,and my license Is in full force and effect_Lic..4� )(ClassM�l/�" ✓ Contract SignatureraAir�k LDete:1C'� 7 CONSTRUCTION LENDING AGEN : 7�p/ ❑ 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 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.). ❑ 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 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). o 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? ❑Yes ❑No (Section 25533 of the California Health end 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). the applicant .r..r 3 Does or will the aplicaor 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? ❑Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit for such construction or modification from the South Coast Alr Quality Management District or from any other air pollution control district or agency? 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? ❑Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air 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 ❑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 AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, er(s) q 7 Dat tweeApplicant.-76 0� r ��thoriTstl CODE 0 INSPECTION TYPE QATE' NTITIALS CODE I INSPECTION TYPE I J 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 250 Final Building/Occupancy KW CITY OF COSTA MESA . _ 4:, 9 BUILDING DIVISION FDEVELOPMENT SERVICES DEPARTMENT PERMIT MBER J PERMIT 41-beftla'snip!'�fi' 00-00666 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No A Applied: 12/01/2000 Issued: 12/01/2000 Vicinity: UNITA Parcel Nunmber: 42619317 ISSUED BY: Applicant: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 License: 317026 Arch / Eng: Address: Phone: Zip: License: SCOPE OF PERMIT PLUMBING PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT A). INSTALL 2 BATHTUBS, 1 DISHWASHER, 1 EXPANSION TANK,5 GAS OUTLETS, 1 WASHER, 1 PRESSURE REGULATOR, 1 SHOWER, 1 KITCHEN SINK,UP TO 4 VACUUM BREAKERS,4 WASH BASINS, 3 WATER CLOSETS,& 1 WATER HEATER. REF:B00-00984 FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $9.80 1 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $19.60 2 Pressure Regulator $9.80 1 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $12.30 1 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $39.20 4 Dishwasher $9.80 1 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain,Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $29.40 3 Drain,Roof $0.00 0 Shower $9.80 1 Water Heater/vent $12.30 1 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $9.80 1 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $6.15 1 Sink,kitchen $9.80 1 Water Softener $0.00 0 Gas(Over 4 outlets) $1.10 1 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto.) $0.00 0 TOTAL CALCULATED FEES: $202.35 NOTICE: The work authorized by this permit cQDMMgtJI$/aSP A4la G INCIFACMIS 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, 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 CZ 2446.46(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 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: A Carrier:—Carrier: frIntom, rPolicy Number:-CA-) Lr(This section need not be tomplered if the permit is valued at one hundred dollars($100)or less.) l� `__^' - ❑ 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 to become subject to the workers' compensation laws of California,and agree that if I;hould become subject to the workers'compensation provisions of Sectl 370 of the Labor Code,I shall forthwith comply with these pr- i •-- - -./......" •n . / / v `ApplicanDSigneture: .—.S i/ .,..d 1 �Dete:-- 'WARNING.'FAILURE TO SECURE W.- ERS•• TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI PE TIES AND CIVIL RUES UP TO ONE HUNDRED THOUSAND DOLLARE(5100,000),IITION TO • T 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 amiic:r ed nder provisions of Chapter 9(commencing with Section 7000)of Division 3.of.the Business and�•Pryyfesslons Code,and my license Is in full force and efits ignatu a dee_ / L-,Date: 1: /Y Contractors Sign t rue e:— , • •• Date:--.�7 �' — CONSTRUCTION LENDING Ac,NCY: ❑ 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 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.). ❑ 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 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 0N (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? ❑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? 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 pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑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 prescnbed by California Health and Safety Code Section 42303 been made? ❑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 AND AUTHORIZATION OF ENTRY:1 certify under penalty of perjury that I have read this application and slate that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. �y a r egal Owner(s) Date /. # �. ./,_a r • Authorized Applicant- -firL.Date CODE.. . . ...• s'. DATE I AL.5 CODE I INSPECTION TYPE gra It�ELS 1616 Fixed System Final Fire Prevention 206 Final Mechanical (n� ^ /_ 1266 Pool Spa Final 208 Final Plumbing l Da'/1 'o( _S11Y._ 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 _ 250 Final Building/Occupancy • a.. CITY OF COSTA MESA o r ', BUILDING DIVISION > DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 41 i`Za t PERMIT stoe„„ se natiO 01-00167 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No A Applied: 04/02/2001 Issued: 04/02/2001 Vicinity: t// Parcel Number: 42619317 -- ISSUED BY: 36 Applicant: RENZ, RUSS Address: Phone: 714-577-0771 Zip: ,i/ `- ' . _ . 7' Owner: i. INFINITYtHOMES-CM I, LLC Address:' _CLIFTON /JONES III , ' CERRITOS,CA, ' Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 , Contractor: ",iSENTRYMECHANICAL, INC. ' Address: ` 540 S JEFFERSON'. ' ' - '\ ' I CA - . �, -Phone: 714-577-0771 • .1 PLACENTIA,CA- . Zip: 92870 License:631049 ' - SCOPE OF PERMIT • INSTAL HEATING AND AIR CONDITIONING IN NEW SFR. REF: B00-00984.-CONTRACTOR IS DOING HEATING AND AIR CONDITIONING ONLY. '\ , - FEE SUMMARY - Quantity- Quantity; ISSUE FEE $23.50 - - - - - - - Repair/Alt Absorbtion Unit ;. $0.00 0 - , . Inst FAU<100 k.BTU ' $0.00 • .0 - • . ' Repair/Alt Refrigeration Unit ' $0.00 0, Inst FAU>100 k BTU $18.20 1 Ventillation System h ' $0.00 0 / Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler ,' $0.00- 0 , . Inst/Rep. Recess-Wall Htr $0.00 0 Commercial Incinerator �� Refrig Sys<100 k BTU . $0.00 0 Domestic Incinerator Refrig Sys>100 k BTU $0.00 0 - , ... -Compressors/Absorption Systems " ,^/ _ ' Gas Piping •, $0.00 0 - " Up to3 hp/100 k BTU ,' / 10.00 '0 7 Factory Fireplace _ - . $0.00 0 3 To 15 hp/500 k BTU . ' / , $0.00 . 0/ Hood w/Mech Exhaust v. $0.00 0 • .15 To 30 hp/1,000 k BTU . - -$0.00', 0 VAV Box V,�, ' " _ v -$0.00-=-0--4 • - 30 To 50 hp/1 750 k BTU -- / / . $O.00i 0 Vent Fan/Single'Duct - - '$0.00 0 • , = -;Over 50 hp/Over i,750 BTU / / v $0.00 0 Appliance \\\K-T\ // v $6.09. ',.,0„, ^ .' _ , Boilers i Fire Dampers \y\ <7 //$0.00N �- " . Upto3hp �� / 7 /' ' j$0.00 0 Smoke Dampers v ��. \ //SOM.., 0'-, 3 To 15 hp,- , -.,--j- - ,-, `$27.15 1 Inst or Relocate Appl Vent.\7 7-$0.00,,`0_ - "15 to 30 hp 'AV'',' ✓ <2 $0.00 0 Air Handlers< 10000cfm\ ,v '$0.00 , ,ti',.- 30 to 50 hp - $0.00 0 Air Handlers> 10000cfm $0:00 /0 '' " Over 50 hp 2- , - $0.00 0 Floor Furnace �- 'WOO "0 V , - - ' Other Mechanical Fee Floor or Suspend Heater $0.00 0_ Investigation Fee' $0.00 ' • Plan Check Fee $0.00 -� - Reinspection-Fee - $0.00 -- --/ TOTAL CALCULATED FEES $68.85 COMMENTS/SPECIAL CONDITIONS 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 i 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(6/00) ///v 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 for which this permit is issued. ��I.have end 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. iy work'ers'compensation Insurance-C7lmor and policy number are: /I ✓�� ,. CL -Cartier..., in da I�'V 0. ✓1 L)i& V k A u1/k C 2 Policy Number: C 0 10) zbc, — '(This section need not be Completed if the permit is valued at one hundred dollars($100)or less.) U— . ❑ 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 to become subject to the workers' compensation la I California, -'d:gr:e • If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with th. visions. ApplicanaSignature:. A V _ . � ���_ ,pate:. . (1)-3 -0 l WINO:FAILURE TO SECURE WORKERS'•• -ENSATION•• i GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANDOW.ARE(51W,000).IN ADDITION TOTHE COST OF•• - NSATION,DAMAGES A5 PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST.AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm than-am-licensed under provisions of Chapter 9(commencing with Section 7000)of Division.3 of-the Business and Professions Code,and my license is in lull force and efecd:Lic:k"" 1 Oy \ t--Class-q LLL — 2 (- ) ConirectofsSignature: V / Date: ! ^ 3 _O 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). 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).): 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 properly,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 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-properly 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,taisework,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). O 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 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. .r..e fly required, has 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 aPPermit for such construction or modification from the South Coast Air Duality Management District or from any other air pollution control district or agency? 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 ❑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 AND AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. a,iFl@e Of Legal Owner(s) -0 1 Date l An. •r Autho id Applicant / r�Date-- - - CODE r )NSPECTIONTYPE PATE' INTRIALS CODE( INSPECDONTYPE PAN prTrnAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical a- `o I (Lit 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 - 250 Final Building/Occupancy F CITY OF COSTA MESA M) BUILDING DIVISION ;•, '`��t DEVELOPMENT SERVICES DEPARTMENT P RMIT NUMBER a PERMIT1. 01-00330 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No A Applied: 05/01/2001 Vicinity: UNIT A Issued: 05/01/2001 • Parcel Nunmber: 42619317 Applicant: INGRAM, STEVEN ISSUED BY: 77 Address: 9415 BELLEGRAVE AVE . Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: . ELITE ELECTRIC Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 License: 418242 SCOPE OF PERMIT ELECTRICAL PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT A). ' INSTALL NEW ELECTRICAL THROUGHOUT RESIDENCE& 1 LIGHT,2 OUTLETS, &1 SWITCH IN " GARAGE. REF:B00-00984 FEE SUMMARY Quantity - Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 , Temp service test $0.00 . Busway/100 ft $0.00 0 • Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $120.68 2155 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 . 0 Transformers up to 1 kva/kw $0.00 0 . , Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts , $1.10 1 up to 50 kva/kw $0.00 0 Recept Outlets "� $2.20 _ 2 up to 100 kva/kw Switches ' ' $1.10 . -1 over 100 kva/kw " $0.00 ‘ 0 /, Non Res Appl $0.00 0 . Low Voltage Equipment $0.00 ,' 0" / Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0,00 0 Motors to 1 hp $0.00 0 ' Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 .0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $148.58 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned' for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes and all required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration.of this permit. FOR INSPECTIONS CALL: (714)754-5626 c// 2446-46(6/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: O I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the �w.ork for which this permit Is Issued. - I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. Vi ____--My$vorkers'compensation Insurance carrier and policy number are: Carder:–-'t I Policy Numtiec. ( -his section need not be completed if the•'• it is valued at one hundred dollars($100)or less.) L– ❑ I certify that in the Woe--n ,0 0-a work for which this permit is issued I hall not employ any person in any manner so as to become subject to the workers' compensation laws• elil�,-,and a•r== -. - ... r-r . . I a ' workers'o the workecompensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these•rov.rr•• . / _ . .__ ! ' ( Applicant Signature: Date: J '' Q ( WARNINO:'FAILURE Te SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL DNES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706OF THE LABOR CODE.INTEREST.AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that.l,am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of.the.Business and Professions Code,and my license Is in full force and effect.ILIc.e,_--) _ 1Class.N---) Contractors Signatu•re:_ •- Date:. 2 i –( —U 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), 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 penally 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 end 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: 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 Administrative Code). O 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 preset 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 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 end 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 aggermit for such construction or modification from the South Coast Air(Duality 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 pan 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 end 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 ❑No B (If'yes's,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 '• 0 AUTHORIZATION.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 •I state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property • r •• •oses.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Date p .. 57.– I — C7 ( d/• •. . e• •pplicant _ • ( Date CODE• ILISPECTION TYPE RATE- I=IlIIAL$ CODE( JNSPECION TYPE Pill LNTITI(LL¢ 1616 FixedSystem Final Fire Prevention 206 Final Mechanical 1266 PoollSpa Final 208 Final Plumbing �,/ 200 Final Re-Roof 210 Final Electrical 9 4'E' egaffi& 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 250 Final Building/Occupancy • �4 'l Mtc CITY OF COSTA MESA a BUILDING DIVISION :i;,*i ThI`ni DEVELOPMENT SERVICES DEPARTMENT PER NUMBER F t WOW Tea /,a . PERMIT itbiePonno MI. 00-01364 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite: A Applied: 09/05/2000 Vicinity: UNIT A Issued: 09/05/2000 Parcel Number: 42619317 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 889 SO FT SINGLE FAMILY RESIDENCE(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 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- j 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 1// 2446.461600) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: O I have end 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 sect! need not be complete. pe• it is valued et one hundred dollars($100)or less.) C , certify that in the perfo ••- e•e' 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 laws•• I: n• agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shell forthwith comply with(hes: •• • 0 / / ��r Applicant Signature:_- / Date: �,y—GPS WARNING:FAILURE TO 5,CURE W"IRS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARS(SI...DM,IN J a•TION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 371x!OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am li e4uu deerrfprovisi•• •(commencing with Section 7000)of Division 3 of.the.Busine nd Professions Code,and my license Is In full force and effect Lic.M - /7C7 �siii_„.•Ic " • - Class.#- ) Contractors.Signature: ill_ i.- Late 9�S"-•crJ CONSTRUCTION LENDING AGENCY: D 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 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 safe.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 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: ❑ I hereby certify that no excavation live(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 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 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 agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? DI Yes LJ No (Section 65850.2 of the California Govemment 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 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? 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 AND A •• • •N 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 city 'rdinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for i�� I :tree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 1 eg� r(/ Dae And/Or Aut • ^ ed Applioerh— �_ l(/ IDate--------_, CODE II INSPECTIONTYPE PAIS =Ma CODER fNSPECNONTTPE DALE BMW 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 £f-J6192 ,,(jam 250 Final Building/Occupancy 5111 CITY OF COSTA MESA aA 9 BUILDING DIVISION Y 4-• t- . DEVELOPMENT SERVICES DEPARTMENT PERM NUMBER t p •al 1 PERMIT 01-00337 dA (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No H Applied: 05/01/2001 Vicinity: UNIT H Issued: 05/01/2001 Parcel Nunmber: 42619317 Applicant: INGRAM, STEVEN ISSUED BY: Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 Owner INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor ELITE ELECTRIC - Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 License: 418242 SCOPE OF PERMIT ELECTRICAL PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT H). INSTALL NEW ELECTRICAL THROUGHOUT HOUSE,AND INSTALL 1 LIGHT,2 OUTLETS, &1 SWITCH IN GARAGE. REF:B00-00992 FEE SUMMARY • Quantity - Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $137.09 2448 • Misc Electrical Equipment _ $0.00 0 New Res(3+units) $0.00 - ,'0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 - 0 up to 10 kva/kw $0.00 0 Lighting Fixts / $1.10 - 1 _ up to 50 kva/kw $0.00 O. Recept Outlets ' , $2.20 ' ';2 - up to 100 kva/kw- $0.00' 0 Switches - $1.10- -1 over 100 kva/kw" -$0.00 ` 0 -, Non Res Appl - $0.00 0 Low Voltage Equipment $0.00 0 , Res Appl $0.00 0 Low Volt Wring System/Ckt $0.00 0 Service to 200a $0.00 , 0 Misc.Conduit $0.00 0 Service to 1000a -$0.00 .0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1hp $0.00 `0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 - 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 .0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $164.99 Intermed Pole $0.00 0 COMMENTS I SPECIAL CONDITIONS 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(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 J. for which this permit is issued. 11 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 i<m,od. My workers'compensation Insurence carder and policy number are: Carter: CPWicy Numbec- (This section need not be completed i/the permit is valued at one hundred dollars($100)or less.) ❑ 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 to become subject to the workers' compensation laws of Calla,.r't!.�,.that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these prLi,�rf��� _- p ------- _Applicant Signature:, CDatef - _: �� / — 0 -WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS NLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND GVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARE(S100A001,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37000F THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm.thatl am licensed under prov' sof Chapter 9(commencing with Section 7000)of Division 3 ofthee•Business and Professions Code,and my license is in full I force and effec(rCic:10 / a_— itlass.W Contractors _.--ure:.. -- Date:'—'-� ( —lj( 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). 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(commenting 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 penally of not more than five hundred dollars($500).): ❑ 1,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 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. ❑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,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 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 ❑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? ❑Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this aEe plication armit for such construction or modification from the South Coast Air Duality Management District or from any other air pollution control district or agency? Ll 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? ❑Yes ❑No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). ...t..Management 7 If a permit fromn the South Coast res Duality ed by gement Di Heal or other air pollution ooncontrol district3 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 ❑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 AUTHORIZATIONOF ENTRY:1 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. • . .. / I Q pate /✓�And/OrAuthorizedApplicant /Date ;ODE I INSPECTION TYPE PEE' BMA COOFE INSPECTION TYPE PAh INTl11ALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing /� 200 Final Re-Root 210 Final Electrical / &R _z 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 _ 250 Final Building/Occupancy _ ' M CITY OF COSTA MESAt. 4 BUILDING DIVISION F „,,, I DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER r.-Z PERMIT B00-00992 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.usNG PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDIJob Address: 169 21ST ST Status: ISSUED Suite: H Applied: 06/30/2000 Vicinity: UNIT H Issued: 11/22/2000 Parcel Number: 42619317 Zoning: Applicant: JONES, CLIFTON ISSUED BY: 1, Address: 10945 SOUTH ST#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 : WILKINSON ASSOCIATES Eng: STRUCTURES WEST Address: 17932 SKYPARK CI#A Address: 3430 E FLAMINGO RD#240 Phone: (949)852-8596 Phone: (702)435-1307 IRVINE,CA LAS VEGAS, NEVADA Zip: 92614 License: 89121 License: SCOPE OF PERMIT CONSTRUCT NEW 2-STORY SINGLE FAMILY RESIDENCE WITH ATTACHED GARAGE FOR"INFINITY HOMES"(UNIT H)- 1268 SQ FT 1ST FLR, 1080 SQ FT 2ND FLR,&442 SQ FT GARAGE.ALSO,44 SQ FT OF FRONT&REAR PORCH. FEE SUMMARY Plan Check: $1,082.74 Calc Valuation: $219,764.84 Permit: $1,665.75 Claim Valuation: So.00 SMIP Res: $21.98 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $2,770.47 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(6/00) !!! • DECLARATIONS I , WORKERS'COMPENSATION DECLARATION: • I hereby affirm under penalty of perjury one of the following declarations: ❑ I have end 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 Ion need not be completed if the•:r it is valued at one hundred dollars($100)or less.) I certify.that in the perfo - �the o 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 of:.Ifoagr:.that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with-these. • 'sio•r 'AppSignature:-- L ,rte/_i% , Date: //z 2- WARNING:FAILURE TO SE -E .• PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),I 0 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 thall.am.licensed under•ro;sic • C•• . ••mmencing with Section 7000)of Division 3 of the.Busine d Professions Code,and my license is in full force and effeclruc..e - / i i a� LClass (�� IContrebtors Signature: imp �� Date: CONSTRUCTION LENDING AGENCY: O I hereby affirm that there is a construction le •ng 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 t0 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.). r of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions • e:Tie 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: Dale: Owner ID verified by drivers 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: 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 6,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 Califomia 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 wit 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? ❑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? 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 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 Califomia 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 AND AUTHORIZATION 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 r. . • city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for ins•:9 .urpose' I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. _dorOf Lewner(s) -411J� //��at� And/Or • Cho_ed__pp SODE/ r•. s-. PAIL RfmbJ5 CODEC INSPECTIONTYPL PAM IffIIIIALS 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 250 Final Building/Occupancy /-2 �2- E� e✓6/ • / \ - i 360 .9 . NEWPORT-MESA UNIFIED SCHOOL DISTRICT CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES PURSUANT TO AB 1600 AND AB 181 To: (X ) City of Costa Mesa District Receipt No. ( ) City of Newport Beach ( ) County of Orange Plan Check No.800-0013192 Applicant: INFINITY HOMES COSTA MESA Address: 10945 SOUTH STREET STE 301, CERRITOS, CA 90703 Telephone Number: 562/ 924-4491 Tract/Parcel and Lot Number(s): TRACT 15995 Location of Project: 169 EAST 21st ST UNIT H, COSTA MESA, CA Number of Square Feet of: Residential Space 16166 SF x $1.84 Total $2881.44 Commercial and Industrial Space x $ .30 Total Commercial/ndustrial Project is: (Check One) Warehouse _ Motel _ Preschool R 8 D _ Bank _ Auto Repair Movie Theater _ Neighborhood Shops _ Hospital Mini-storage Racquet/Health _ Large Office Heavy Industrial _ Hotel _ Office Bldg. Regional Shops _ Medical Office _ Restaurant Light Industrial _ Office Park _ Fast Food This project is exempt because i his certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Government Code sections 53080 and 65995. The Building Pemiits for this square footage in this proposed development may now be issued by your jurisdiction. Checks are to be made payable to Newport-Mesa Unified School District. By: BONNIE KUBOTA Authorized Representative The above representation as to square footage is true. Applicant agrees the it is -.ter determined that such representations are not true,then this certificate shall automatically terminate and the appro : e i /C. my shall be notified nuv 22 2888/2:82 PM/f 21671.52 RCP18:81-4869238 Date: /7-'12? - • / 112345 ROBIN B. HAMERS234 E. 17TH ST.. SUITE 205 & ASSOCIATES, INC. COSTA MESA. CA 92627 CIVIL ENGINEERS • PLANNERS • SURVEYORS (949)546-1192 FAX(949) 545-6616 December 21, 2000 City of Costa Mesa Building Dept. 77 Fair Drive Costa Mesa, CA 92628 RE: 169H 21`t. St., Costa Mesa Lot 8, Tract No. 15969 Attention: City Building Inspector This letter is to certify that the foundation forms were surveyed for line and grade on December 18, 2000, and are in substantial conformance with the approved grading plan and site plan for the above project. n'a Robin B. Hamers R.C.E. 31720 Q\ApFESS/py cc. Infinity Homes � �0 N B.H q y ict co m RCE31720 ^'' rt EXP. 12/31/2004 SA C-17IVIL ��Q F°F CALI�� yn Printed on Recycled Paper. INSULATION CER_ .AICATE IC-1 169-H 21st Street Costa Mesa Number and Street City Orange Amber way—#15969 H County Subdivision Lot Number Description of Installation 1. ROOF Material Brand Name Thickness (inches) Thermal Resistance(R-Value) 2. CEILING Batt or Blanket Type Batts Brand Name Certainteed • Thickness (inches) 10" Thermal Resistance(R-Value) R-30 Loose Fill Type Brand Contractor's min installed weight/ft2 lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance(R-Value) 3. EXTERIOR WALL Frame Type A. Cavity Insulation Material Fiberglass Brand Name Certainteed Thickness(inches) 3 1 /2" Thermal Resistance(R-Value) R-13 . B . Exterior Foam Sheathing Material Brand Name Thickness (inches) Thermal Resistance (R-Value) 4. RAISED FLOOR Material Fiberglass Brand Name Certainteed Thickness (inches) 6 1 /4" Thermal Resistance (R-Value) R-19 S. SLAB FLOOR/PERIMETER Material Brand Name Thickness (inches) Thermal Resistance (R-Value) Perimeter Insulation Depth (inches) 6. FOUNDATION WALL Material Brand Name Thickness(inches) Thermal Resistance (R-Value) Declaration I hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficiency Standards for residential buildings(Title 24, Part 6, California Code of Regulations)as indicated on the Certificate of Complia . here .L'II icabI-. t �'� I, � /'I •/26/01OJ Insulation Co. , Inc. Item #s '' gnature, Date111, Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item #5 Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item#s Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner • Revised March 1, 1996 i . FINAL GRADING CERTIFICATION • Project Address: 169 21st Street Costa Mesa Lot Number: • F Permit Number: G00-00026 By Civil Engineer: I certify to the satisfactory completion of grading in accordance with the approved plans, specifications, local and state codes. All drainage devices required by the grading permit, grading plan and grading ordinance have been installed. Adequate provisions have been made . for drainage of surface water from each building site. The minimums are: 2% Fall from structures within 5 feet from exterior walls. I% Fall for asphalt surfaces and landscaped areas. 0.5% Fall for concrete surfaces to approved disposal areas. The final monuments as shown on the recorded tract 'map were set. All final grading eleva- tions ire within ± 1/10 of the desig d elevations. . Supervising Civil Engineer •' Reg. No. 31720 • (Signature) 11/19/01 Date MI° p ESS/"444% �,q'f' CCC ExpR7x004 RCE3,7�Q rjj CF IFO 4, NIL / CAl • STAMP and SIGN '69.<l CITY OF COSTA MESA 4(k. ►� BUILDING DIVISION rj,�"l» PERM! UMBER DEVELOPMENT SERVICES DEPARTMENT . • rromlfirl. t PERMIT M01-00215 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No H Applied: 04/24/2001 Issued: 04/24/2001 Vicinity: UNIT H Parcel Number: 42619317 ISSUED BY: Applicant: PETERS, RANDY Address: 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA Zip: 91702 Owner INFINITY'HOMES CM I, LLC Address: CLIFTON JONES III CERRITOS, CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 • Contractor , OJ INSULATION INC Address: 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA Zip: 91702 License:465709 SCOPE OF PERMIT INSTALL MECHANICAL FIREPLACE IN NEW SINGLE FAMILY RESIDENCE FOR"INFINITY " HOMES"(UNIT H). • REF:B00-00992 FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100-k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00- 0 Inst/Rep.Recess Wall Htr $0.00 0 - - • Commercial Incinerator / $0.00. 0' / Refrig Sys<100 k BTU $0.00 0 Domestic Incinerator -$0.00 0 ' Refrig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems Gas Piping $0.00. 0 Up to 3 hp/100 k BTU $0.00. - 0 Factory Fireplace, $10.65'' 1 3 To 15 hp/500k BTU - $0.00' '0 Hood w/Meth Exhaust $0.00 0 15 To 30 hp/1,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp/1,750 k BTU -$0.00', 0 Vent Fan/Single Duct' " , $0.00 0 ' Over 50 hp/Over 1,750 BTU - -' $0.00 0 Appliance _ . - $0.00 0' Boilers - _ Fire Dampers , ' - $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers< 10000cfm $0.00 ' 0 30 to 50 hp $0.00 0 Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00' 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $34.15 COMMENTS/SPECIAL CONDITIONS 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(6100) 6/ 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 ce2work 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' p nationurance c mer and policy number are: �y 'Carder. qNM [Policy Number:OY 9,.(J 3 ,(Thissection need not be comp/et d if the permit is valued et one hundred dollars($700)or less.) • ❑ 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 to become subject to the workers' compensation laws o a ornia,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these ' ' ns. Applicant SIgnatura-1 / Date: (-1-26-0/ -WARNING FAILURE TO SECURE WORKE MPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLIARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that l em t'.: .'d under•ro isions of Chapter 9(commencing with Section 7000)of Division 3 o the BI„iness and Prgfyssieps Code,and my license is in full force and effect.Lit_# • r Class N-/ [1 .,I(f/ c. Contractors Signature: Jan" • `Date:J9; 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 end 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.). ❑ 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: ❑ 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)feat 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 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 ❑No (Section 25533 of the California Health end 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? ❑Yes ❑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? j�Yes t_J 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 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? 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 AND AUTHORIZATION_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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 41j, 0 natur_,Of Legal Owner s) Dat,// d/Or Authorized Applicant - Dat , CODEC ItliPECTIONTYPE REE' INTITIAL5 CODEf INSPECTION TYPE 0�A/TE f(iLIBB. 14L 1616 Fixed System Final Fire Prevention 206 Final Mechanical 2"/`0�— (e f'L('T 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 250 Final Building/Occupancy 0111 F CITY OF COSTA MESA 4401 ,►9@ BUILDING DIVISION `j g DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER PERMIT Sbibromunee /N101-00174 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No H Applied: 04/02/2001 Issued: 04/02/2001 Vicinity: 1 Parcel Number: 42619317 ISSUED BY: f'�J Applicant: RENZ, RUSS Address: Phone: 714-577-0771 Zip: Owner / INFINITY HOMES CM I, LLC Address:" ,CLIFTON JONES III - CERRITOS,CA, Phone: 562 924 4491 ' ,' 10945 SOUTH STREET,#301 Zip: 90703 bontractor:',,, SENTRY MECHANICAL, INC. - ' Address: ' 540 S JEFFERSON - ' CA . Phone: 714-577-0771 PLACENTIA,CA Zip: 92870 • License:631049 " SCOPE OF PERMIT / • INSTAL HEATING AND.AIR CONDITIONING IN NEW SFR , , REF:B00-00992.CONTRACTOR IS DOING HEATING AND AIR CONDITIONING ONLY. FEE SUMMARY - Quantity , . Quantity ISSUE FEE $23.50 - - • Repair/Alt Absorbtion Unit . '$0.00 0 , Inst FAU<100 k BTU $0.00 •0 - . Repair/Alt Refrigeration Unit C $0.00 0, , Inst FAU>100 k BTU $18.20 1 Ventillation System �' ;$0.00 0 . - Repair(Alt Cooling/Heat $0.00 0 Evaporative Cooler /i $0.00 "-0 ..' Inst/Rep. Recess Wall Htr , $0.00 0 Commercial Incinerator i/ ' $0.00 ,�0, , / Refrig Sys<100 k BTU C, $0.00 0 Domestic Incinerator {"/// ,'$0.00 " 0-L Refrig Sys>100 k-BTU $0.00 0 - Compressors/Absorption Systems Gas Piping_ , '� -�$0.00 0 - - Up to 3 hp/100 k BTU � / - $0.00 /0 / Factory Fireplace - $0.00 0 ' , 3 To 15 hp/500 k BTU Hood w/Mech Exhaust \ $0.00 0 ,15 To 30,hp/1000k BTU - .$0.00, 0 VAV Box `� ��� ' $0.00 �0 . - 30 To 50 hp/1,750k BTU -�� \. $0 00'i /0 Vent Fan/Single'Duct \ '$0.00 00 ' Over 50 hp/Over 1,750 BTU , , ,' Sado 0 Appliance ` ��A 4 /v $0.00��0 C - ,Bbilers - ..� /�" moi/ /$ ' Fire Dampers \�; ./ �� $0.00-- 0 - Up to 3 hp Smoke Dampers A >� - /$0.00 , 0f - -- _ ' 3 To 15 hp i----- ,v."/ . /"$27.15 1 Inst or Relocate Appl Vent.,:, v :-$0.00- '0 ' 15 to 30hp - ;Av. 'i-, $0.00 0 Air Handlers< 10000cfni i$0.00 /�0 Air Handlers> 10000cfm -$0.00 '/0. - _ , Over 50hp v . " $0.00 0 Floor Furnace �".- _$0.00 '--0 ,0 - - Other Mechanical Fee �'� i Floor or Suspend Heater ,_.$0.00\-0 i i InvestigationFee" ,'' �-� $0.00 Plan Check Fee $0.00 Reinspection ,Fee0.00 TOTAL CALCULATED FEES $68.85 COMMENTS I SPECIAL CONDITIONS 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(6/00) V DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ t 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. pj 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. i My workers'cq�Ipensatlon Ins�@nce carder and policy number are: (carrier: 0OO dLVhfe 4.h C Q Cc, Policy Numb&I#U C 010 i-) 00-00 (This section need not be completed it the permit is valued at one hundred dollars($100)or less.) ❑ 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 to become subject to the workers' compensation laws of Catifoml: and a!re: at If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with theyyuavislons. Applicant Signature: 4a A. .� ►: 4 1-i I I M - A WARNG'FAILURE TO SECURE WORKERS'oft ' SATION COVE_GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100.000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE,INTEREST.AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm Ihat.l.am Ikep?s u',,reer Fri Ions of Chapter 9(commencing with Section 7000)of Division 3 0l the BusinAss a Professions Code,and my license is in full force and effect.Uc._X,-- -(O{ ) /0 4 ( Class LY Contractor's Sign /V'� ature: (Date:- . y) 1 /V I 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). 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 Cale: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 am 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 properly,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 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,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: I Wit 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 greeter 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.;present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑Wo (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 ap$ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? lYes 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 California Health and Safety Code). 7 tf 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 Califomia 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 AND AUTHORIZATION.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 laws end city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. \r\ OQ /SI nn ylre Of Legal Owner(s) 9 ^\^ Dale J\C'AemJ(X a , nd/OrAu rued Applicant /Date COMF INSPECTION rIPF . OaIE' ItIT8BAL5 PDF( INSPECTION TYPE / PACE 41 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1268 Pool Spa Final 208 Final Plumbing 200 Final Re-Rolf 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 250 Final Building/Occupancy t`, ' MF 9 - CITY OF COSTA MESA BUILDING DIVISION > 4-.7 -1.4,;,,,illICUit DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 1 • �a t PERMIT J bgro Ernle JP00-00674 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No H Applied: 12/01/2000 Issued: 12/01/2000 Vicinity: UNIT H Parcel Nunmber: 42619317 ISSUED BY: _?adic-- Applicant: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 License: 317026 Arch / Eng: Address: Phone: Zip: • License: SCOPE OF PERMIT PLUMBING PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT H). INSTALL 3 BATHTUBS, 1 DISWASHER, 1 EXPANSION TANK,5 GAS OUTLETS, 1 WASHER, 1 PRESSURE REGULATOR, 1 SHOWER, 1 KITCHEN SINK,UP TO 4 VACUUM BREAKERS,4 WASH BASINS,3 WATER CLOSETS,& 1 WATER HEATER. REF:B00-00992 FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $9.80 1 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $29.40 3 Pressure Regulator $9.80 1 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $12.30 1 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $39.20 4 Dishwasher $9.80 1 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $29.40 3 Drain, Roof $0.00 0 Shower $9.80 1 Water Heater/vent $12.30 1 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $9.80 1 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $6.15 1 Sink,kitchen $9.80 1 Water Softener $0.00 0 Gas(Over 4 outlets) $1.10 1 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $212.15 NOTICE: The work authorized by this permit seeM MIH'tivTia iaSRiplalMe 6 dNDIT4@NS 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 cend all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expirati6n oof.thls permit. FOR INSPECTIONS CALL: (714)754-5626 2446-48(elm) DECLARATIONS . WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have end 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 antlwill 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'corn ensatlon Insurance carrier and policy number are: ---- Carrier: C)1, I-LC Policy Number: -Cfa Pt LIZ- --(This section need not be completed if the permit is valued at one hundred dollars(5100)or less.) t- 0 ❑ 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 to become subject to the workers' compensation laws of California,and agree that If I .hould become subject to the workers'compensation provisions of Section 700 of the Labor Code,I shall forthwith comply-with these•r• Inions. C---- /2e-7(0 99 r /� Appllcan6SIgnature:— '.--Ag...... ' .t. Si ( Date: /G 7 ( (l WARNING:FAILURE TO SECURE iERS'•• -TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI NAL- TIES AND CIVIL FINES UP TO ONE HUNDRED ir THOUSAND DOLLARE(5108000),r ADDfTION T. MST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirmIthaDhem licensed.under•revisions of Chapter 9(commenting with Section 7000)of Division 3 of.the.Business and Professions Code,and my license Is in full farce and rs Signature I Class It—�:_//Y3G Contract Sr' Iso gnature; //. A Dete: __- Or CONSTRUCTION LENDING AGE /y: ❑ 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). 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 end the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant toe 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.). ❑ 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 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,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? ❑Yes 0 No (Section 25533 of the Califomia 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 greeter 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 a_permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 011 Yes U No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any pan 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 Califomia 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 prescnbed by Califomia 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 AND AUTHORIZATION 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 ell state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ignat Of Legal Owner(s) Date A ./.....ife.' . _ . A i 40 AZ/SA) r.---____ _ , •r'Authorized Applicant `Date BODE I .I•, I' QAIE ItdllDALE QDDFI INSPECTION TYPE PAH .1s. . 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing /L y/ 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 250 Final Building/Occupancy . F 9 CITY OF COSTA MESA. 4 • BUILDING DIVISION F N •. � : DEVELOPMENT SERVICES DEPARTMENT PERMIT N BER PERMIT 4. Ira BO -00988 SwPoRmsse# (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa. �LDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 169 21ST ST Status: ISSUED Suite: J Applied: 06/30/2000 Vicinity: UNIT J Issued: 11/22/2000 Parcel Number 42619317 Zoning: • Applicant: JONES, CLIFTON ISSUED BY: I' Address: 10945 SOUTH ST#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 : WILKINSON ASSOCIATES Eng: STRUCTURES WEST Address: 17932 SKYPARK CI#A Address: 3430 E FLAMINGO RD#240 Phone: (949)852-8596 Phone: (702)435-1307 IRVINE,CA LAS VEGAS, NEVADA Zip: 92614 License: 89121 License: SCOPE OF PERMIT CONSTRUCT NEW 2-STORY SINGLE FAMILY RESIDENCE WITH ATTACHED GARAGE FOR"INFINITY HOMES"(UNIT J)- 1080 SQ FT 1ST FLR, 1075 SQ FT 2ND FLR,&424 SO FT GARAGE.ALSO,44 SO FT OF FRONT&REAR PORCH. FEE SUMMARY Plan Check: $991.74 Calc Valuation: $194,545.78 Permit: $1,525.75 Claim Valuation: $o.00 SMIP Res: $19.46 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $2,536.95 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(6/00) DECLARATIONS (r) - " 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 work for which this permit Is issued. O I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Cade,for the performance of the work for which this permit is issued. My rkers'compensation Insurance carrier and policy number are: Came Policy Number: (Thi section need not be comp/ permit is valued at one hundred dollars($100)or less.) lI certify that in the pert• work 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• agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith _comply.with.th: �'.1 Applicant Signature:- A-///.. ,I1—Date:—/I---56 Z--r'/(/ WARNING:FAILURE TO S )/'5'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL-PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100, ION 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.Lam.licQOs ypier ylsio commencing with Section 7000)of Division aoff.t�Business nd Professions Code,and my license is in full force end effect.Lia,k G�,(� (��il L. al Contractor's Sire:. "" nr Date: /�ZL 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). 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.). I OW er of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to Construct the project(Sec.7044,Business and Professions o . e 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 exam t under sec. Business and Prole ions Code for this reason: rig u L a . —` nor verifiedby driver's license. ❑Yes 0 No (1)..r• or_I,(cda aNo. '_ I Elpirr0; s - 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 e 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? ❑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 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 Cost."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? LJ Yes LLI 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 Califomia Health and Safety Code). 7 II 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 Califomia 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 AND AUTHORIZATION 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 laws and ci noes relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes,' o occupy or allow occupancy of any building authorized by this permit until final inspection. Si�na�_O) - Q_ //2Z __J'L— And/• onzed Ap•" .' w- ( ��LDatee -- CODE P INSPECTION TYPE --4--- 0n iuImM65 CODE it INSPECTION TYPE ME VEEN& 1616 Fixed System Final Fire Prey: '. 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 �[ 7T�f_ 204 Final Demolition 250 Final Building/Occupancy / '1 fP2_,. (�u(�� 3610: NEWPORT-MESA UNIFIED SCHOOL DISTRICT CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES PURSUANT TO AB 1600 AND AB 181 To: ( X) City of Costa Mesa District Receipt No. ( ) City of Newport Beach ( ) County of Orange Plan Check No B00-00988 Applicant: INFINITY HOMES COSTA MESA Address: 10945 SOUTH STREET STE 301, CERRITOS, CA 90703 Telephone Number: 562/ 924-4491 Tract/Parcel and Lot Number(s): TRACT 15995 Location of Project: 169 EAST 21st ST UNIT J, COSTA MESA, CA Number of Square Feet of: Residential Space 1051 SF x $1.84 Total $1933.84 Commercial and Industrial Space x $ .30 Total Commercial/Industrial Project is: (Check One) _ Warehouse _ Motel _ Preschool R 8 D _ Bank _ Auto Repair Movie Theater _ Neighborhood Shops _ Hospital Mini-storage Racquet/Health _ Large Office Heavy Industrial _ Hotel _ Office Bldg. Regional Shops _ Medical Office _ Restaurant Light Industrial Office Park _ Fast Food This project is exempt because Phis certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Government Code sections 53080 and 65995. The Building Permits for this square footage in this proposed development may now be issued by your jurisdiction. Checks are to be made payable to Newport-Mesa Unified School District. By: BONNIE KUBOTA Authorized Representative The above representation as to square footage is true. Applicant agrees that' ' ' ater determined that such representations are not true, then this certificate shall automatically terminate and the appro• 'a Agai /C,unty shall be notified. NOV 22 2888/2:82 PM/1 21671.52 RCPT8:81-8869238 Date: /I-2 2- C 112345 FINAL GRALIING CERTIFICATION Project Address: 169 21st Street Costa Mesa Lot Number: A Permit Number: G00-00026 By Civil Engineer: • I certify to the satisfactory completion of grading in accordance with the approved plans, specifications, local and state codes. All drainage devices required by the'grading permit, nrarlinn plan and grading ordinance have been installed. Herniate.. provisions have hee.n made for drainage of surface water from each building site. The minimums are: • • 2% Fall from structures within 5 feet from exterior walls. 1% Fall for asphalt surfaces and landscaped areas. 0.5% Fall for concrete surfaces to approved disposal areas. The final monuments as shown on the recorded tract map were set. All final grading eleva- tions ate within ± 1/10 of the desi /��d elevations. Supervising Civil Engineer /N'I"' Reg. No. 31720 1f (Signature) 11/19/01 Date QR /oOFESS4 O r co z • 761,,0 mEXP • t.q 47,r PAL Vic ��; IcO STAMP and SIGN 1Ba'<L ROBIN B. HAMERS 234 E. t HST., SUITE 205 & ASSOCIATES, INC. COSTA MESA, CA 92627 CIVIL ENGINEERS • PLANNERS • SURVEYORS (949)549-1192 FAX(949)546-6516 December21, 2000 City of Costa Mesa Building Dept. 77 Fair Drive Costa Mesa, CA 92628 RE: 169J 216'. St., Costa Mesa Lot 9, Tract No. 15969 Attention: City Building Inspector This letter is to certify that the foundation forms were surveyed for line and grade on December 18, 2000, and are in substantial conformance with the approved grading plan and site plan for the above project. Robin B. Hamers R.C.E. 31720 cc. Infinity Homes QROFESS/04, ���0 0�N B. HAyr ect cO ci) 2c ( ) -i- co RCE31720 rn m w = EXP. 12/31/2004 �yT CIVIL s,/ f FCF CAL0.> ® Printed on Recycled Paper. . FINAL GRAOING CERTIFICATION Project Address: 169: 21st Street Costa Mesa Lot Number: Permit Number: G00-00026 By Civil Engineer: • I certify to the satisfactory completion of grading in accordance with the approved plans, specifications, local and state codes. All drainage devices required by the grading permit, grading plan and grading Ordinance have been installed. Adequate provisions have been made . for drainage of surface water from each building site. The minimums are: 2% Fall from structures within 5 feet from exterior walls. • . 1% Fall for asphalt surfaces and landscaped areas. 0.5% Fall for concrete surfaces to approved disposal areas. The final monuments as shown on the recorded tract map were set. All final grading eleva- tions are within ± 1/10 of the designed Elevations. Supervising Civil Engineer Reg. No. 31720 (Signature) 11/19/01 Date • ()FESS/p y/ oQR RCE ��b 1 XP.c2l3 Iq � � xr CNIL oQ' TFCF CALIFOci, STA-IP and SIGN fio.g 'F 44, ° CITY OF COSTA MESA BUILDING DIVISION H• ___ _ DEVELOPMENT SERVICES DEPARTMENT PERMIT NU BER PERMIT �, E010 38 4%•01..affin se (714)754-5273 • Fax(714)7544856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No J Applied: 05/01/2001 Vicinity: UNIT J Issued: 05/01/2001 Parcel Nunmber: 42619317 Applicant: INGRAM, STEVEN ISSUED BY: Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 • Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: ELITE ELECTRIC Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 License: 418242 SCOPE OF PERMIT ELECTRICAL PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT J). INSTALL NEW ELECTRICAL THROUGHOUT HOUSE,AND INSTALL 1 LIGHT,2 OUTLETS,& 1 SWITCH IN GARAGE. REF:800-00988 FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $120.68 2155 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $1.10 1 up to 50 kva/kw $0.00 0 Recept Outlets $2.20 .2 up to 100 kva/kw $0.00 0 • , ' Switches $1.10 1 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 .0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $148.58 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS 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: 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.ot this permit. 1 FOR INSPECTIONS CALL: (714)754-5626 / (// 2446-46(coo) v 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 _ rk for which this permit iS issued. ?;have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Cade,for the performance of the work for which this permit Is issued. —— My workers'compensation Insurance carrier and policy number are: Cardoza\ Policy Number: '(This section need not be completed i1 the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance I the work 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 of Calif ,and agree 1 I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisi . VApPllcant Signature: , i a �— — 0 WARNING:FAILURE TO SECURE WORkERs'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML RNES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under sions of Chapter 9(commencing with Section 7000)of Division 3 of.the Business and Professions Code,end my license is in full force and effect.Lic.FN _ Class 4. Contractor's Slgrlleturd: _� Daa 1 J — ( --O/ 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 Cale). 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.). ❑ 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 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: 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,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: I 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 California Health and Safety Code been fully complied with? 0 Yes 0 No —.._ _.._ it; _ tio.._ _ ..__....___.io._.—_odi—. 5 Does or willo the applicant or present a future building occupant at y ohier for toe work which is the sor of this a estion eEermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? �Yes LJ No (Section 85850.2 Of the California Govemment 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? ❑Yes ❑No (if yes',the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air 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 0 No B (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 AUTHORIZATION 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. • -gnature Of Legal Own: Date �— / 67 — R And/Or Authorized Applicant, Date—___ ;ODE r INSPECTION TYPE RAIE' !Nati CODEI INSPECTION TYPE PAIS INRT1ALS 1618 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical �'BL 201 Final Block/Retaining Wall 212 Final Fire Prevention I 202 Final Factory Fire Place 220 Final Planning Approval • vr-� 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Ib�c CITY OF COSTA MESA 4, ►- BUILDING DIVISION F <., .t. . DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER inn o ePt4 PERMIT ` I 04. M01-00216 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No J Applied: 04/24/2001 Issued: 04/24/2001 Vicinity: UNIT J Parcel Number: 42619317 ISSUED BY: / Applicant: PETERS, RANDY Address: 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA Zip: 91702 Owner: INFINITY HOMES CM I, LLC Address: CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor OJ INSULATION INC Address: 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA Zip: 91702 License:465709 SCOPE OF PERMIT INSTALL MECHANICAL FIREPLACE IN NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT J). REF:B00-00988 • FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100,k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 Inst/Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 ' 0 Refrig Sys<100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems Gas Piping $0.00 0 Up to 3 hp/100 k BTU $0.00 0 Factory Fireplace $10.65 1 3 To 15 hp/500'k BTU $0.00' :0 Hood w/Mech Exhaust $0.00 0 15 To 30 hp/1,000 k BTU $0.00/ 0 VAV Box - $0.00 0 30 To 50 hp/1,750 k BTU 10.00 0 Vent Fan/Single Duct , $0.00 0 Over 50 hp/Over 1,750 BTU - " $0.00 0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 Up to 3 hp = $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp - $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers< 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $34.15 -COMMENTS/SPECIAL CONDITIONS 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 it work Is not commenced within 180 days,or it 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 expirationof this permit/ FOR INSPECTIONS CALL: (714)754.5626 2446-46(600) 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 for which this permit i5 issued. ..,_work ;AveI nand 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. c�My work rs..'Lcomp sation I surance carder and policy number are: L/ v_ _ ,„�r�/�2 Carder:— eedno e omplo rPbllcyNumber:—O-/,6ClilYlil!/�I]LT,LI/( ,�5.7 (YIDS section need not be cornet°7ed it the permit Is valued et one hundred dollars($100)or less.) ❑ 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 to become Subject to the workers' compensation laws lifomi ,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these ov' ions. / App can�(�Signature-? ,14J r Date: 7f7 / .0 WARNING:FAILURE TO SECURE WORIf2R5'COMPENSATION COVERAGE IS UNLAWFUL ANC/SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TOONE HUNDRED THOUSAND DOlARE($100,000),IN AODmON 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.l.am lice d der pr visions of Chapter 9(commencing with Section 7000)of Division 3 of.the.Bu5pesls and Pro ions Cale,and my license is In full force and efect/IJ c.p, /47670 P� p Contractdr's Signature: -- `( _%." —' (Date:c/�`J6•Q� 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 properly,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 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 Drivers 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,faisework,or demolition or dismantling thereof,will be more than thirty-six(38)feel high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Cale). ❑ 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 Cale requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Flre 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 al 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 Celifomia Health and Safety Code been fully complied with? ❑Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application aEPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LI Yes Ul 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 Of 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? 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 COMPIJANCE AND AUTHORIZATION.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 laws end city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, I Of Le .l Owner(s) at .'. . .�� ._- ndiOr •uthorized Applicant �L_e / CODE A INSPECTION TYPE PATE' INTITIAL$ CODE it INSPECTIONTYPE gdIpE 1[QRIAL,�� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 7�p "�^ L/G�i �"— 1268 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical _ 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 4-0111/4e CITY OF COSTA MESA __ ' 4I 9 BUILDING DIVISION >• ,i DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F t /i t PERMIT , k l Rantfe 1 P00-00670 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No J Applied: 12/01/2000 Issued: 12/01/2000 Vicinity: UNIT J Parcel Nunmber: 42619317 ISSUED BY: Applicant: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 License: 317026 . Arch / Eng: Address: Phone: Zip: License: SCOPE OF PERMIT PLUMBING PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT J). INSTALL 2 BATHTUBS, 1 DISHWASHER, 1 EXPANSION TANK,5 GAS OUTLETS, 1 WASHER, 1 PRESSURE REGULATOR, 1 SHOWER, 1 KITCHEN SINK,UP TO 4 VACUUM BREAKERS,4 WASH BASINS,3 WATER CLOSETS,& 1 WATER HEATER. REF: B00-00988 FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $9.80 1 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $19.60 2 Pressure Regulator $9.80 1 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $12.30 1 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $39.20 4 Dishwasher $9.80 1 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $29.40 3 Drain,Roof $0.00 0 Shower $9.80 1 Water Heater/vent $12.30 1 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $9.80 1 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $6.15 1 Sink,kitchen $9.80 1 Water Softener $0.00 0 Gas(Over 4 outlets) $1.10 1 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $202.35 NOTICE: The work authorized by this permit sCOMMEJ.VU$bSPECIAL QOND$TIONS 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. r 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 p FOR INSPECTIONS CALL: (714)754-5626 244648(8/00) WORKERS'COMPENSATION DECLARATIO I hereby affirm under penalty of perjury one of the following declarations: O 1 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. C .i l 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 Ls issued. My workers'comOensation Insurance carrier and policy number are: Cardec (7 f..) .-Fi Policy Number:_ -O.N FI L& C _(This sectidn need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ 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 to become subject to the workers' compensation laws of California,and a•ree that if should become subject to the workers'compensation provisions of Setion 700 of the Labor Code,I shall forthwith comply with these•,. ons. 7 _ Applicant Signature: a./. ALA. ./moi Date:— J,2 5 CL//� WARNIND:FAILURE TO SECUREERS'... TION COVERAGE IS LINLAW FUL AND SHAH SUBJECT AN EMPLOYER TO CRIMII�jAL TES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000), DmcN TO COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. .. LICENSED CONTRACTORS DECLARATION: I hereby affirmrthat1.am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the•Business and Professions Code,and my license is In full force and effect._Lic..e—a-1.7 fla (,Class w --- Contractor's Signature: /Date: CONSTRUCTION LENDING AGEN Y: II ❑ 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 is sold within one year o1 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 drivers 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,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 Wit the applicant or present or future building occupant need to filo 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 al standard temperature and pressure). _._..._. or w tete...__ f_ _tete_.__ 0 ..._...._. 2 Does or will the applicant or present or future building occupant need to file a registration forth for acutely hazardous materials? Ves 0 No (Section 25533 of the Califomia Health and Safety Code.with some exceptions.requires registration with the Costa Mesa Flre 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). rote_..._ _ _...._._ ate all) 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management end Prevention Program for acutely hazardous materials)? ❑vas ❑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 en 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 a_EPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? IQ Yes LJ No (Section 65850.2 of the California Govemment 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 11 a permit from the South Coact 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? 0 Yes 0 No v(If yes',attach 8certificate 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 AUTHORIZATION 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. n nature• Legal Owner(s) Date A Ate/ 1 -4011-.”,,,- il /0V50 _____________ s .r •uthorized Applicant,- - . . —- r--Date__ BODE F .y *se•, .' PATE Itl1IDE65 PDF If INSPFCTION TYPE DAM a - 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1268 Pool Spa Final 208 Final Plumbingwic if 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 250 Final Building/Occupancy 4`On tz 9 CITY OF COSTA MESA a) BUILDING DIVISION e2' ____ DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 1. 1 J 11%,-....,0 oAr PERMIT 1101-00166 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No J Applied: 04/02/2001 Issued: 04/02/2001 Vicinity:. 1 Parcel Number: 42619317 ISSUED BY: .J°it • Applicant: RENZ, RUSS " Address: Phone: 714-577-0771 ! Zip: Owner: , INFINITY'HOMES CM I, LLC Address:, CLIFTON JONESIII CERRITOS,-CA Phone: 562 924 4491 , , ' , 10945 SOUTH STREET,#301 Zip: 90703 , E .. �. ��. Contractor: .,; SENTRY MECHANICAL, INC. , ' , r Address: '' 540 S JEFFERSON . - 1 \\ CA Phone: 714-577-0771 ' PLACENTIA,CA Zip: 92870 ' License:631049 ' SCOPE OF PERMIT INSTAL HEATING AND AIR CONDITIONING IN NEW SFR. ' REF:B00-00988.CONTRACTOR IS DOING HEATING AND AIR CONDITIONING ONLY. F_EE SUMMARY Quantity Quantity, ISSUE FEE $23.50 Repair/Alt Absorbtion Unit ; $0.00 0- Inst FAU <100 k-BTU $0.00 0 - Repair/Alt Refrigeration Unit Y $0.00 0, ' Inst FAU>100 k BTU $18.20 1 Ventillation System 7' $0.00 0 Repair/Alt Cooling/Heat $0.00. 0 • Evaporative Cooler /; $0.00 • -0 Inst/Rep.Recess Wall Htr $0.00 0 Commercial Incinerator ' / $0.00..- ,0 - Refrig Sys<100 k BTU ' • $0.00 0 Domestic Incinerator i' .$0.00 ' 0 ' Refrig Sys>700 k BTU $0.00 0 -Compressors/Absorption Systems ;%/' Z '' ,./ Gas Piping $0.00 0 Up to3 hp/100 k BTU - $0.00 0 Factory Fireplace $0.00 0 3 To,15'hp/500 k BTU $0.00 0 ' Hood w/Mech-Exhaust . $0.00 0 • .15 To 30 hp/1,000 k BTU ,< - .$0.00, '0 VAV Box ' v,.A • ' $0.00 `•0 ' ' -, 30 To 50 hp/1750kBTU $0002 %0 Vent Fan/Singled Duct '$0.00 0 - , Over 50 hp/Over 1,750j BTU ' $0 06 0 Appliance '.\ ` <,/,/ /7 $00O / 0. , Boilers " , ,f Fire Dampers ��.</ .,/ / $0.00\0 Up to 3 hp - 1 v�' 7,$000 0 Smoke Dampers ,� , 7,/,,-$0.00.. 0- .-- '3 To 15 hp- " ' $27 15 1 Inst or Relocate Appl Vent.;-,A ‘,-..$0.0,0-- 0 - '- '15:to30 hp A\ , c 2/ $0.00 0 Air Handlers< 10000cfmV "$0.00 0 - 30to 50 hp - � $0.00 0 Air Handlers> 10000cfm '" .$0.00 ' '0 - - Over 50 hp ,- - ` `. $0.00 0 Floor Furnace A -2$0:00 `0 , - ' Other Mechanical Fee - ', Floor or Suspend Heater `-$0.00--"Z„-0 - .,, c -_ Investigation Fee $0.00 �, - Plan Check Fee - $0.00 Reinspectidn-Fee $0.00 • >_ - _ TOTAL CALCULATED FEES $68.85 COMMENTS/SPECIAL CONDITIONS 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 it 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 7 / 2446.46(6ro0) (/ 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 sell-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. C -N7:"..1 have and will miintain 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 w ars'compensation nsurance carrier and policy number are: ,q-7 ( -Cartier.' 1 r� U l(€z (t , Policy.Numher UNE- a' 10700 " �(• \\ -(this section need t b Meted if the pa it Is v lued t one hundred dol ars(_$100)or less.) ❑ 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 to become subject to the workers' compensation I of California d r I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith r _ comply with the: sypv�p7�v�ision,�s�. ,ap\ _ �/1I) 1 Signature: `tt'1ti/^ � Dale:—." WARNING:FAILURE TO SECURE WORKERS'COMPE TION COVE E IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060F THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm thatl am licensed under provision of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Pro�ss�' nsw Code,and my license Is in full force and effect Lic. �.�' Class», • 1. conic s signatu �r 4' I' -llb r [ pate: yl3/n 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: 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 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.). ❑ 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 Drivers 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 feel 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,Titles;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: I 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? ❑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 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 a_aermit 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 Califomia 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 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 0 No 8 (It 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 AllTHORVATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nature Of Legal Owner(s) Date Aa - - I —And/0 r•uthorized Applicant -- IO) Date- - 1 CODE. INSPECTION TYPE DATE' MAO CODE. WSPECTIONTYPE D �.rr. 1616 Fixed System Final Fire Prevention 206 Final Mechanical T. 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Root 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 250 Final Building/Occupancy 4c 9 BUILDING COSTA MESA DIVISION F• r,,,•' ,�mewirs DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER / ° PERMIT 11 +y� BOO-01366 `"boaa,N (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.usNG PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDIJob Address: 169 21ST ST Status: ISSUED Suite: C&D Applied: 09/05/2000 Vicinity: DUPLEX-UNITS C&D Issued: 09/05/2000 Parcel Number: 42619317 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 2017 SQ FT DUPLEX(UNITS C&D). FEE SUMMARY Plan Check: $0.00 Calc Valuation: $3,500.00 Permit: $97.25 Claim Valuation: $3,500.00 SMIP Res: $0.00 SMIP Com: $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 2446-46 f6i00l 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 for which this permit Is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Cale,for the performance of the work for which this permit is Issued. My workers'compensation Insurance carder and policy number are: Carder: Policy Number: (This ren need not be completed if the permit is valued at one hundred dollars($100)or less) 1 certify that in the perto e work 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 of, agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply withthese • de ApplicaniSgnature:--v . -Date:- CWARNINOrFAILURE TO-I CURE • ERS' COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER-TO-CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND COLLARS(SI v,00o),I ,•DRION 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.l.am.licens d n,Q�,er•rovisi•.iii 9(commencing with Section 7000)of Division 3 of the Busines nd Professions Code,and my license is in full force and effect.Lic.B tZ' C) 1tClass a i Cantreaors Signature: ', — r Dete:=� I • CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construc • ending 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:My 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 fora 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.). ❑ 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,Le.-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 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: I 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 then 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 en 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 aapernit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes O No (Section 65650.2 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 ❑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 Safely Code Section 42303 been made? 0 Yes 0 No ...r fce ofcopi compliance from the p.. print...i.pollution .l ...no.......). 8 (If"yes'.attach certificate of compliance from the appropriate air ptocontrol 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 AUTHORIZATION 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 laws end : ances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection iiiipurp• •, not to occupy or allow occupancy of any building authorized by Ihis permit until final inspection. iiv •. er(As) S-cote • /�•Icon Date —CODE r QA18—'---"ff:l➢A4$ -- CODE! INSPECfONTYPE —PALE INImM$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing _ 200 Final Re-Root 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 //A7,, ft 2-- ( 250 Final Building/Occupancy •. CITY OF COSTA MESA 41111‘.. BUILDING DIVISION ►. DEVELOPMENT SERVICES DEPARTMENT P NUMBER HI (-Z I ri - PERMIT �' 00-00986 o (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.usNG PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDIJob Address: 169 21ST ST Status: ISSUED Suite: C Applied: 06/30/2000 Vicinity: UNIT C Issued: 11/22/2000 Parcel Number 42619317 Zoning: Applicant: JONES, CLIFTON ISSUED BY: /1 Address: 10945 SOUTH ST#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 : WILKINSON ASSOCIATES Eng: STRUCTURES WEST Address: 17932 SKYPARK CI#A Address: 3430 E FLAMINGO RD#240 Phone: (949)852-8596 Phone: (702)435-1307 IRVINE, CA LAS VEGAS, NEVADA Zip: 92614 License: 89121 License: SCOPE OF PERMIT CONSTRUCT NEW TWO-STORY SFD WITH ATTACHED GARAGE FOR"INFINITY HOMES"(UNIT C)-1080 SQ FT 1ST FLR, 1075 SQ FT 2ND FLR,&424 SQ FT GARAGE.ALSO,44 SQ FT FRONT&REAR PORCH. FEE SUMMARY Plan Check: $991.74 Calc Valuation: $194,545.78 Permit: $1,525.75 Claim Valuation: $0.00 SMIP Res: $19.46 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $2,536.95 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(6/00) • , •- 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: Carder: Policy Number: (This tion need not be complet:• e p: mit is valued at one hundred dollars($100)or less.) I.certi that in the pe•• The 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- •f C nd gree tha ' ;,.•ecome subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith complywith.the-:pro '-•I. q Applicant Signature:• �� ��� (Date: !/ � `�'� `WARNING:FAILURE TO SE URE WORK,'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($1..,0001,IN'••Ir ION 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.lic rtd/{•zvisisns o J;�T r. mmencing with Section 7000)of Division 3 of the.Busin nd Professions Code,and my license Is In full force and effect.c u C,- -,.g �• s Glass_N j� _: -//-2 T-,�7 U ConlractolsSignat ru e: i, - .,S/ Date: CONSTRUCTION LENDING AGENCY: Ilir ❑ 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). 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.). El 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. El 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,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: I 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? El 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? ❑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 Cost,.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? El Yes El 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? IID Yes j No (Section 65850.2 of the California Govemment 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? ❑Yes ❑No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 11 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 AUTHORIZATION 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 laws :.• city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspecti.. • ree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si...,,: Cf •wner(s) Date i/'7Z-CZ) -011.11Pt Aut d pplicant _ (Date ;ODE I INSPECTION TYPE DATE INTRIAI5 $,ODE! INSPECTION TYPE PAIR 1�L5 1616 Fixed System Fina Ire 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 250 Final Building/Occupancy �7-� 4u!F!�t _ "'l�' • 3604 NEWPORT-MESA UNIFIED SCHOOL DISTRICT CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES PURSUANT TO AB 1600 AND AB 181 To: (X ) City of Costa Mesa District Receipt No. ( ) City of Newport Beach ( ) County of Orange Plan Check No.B00-00986 Applicant: INFINITY HOMES COSTA MESA Address: 10945 SOUTH STREET STE 301, CERRITOS, CA 90703 Telephone Number: 562/ 924-4491 Tract/Parcel and Lot Number(s): TRACT 15995 Location of Project: 169 EAST 21st ST UNIT C, COSTA MESA, CA Number of Square Feet of: Residential Space 1147 SF x $1.84 Total $2110.48 Commercial and Industrial Space x $ .30 Total Commercial/Industrial Project is: (Check One) Warehouse _____ Motel _ Preschool R & D _ Bank _ Auto Repair Movie Theater _ Neighborhood Shops _ Hospital Mini-storage Racquet/Health _ Large Office Heavy Industrial _ Hotel _ Office Bldg. Regional Shops _ Medical Office _ Restaurant Light Industrial _ Office Park _ Fast Food This project is exempt because chis certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Government Code sections 53080 and 65995. The Building Permits for this square footage in this proposed development may now be issued by your jurisdiction. Checks are to be made payable to Newport-Mesa Unified School District. By: BONNIE KUBOTA Authorized Representative The above representation as to square footage is true. Applicant agrees that if d is lat:r determined that such representations are not true,then this certificate shall automatically terminate and the appr• • .tet ity/Cou shall be notified. NOV 22 2888/2:02 PM/1 21671.52 RCPTII:81-8069238 Date: 4-22 -au - -At Cc 112345 • \ ROBIN B. HAMERS 234 E. 17THST. SUITE 205 Si. ASSOCIATES, INC. COSTA MESA. CA 92627 CIVIL ENGINEERS • PLANNERS • SURVEYORS 0949) 546-1192 FAX(949)548-6516 December 21, 2000 City of Costa Mesa Building Dept. 77 Fair Drive Costa Mesa, CA 92628 RE: 169C 21st. St., Costa Mesa Lot 3, Tract No. 15969 Attention: City Building Inspector This letter is to certify that the foundation forms were surveyed for line and grade on December 18, 2000, and are in substantial conformance with the approved grading plan and site plan for the above project. Robin B. Hamers R.C.E. 31720 ��QROFESsioik ,`�Q 001A B.HA,yi !F cc. Infinity Homes L, ccP o co N2 fr RCE31720 m <tt .XP12/31/2004 s i CIVIL �- F°F CAt.1?0\ a Cll Printed on Recycled Paper. FINAL GRACING CERTIFICATION • Project Address: 169 21st Street Costa Mesa Lot Number: C Permit Number: G00-00026 By Civil Engineer: • I certify to the satisfactory completion of grading in accordance with the approved plans, • specifications, local and state codes. All drainage devices required by the•grading permit, grading plan and grading ordinance have been installed. Adequate provisions have been made for drainage of surface water from each building site. The minimums are: • 2% Fall from structures within 5 feet from exterior walls. 1% Fall for asphalt surfaces and landscaped areas. 0-5% Fall for concrete surfaces to approved disposal areas. • The final monuments as shown on the recorded tract map were set. All final grading eleva- tions ate within ± I/10 of the designed elevations. 31720 Supervising Civil Engineer • Reg. No. (Signature) 11/19/01 Date �oQROFESS/04, �c3b` B.H114%,6 Fyc m I M720E12004 yr zs sfNT CIVIL O\P' CF CALFf STN-IP and SIGN ee+sc INSULATION CERT aCATE - r'IIC-1 169—C 21st Street Costa Mesa Number and Street City Orange Amber Way—#15969 C County Subdivision Lot Number Description of Installation 1. ROOF Material Brand Name Thickness (inches) Thermal Resistance(R-Value) 2. CEILING Batt or Blanket Type Batts Brand Name Certaintccd Thickness (inches) 10" Thermal Resistance(R-Value) R-30 Loose Fill Type Brand Contractor's min installed weight/ft2 lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance(R-Value) 3. EXTERIOR WALL Frame Type A. Cavity Insulation Material Ft hergl acc Brand Name Certainteed Thickness(inches) 3 1 /2" Thermal Resistance(R-Value) R-13 B . Exterior Foam Sheathing Material Brand Name Thickness (inches) Thermal Resistance(R-Value) 4, RAISED FLOOR Material Fiberglass Brand Name Certainteed Thickness (inches) 6 1 /4" Thermal Resistance (R-Value) R-19 5, SLAB FLOOR/PERIMETER Material Brand Name Thickness (inches) Thermal Resistance(R-Value) Perimeter Insulation Depth(inches) 6, FOUNDATION WALL Material Brand Name Thickness (inches) Thermal Resistance (R-Value) Declaration I hereby certify that the above insulation was installed in the building at the above location in conformance with the current ii), Energy Efficiency St. rds for residential Ejuildings(Title 24, Part 6,California Code of Regulations)as indicated on the Certificate of Comp e, wheel- A..plicab ///A/ r�_..r- , 6/26/01 OJ Insulation Co. , Inc. Item #s Signature, Dat- k Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item #s Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item #s Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Revised March I, 1996 CITY OF COSTA MESA ' fl 9 BUILDING DIVISION F •_,g I DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER , o,� PERMIT J• ' F00-00 3 (714)754-5273 • Fax(714)754-4856 • w.ci.costa-F REaSUPRESSION PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 169 21ST ST Status: ISSUED Suite: C Applied: 11/02/2000 Vicinity: UNIT C • Issued: 04/11/2001 Parcel Number: 42619317 Zoning: ISSUED BY: Applicant: MARTINEZ, MONA LISA Address: 1787 POMONA RD SUITES D&E Phone: (800)915-3473 CORONA,CA • Zip: 91720 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor FIRE SPRINKLER SYSTEMS Address: 1787 POMONA RD SUITES D&E Phone: (800)915.3473 CORONA, CA Zip: 91720 License: 684600 SCOPE OF PERMIT FIRE SPRINKLER PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT C). INSTALL 25 FIRE SPRINKLER HEADS. REF:1300-00986 FEE SUMMARY Plan Check: $39.07 Calc Valuation: $1,7oo.0o Permit: $60.10 Claimed Valuation: 81,700.00- Other: $0.00 Total: $99.17 • • 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(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 for which this permit is issued. `—t 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'pom�.p{pp-nsatlon I uranceearrler and policy number are: _ / C -Cartier:- V/ "'^ p /nor Policy Number: C/D-S-lL Lind o0con�f' (This section need not be bomple ed if the permit is valued at one hundred dollars($100)or less) ❑ 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 to become subject to the workers' compensation laws of California,and agree that If I should ubject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these rovisions. r Applicant Signature: ion - // /(j/'7/ Data: 47/ 1 WARNING FNLURE TO SECURE W ERS'COMPENSATION GE IS UNLAWFUL AND SHALL SU0IECT AN EMPLOYER TO CRIMINAL PENAL ES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,061),IN ADDITION TO THE COST OF NSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I-am Ilcer9seOu er rpvisio of Chapter 9(commencing with Section 7000)of Division 3 of.the Business aqd Profepsions Code,and my license is in full force and effect.-Llc:F cx �/ J Class a _ ( /(�/r Contractors Signature: m 07 1174 (/ Date: - 41/4/(/O/ Jl} 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). Lender's 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 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.). ❑ 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 ❑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: ❑ 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 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 California Health and Safety Code been fully complied with? 0 Yes ❑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? ❑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? 0 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 AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until finalfi` inspection. „e/„..., /� Si a Of L ner(s) /% LT4�, AnNOr Au Applicant Dat CODE I, INSPECTION TYPE .. I PATE' 7�8 TIAL5 CODE If INSPECTION TYPE fN4TIALS 1616 Fixed System Final Fire Prevention �'-T 'U) wr' 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 1 // 201 Final Block/Retaining Wall 212 Final Fire Prevention id -'(p'Ot .3'3 202 Final Factory Fire Place 220 Final Planning Approval . 203 Final Sign 222 Final Site 204 Final Demolition - 250 Final Building/Occupancy CITY OF COSTA MESA Ci tar) ar BUILDING DIVISION • •rJ arra.,,m; DEVELOPMENT SERVICES DEPARTMENT P RMIT NUMBER : PERMIT E01-00332 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No C Applied: 05/01/2001 Vicinity: UNIT C Issued: 05/01/2001 • Parcel Nunmber: 42619317 Applicant: INGRAM, STEVEN ISSUED BY: Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 • Owner: / INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: • ELITE ELECTRIC Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 License: 418242 SCOPE OF PERMIT • ELECTRICAL PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT C). INSTALL NEW ELECTRICAL THROUGHOUT RESIDENCE& 1 LIGHT,2 OUTLETS,& 1 SWITCH IN . GARAGE. REF: B00-00986 FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 . Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $120.68 2155 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $1.10 • 1 up to 50 kva/kw $0.00 0 Recept Outlets $2.20 • :2. up to 100 kva/kw - $0.00" ,0 Switches $1.10 : 1 over 100 kva/kw $0.00 - 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl N $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 . 0 Misc.Conduit $0.00 0 Service to 1000a $0.00 , 0 Misc.Conductor $0.00 0 Service over 10003 $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 .0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $148.58 Intermed Pole $0.00 0 COMMENTS I SPECIAL CONDITIONS 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 air 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: ❑ 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 ork for which this permit is issued. r 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. t•My workers'compensation Insurance carrier and policy number are: "Carrier:- (Policy Number: -(This'section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the perfor .•-= •.II• • 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 • atifo -. ' •• " •. • esubject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with the :pro •-• • •• — O r _Applicant.Signature: — �Dete: WARNWG:.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under �� of Chapter 9(commencing with Section 7000)of Division 3 of the.Business and Professions Code,and my license is in full force and effect:Lic.x ) Class A ,) Contractors Signature: - TD5tei x{ —1 —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). 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).): 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 property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). O I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑Yes ❑No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or dead): 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 ❑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 aggermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? IJ 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 Califomia 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? ❑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 AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ..4.1111.1r• lure Of Legal• n Dto AndlOrAuthorized A.. cant f Date ' CODE t. INSPECTION TYPE PATE' INTITIALS CODE• INSPFSTl N TYP DATE INTITIALS J////,///� 1616 Fixed System Final Fire Prevention - 206 Final Mechanical ..[�" 1266 Pool Spa Final _ 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 9.4 • 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 - 250 Final Building/Occupancy _ CITY OF COSTA MESA :a.)) BUILDING DIVISION / Y iDEVELOPMENT SERVICES DEPARTMENT PERMIT N MBER tel MINI PERMIT %women'se VVV M01-00209 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No C Applied: 04/24/2001 Issued: 04/24/2001 Vicinity: UNIT C Parcel Number 42619317 ISSUED BY: Applicant: PETERS, RANDY ' Address: 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA, Zip: 91702 Owner: INFINITY'HOMES CM I, LLC Address: CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor , OJ INSULATION INC Address: 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA Zip: 91702 , License:465709 ' ' SCOPE OF PERMIT INSTALL MECHANICAL FIREPLACE FOR NEW SINGLE FAMILY RESIDENCE(UNIT C). ' REF: B00-00986 - - FEE SUMMARY . Quantity Quantity' ISSUE FEE $23.50 - Repair/Alt Absorbtion Unit $0.00 0. Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00 0 , Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler - $0.00 0 Inst/Rep. Recess Wall Htr $0.00 0 Commercial Incinerator , / .$0.00 0 ; Refrig Sys<100 k BTU, $0.00 0 Domestic Incinerator ;' $0.00' 0 Refrig Sys>100 k BTU $0.00 0 - ' Compressors/Absorption Systems / - Gas Piping $0.00 0 Up to 3 hp/100 k BTU $0.00,, 0 Factory Fireplace . $10.65. 1 3 To 15 hp/500 k BTU .$0.00 0 Hood w/Meeh Exhaust ' $0.00- --0 15 To 30 hp/1,000 k BTU . $0.00, /0 VAV Box - -$0.00 0 . 30 To 50 hp/1,750 k BTU ' ' , $0.00/ 0 Vent Fan/Single Duct . '' .. $0.00 0 _ ' Over 50 hp/Over 1,750 BTU ..$0:00 0 Appliance / -$0.00 '`0 Boilers ,,. Fire Dampers , , '',.$0.00 0 Up to 3 hp - /- ' $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp - / $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers< 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers> 10000cfm .$0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 • Reinspection Fee $0.00 TOTAL CALCULATED FEES $34.15 COMMENTS I SPECIAL CONDITIONS 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(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 for which this permit is issued. ?rictus 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 r:- ---Workers'',compo Lation1-surance Carrier and policy number are: rNumber:, r 4003 Carder. `I--dr•LJlll•'• 0r•,`^/1�/19rm Polic Number:- ((Thissection nee not be completed if the p it is valued at one hundred dollars($100)or less.) O 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 to become subject to the workers' compensation I(.��y,.y•,Californi=,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall lonhwith comply with 1.- 1 visi• / Applicant Signature: .y Ati/ .S rDate"1 y- z.(') -o/ '-WARNINGrFAILURE TO S CUR •'KERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND GVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE G100.000).1 ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST.AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that.l.am.lic=n :. ,. pJQv ins of Chapter 9(commencing with Section 7000)of Division 3 of the Busi}Hssw. d Pr 1 yigns Code,and my license is in full force and effect.Lic.R.J / Cl Class pi(C"/ C�.)L Contractors Signet-r WS 74 A. (pate:) (!_ 7 / �'1/ `001 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). Lender's Name:lLender'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 properly,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 tor 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 se0. — Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑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 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 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 a plication akermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes U 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 Safely 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? 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 AND AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ign�ture eget Owner(s) —� (7. ate Date And/OcAuthonzetlApplicant----' rDat§---__ BODES INSPECTION TYPE DATE INTITIALS CODE. INSPECTION TYPE DATE INTRIALS 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 /2'G—O/ /J 1./ - ins.- 220 Final Planning Approval • 203 Final Sign 222 Final Site 204 Final Demolition - _ . 250 Final Building/Occupancy e - CITY OF COSTA MESA I frig BUILDING DIVISION r :� ,,,„' , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER llil VIA 4. rill I PERMIT . e .•ril: ✓P00-00668 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No C Applied: 12/01/2000 Issued: 12/01/2000 Vicinity: UNIT C Parcel Nunmber: 42619317 ISSUED BY: Applicant: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 License: 317026 Arch / Eng : Address: Phone: Zip: License: SCOPE OF PERMIT PLUMBING PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT C). INSTALL 2 BATHTUBS, 1 DISHWASHER, 1 EXPANSION TANK,5 GAS OUTLETS, 1 WASHER, 1 PRESSURE REGULATOR, 1 SHOWER, 1 KITCHEN SINK, UP TO 4 VACUUM BREAKERS,4 WASH BASINS,3 WATER CLOSETS,8 1 WATER HEATER. REF: 600-00986 FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $9.80 1 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $19.60 2 Pressure Regulator $9.80 1 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $12.30 1 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(54-) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $39.20 4 Dishwasher $9.80 1 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $29.40 3 Drain,Roof $0.00 0 Shower $9.80 1 Water Heater/vent $12.30 1 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $9.80 1 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $6.15 1 Sink, kitchen $9.80 1 Water Softener $0.00 0 Gas(Over 4 outlets) $1.10 1 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $202.35 NOTICE: The work authorized by this permit s6".OMMENTS/aSPEOHble BOOWITLONS 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,-an - 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 :-Z- 2446-46 � 2446-46(6/00) • 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. IC7__Mayo 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..—CP FILE' Pbl cy_Number:-f i- Fi LA- — (This section need not be completed if the permit is valued at one hundred dollars(3100)or less.) O 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 to become subject to the workers' compensation laws of California,and agreeshat if should become subject to the workers'compensation provisions of Section 700 of the Labor Code,I shall forthwith comply with these p`vi-ons. Applicant.Signature: - "/ -Ater r LAdd Date:/Z c06 (WARNING:FAILURE TO SECURE ERS'•x - •ATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CR I ENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5100,000) DITION TO •''•fr••�� T OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE R CODE.INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I emilcen-ed nder p ovisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect:,LIc:M--- Ca " Class F.—rf34 Contrctors.Signature:-— Sr.. hi (Date: - -/t-Fr-t?C� CONSTRUCTION LENDING AG: : ❑ 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). 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 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 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 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,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 hes 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 0 N (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? 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 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? 0 Yes 0 No r 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 AUTHORIZATION 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. -legal Owner(s) © Date d 4IsAi i..�1..,, r,/ i�' .Prill AuthodzedApplicant - - • -. -> Date ;ODE 1 • I, a' QM 11211MLS CODE! INSPECTIONTVPE PM IIU 1616 Fixed System Final Fire Prevention 206 Final Mechanical /� p O 1266 Pool Spa Final 208 Final Plumbing 1x1`6-0l iv 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 250 Final Building/Occupancy 4`illi A CITY OF COSTA MESA ',.� BUILDING DIVISION Fe r4' DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBS t I,,..' i /p f • PERMITit- v iteeemee I. , Y M01-00169 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST . Status: ISSUED Suite No C Applied: 04/02/2001 Issued: 04/02/2001 Vicinity: (/" Parcel Number: 42619317 ISSUED BY: Applicant: RENZ, RUSS: "/, / • \ Address: - - ,7///',/-- i Phone: 714-577-0771 i Owner `INFINITYrHOMES CM I, LLC Address: CLIFTON JONES III - 7/ //,"/. � , / - - CERRITOS,CA/ Phone: 562 924 4491 ,_ 10945 SOUTH STREET,#301 Zip: 90703 / \ Contractor 'SENTRY MECHANICAL, INC. ' Y �\ / • / Address: ' 540 S JEFFERSON, '"• - ` - - CA - -Phone: 714-577-0771 . PLACENTIA, CA - Zip: 92870 - - - - : - -T I License:631049 1 / - ?7 SCOPE OF PERMIT ; A. - INSTAL HEATING AND AIR CONDITIONING IN NEW SFR.. , Ti REF:B00-00986.-CONTRACTOR IS DOING HEATING AND AIRCONDITIONING-ONLY. - C _ , FEE SUMMARY - Quantity'- - - ,• Quantity,i ISSUE FEE $23.501 -- - - — / Repair/Alt Absorbtion Unit /„,-$0 00 - 0, r Inst EAU<100.k 0` -- -BTU I ' $0.00 '1 ,, ' Repair/Alt Refrigeration Unit , i$0.00- 0/ Inst FAU>100 k BTU $18.20 1 Ventillation System 1",$0 ,µ 00 - 0 / Repaii(-Alt,Cooling/Heat $0.00. 0 Evaporative Cooler - / ` $0.00='0 /,'I = I / Inst%R,ep. Recess:Wall Htr- $0.00 0 Commercial Incinerator 4o : $0.01).,-,�0 j Refrig Sys<100 k BTU , :i., $0.00$0.00 0 Domestic Incinerator 1/4�/ so.00" 0�!( Refrig Sys>100 k-BTU/' - $0.00 0 -.;-t�.:Compressors/Absorption Systems i ,, <�� /t','/ Gas Piping,`, \\,,,,,----- $0.00 0 Upitoi3 hp/100 k BTU ,"�.7� x$0.00 20' Factory Fireplace $0.00 0 3 To'15-h /500 k BTU p, �,. $0001.0/ Hood w/Mech"Exhaust: -$0 00 0 %"15 To 30 hp/1 000 k BTU- 7.7'71 - $0 00;l00 VAV Box V��K, \'$0.00,->--0- -;- —,,,i30 To 50 hp/-1 750 kBTU- -Ji7 -- $0.001/ 0 Vent Fan/Single'Duct \ '$0:00 0 - 6 ,Over 50 hp/Over 1 750 BTU-' / '- $0.00 0 Appliance \-�� / $000..0� <` O , ,Boilers / �;� 2'1 Fire Dampers \\�/' $0.00 0 �: Up to 3 hp -j% �/\`'2" '2,$0.00 0 Smoke Dampers \V\ �. �$0:00� 0"---,-...,„:, .:,,,,,,,,,,, . -3 Toll5 hp %< „/,..,AV/j/ / $27.15 1 Inst or Relocate Appl Vent.,/,,,, N,>.$6.60 ,, $0.00 `0.. •:- `_''l5 to 30 hp' 11 1 'A(/ it '/ $0.00 0 Air Handlers< t 0000cfm� <.� '$0.00 /0 , 30 to 50 -hp - - A / - '2 ' $0.00 0 Air Handlers> 10000cfm N i.$0.00 f0 -, it/ _ . - Over-50 hp .'-i , \ \'\ /n/j $0.00 0 Floor Furnace '"--,``,T,..$0.00 0 t . ' . - / -Other Medhanical-Fee l Floor or Suspend Heater '$0:00', 0 ' N- - Investigation.Fee'7 - j $0.00 -`---.71 _ - - ' • - Plan Check Fee t - $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $68.85 COMMENTS/SPECIAL CONDITIONS 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. 7 FOR INSPECTIONS CALL: (714)754-5626 2446-46(6/00) U 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 w�for which this permit is Issued. /QUI 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'worrkkers' pensation Insurance carrier and policy number are: r` ( 'Carrier GDO WtG h _.1}-1 c (/V h h c c Cc. Policy Number:--J IAJ c 0 I o 7cc -O C) -(This section need not be completed if the permit is valued at one hundred dollars($100)or less.) L---- -- ❑ 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 to become subject to the workers' compensation laws of California nd agr=e t I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with the.' ovisions. _Applicant Signature:- . AA , .A Date: ��'S—G ,WARNING.FAILURE TO SECURE WORKERS'COW'NSATION COV-111.f E IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 37060F THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisipns of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect•Litt#~ip • �J't (i Class# L 7 r) GontrectbraSigriaturer - /'Date:- y.� —Cr l 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). Lender's 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 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.). ❑ 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,tatsework,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 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? ❑Yes ❑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? ❑Yes ❑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 0 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? ❑Yes ❑No (If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air 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 ❑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 AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ea- Of Legal Owner(s) t \ Date .. tea- �f-3 -E; nT��uthw'.ed.Applicent; Date---- - CODE A INSPECTION TYPE PAIL airMALS PODS I INSPECTION TYPE DATE NTITIAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1D-b-o( R/y/ 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 • 250 Final Building/Occupancy G1 1 • .F CITY OF COSTA MESA BUILDING DIVISION, / :• rDEVELOPMENT SERVICES DEPARTMENT PER IT NUMBER to 1""r ar IZ' PERMIT -00987 , °' 0 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.BUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 169 21ST ST Status: ISSUED Suite: D Applied: 06/30/2000 Vicinity: UNIT D Issued: 11/22/2000 Parcel Number: 42619317 Zoning: Applicant: JONES, CLIFTON 9 ISSUED BY: Address: 10945 SOUTH ST#301 r1 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 : WILKINSON ASSOCIATES Eng: STRUCTURES WEST Address: 17932 SKYPARK CI#A Address: 3430 E FLAMINGO RD#240 Phone: (949)852-8596 Phone: (702)435-1307 IRVINE,CA LAS VEGAS,NEVADA Zip: 92614 License: 89121 License: SCOPE OF PERMIT CONSTRUCT NEW 2-STORY SINGLE FAMILY RESIDENCE WITH ATTACHED GARAGE FOR"INFINITY HOMES"(UNIT D)- 1080 SQ FT 1ST FLR, 1075 SQ FT 2ND FLR,&424 SQ FT GARAGE.ALSO,44 SQ FT FRONT&REAR PORCH. FEE SUMMARY Plan Check: $991.74 Calc Valuation: $194,545.78 Permit: $1,525.75 Claim Valuation: so.00 SMIP Res: $19.46 SMIP Corn: $0.00 Other $0.00 Inspection: $0.00 Total: $2,536.95 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, andla I / 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 C/ 2446-48(WOO) DECLARATIONS lc r WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: O I have end 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 on need not be completed 11 e p: i 's valued at one hundred dollars($100)or less.) 4 —I certify that in the pert• f t :wor or which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' Lc_--compensation law • Call . d Ben:that if I s ome subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with the :gravis• 00Applinant Signature: - - tilli (—Date: WARNING FAILURE TO a'alta WORKER- ''a PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100-n),IN ADD , 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 thaLt.em.licens�¢d under p ovl on 9•w9( mmenci with Section 7000)of Division 3 of the'Busine d Professions Code,and my license Is In full force end effect.Lic.# 77 40& �• (Class q". -------- Contractor'sSignature: - ,i`/J1 Date: /f_Z•7 CO 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: 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 for a permit subjects the applicant to a civil penalty of not more then 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,end 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,em 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.). O I am exempt under sec. Business end 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: I ❑ 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? ❑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 lime 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 a plication a ermit for such construction or modification from the South Coast Air(Duality Management District or from any other air pollution contra district or agency? 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 II 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 6 (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 • • •• IZATION 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 a ' s an: city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property fo '•-' p •oses I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. jaxe ure Of L:•: Owner(s Alz/ z Date_„ ..— And/O A orized Applicant .S. . - . . . _ - Date . - gNOE 1 , ' 11•. u. / — Oa INTITAU CODES INSPECRON TYPE ME P SL$ 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 Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy `/._/G.4,2_ • , . 3605:- NEWPORT-MESA UNIFIED SCHOOL DISTRICT CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES PURSUANT TO AB 1600 AND AB 181 To: (X ) City of Costa Mesa District Receipt No. ( ) City of Newport Beach ( ) County of Orange Plan Check No.B00-00987 Applicant: INFINITY HOMES COSTA MESA Address: 10945 SOUTH STREET STE 301 , CERRITOS, CA 90703 Telephone Number: 562/ 924-4491 Tract/Parcel and Lot Number(s): TRACT 15995 Location of Project: 169 EAST 21st ST UNIT D, COSTA MESA, CA Number of Square Feet of: Residential Space 1147 SF x $1.84 Total $2110.48 Commercial and Industrial Space x $ .30 Total Commercial/Industrial Project is: (Check One) Warehouse _ Motel _ Preschool R 8 D _ Bank _ Auto Repair Movie Theater _ Neighborhood Shops _ Hospital Mini-storage Racquet/Health _ Large Office Heavy Industrial _ Hotel _ Office Bldg. Regional Shops _ Medical Office _ Restaurant Light Industrial _ Office Park _ Fast Food This project is exempt because i his certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Government Code sections 53080 and 65995. The Building Permits for this square footage in this proposed development may now be issued by your jurisdiction. Checks are to be made payable to Newport-Mesa Unified School District. By: BONNIE KUBOTA Authorized Representative The above representation as to square footage is true. Applicant agrees that .ter determined that such representations are not true,then this certificate shall automatically terminate and the appropri=t= /Cou shall be notified. NOV 22 2880/2:82 PM 21671.52 er- REPT8:81-8869238 Date: /7.-72—c c p • . 112345 i ROBIN B. HAMERS • 234 E. 17TH 9T. SUITE 205 & ASSOCIATES, INC. - COSTA MESA. CA 92627 CIVIL ENGINEERS O PLANNERS • SURVEYORS (949)549.1192 FAX(949)549-6516 December 21, 2000 City of Costa Mesa Building Dept. 77 Fair Drive Costa Mesa, CA 92628 RE: 169D 21m. St., Costa Mesa Lot 4, Tract No. 15969 Attention: City Building Inspector This letter is to certify that the foundation forms were surveyed for line and grade on December 18, 2000, and are in substantial conformance with the approved grading plan • and site plan for the above project. R Robin B. Hamers R.C.E. 31720 Qp,OFESS/pN cc. Infinity Homes to B.N4i, 4 C-0 CC RCE31720 m kEXP. 12/31/2004 .,?:,,,, C/Vll@/ ®Printed on Recycled Paper. C FINAL GRATING CERTIFICATION Project Address: 169 21st Street Costa Mesa Lot Number: D • Permit Number: G00-00026 By Civil Engineer: I certify to th'e satisfactory completion of grading in accordance with the approved plans, specifications, local and state codes. All drainage devices required by the grading permit, grading plan and grading ordinance have been installed. Adequate provisions have been made . for drainage of surface water from each building site. The minimums are: • 2% Fall from structures within 5 feet from exterior walls. • . 1% Fall for asphalt surfaces and landscaped areas. 0.5% Fall for concrete surfaces to approved disposal areas. The final monuments as shown on the recorded tract map were set. All final grading eleva- . tions are within ± 1/10 of the desigi�ed elevations. Supervising Civil Engineer • Reg. No. 31720 (Signature) 11/19/01 Date oQ%OfESSA N� ti�Q� og\N B. HAkiP!F2 Rr3 0 D EXP 2b104 ob `P]qr CML �\Q' FpF CAUFOP STAMP and SIGN 1691-0-. • INSULATION CER'. ICATE IC-1 169-D 21st Street Costa Mesa Number and Street City Orange Amber Way-#15969 D County Subdivision Lot Number Description of Installation 1. ROOF Material Brand Name Thickness(inches) Thermal Resistance (R-Value) 2. CEILING Batt or Blanket Type Batt 5 Brand Name Certianteed • Thickness(inches) 10" Thermal Resistance (R-Value) R-30 Loose Fill Type Brand Contractor's min installed weight/ft2 lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance(R-Value) 3. EXTERIOR WALL Frame Type A. Cavity Insulation Material Fiberglass Brand Name Certainteed Thickness (inches) 3 1 /2" Thermal Resistance(R-Value) R-13 •• B . Exterior Foam Sheathing Material Brand Name Thickness (inches) Thermal Resistance (R-Value) 4. RAISED FLOOR Material Fiberglass Brand Name Certainteed Thickness (inches) 6 1 /4" Thermal Resistance(R-Value) R-1 9 5. SLAB FLOOR/PERIMETER • Material Brand Name Thickness(inches) Thermal Resistance(R-Value) Perimeter Insulation Depth(inches) 6. FOUNDATION WALL Material Brand Name Thickness (inches) Thermal Resistance(R-Value) Declaration I hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficiency Sra••.rds for residential buildings(Title 24, Part 6,California Code of Regulations)as indicated on the Certificate of Compl e, whe - I,plic 'le. A .JP1 le. 6/26/01 OJ Insulation Co. , Inc. Item#s i:nature, Date T Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item #s Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner • Item#s Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Revised March 1, 1996 401 '1c CITY OF COSTA MESA fr9 BUILDING DIVISION :r ..1 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUM ER is )IIrr/s PERMIT ,r0 S. fe F00-0 84 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 FIRE SUPRESSION PERMIT Job Address: 169 21ST ST Status: ISSUED • Suite: D Applied: 11/02/2000 Vicinity: UNIT D Issued: 04/11/2001 Parcel Number: 42619317 Zoning: ISSUED BY: -. Applicant: MARTINEZ, MONA LISAill Address: 1787 POMONA RD SUITES D&E Phone: (800)915-3473 CORONA,CA Zip: 91720 Owner INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: FIRE SPRINKLER SYSTEMS Address: 1787 POMONA RD • SUITES D&E Phone: (800)915-3473 CORONA,CA Zip: 91720 License: 684600 SCOPE OF PERMIT FIRE SPRINKLER PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT D). INSTALL 25 FIRE SPRINKLER HEADS. REF:B00-00987, FEE SUMMARY Plan Check: $39.07 Calc Valuation: $1,700.00 Permit: $60.10 - Claimed Valuation: $1,700.00, Other $0.00 Total: $99.17 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(6/00) . - • 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 work for which this permit is Issued. r -yrI have and ill 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: �j-r'�1 - tinni Polity Number.'CaLa-(�(1 11t1i# vT ,(Thissecfion nee not be completed i th permit is valued at one hundred dollars($100)or less.) ❑ 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 to become subject to the workers' compensation laws of California,and agree that If I should become subject to the workers'compensation provisions of Section 3700 the Labor Code,I shall forthwith comply with these prr�ovisions. r _ w Applicant Signature: j',/-r�,r I� _Date: 4/i 6/ WARNING:FAILURE TO SECURE W KERS'COMPENSATION CO RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF ENSATION,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 undeerrrrr i ion of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect(Licrtr �rl'L' I �, ClassContra-eters Signature:Signature: f'I?Lh2wp'7 2 I lb✓ Date: // /0( 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). 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).): 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 property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). O I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑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: ❑ 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: I 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 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 end 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 permit for such construction or modification from the South Coast Air(Duality Management District or from any other air pollution control district or agency? Yes 0 No (Section 65850.2 of the California 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? 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 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? El Yes 0 No S (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 AUTHORIZATION,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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sign t e l Legal rte D e 0. `; And/, Authorizedt Date CODE pispEcnoN TYPE pie' ILLS CODE I INSPECTION TYPE PAIS INRTUL$ 1616 Fixed System Final Fire Prevention ' b-01 206 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 'I)) ' Id-bi Wl.1 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy CITY OF COSTA MESA BUILDING DIVISION C`'x,4.1. DEVELOPMENT SERVICES DEPARTMENT PERMIT MBER i � F PERMIT firla M01-00210 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No D Applied: 04/24/2001 Issued: 04/24/2001 Vicinity: UNIT D Parcel Number: 42619317 ISSUED BY: Applicant: PETERS, RANDY Address: 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA Zip: 91702 Owner INFINITY HOMES CM I, LLC Address: CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor , OJ INSULATION INC • • Address: 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA Zip: 91702 License:465709 SCOPE OF PERMIT INSTALL MECHANICAL FIREPLACE FOR NEW SINGLE FAMILY RESIDENCE(UNIT D). REF:B00-00987 FEE SUMMARY • Quantity Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU , $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 ' Inst/Rep:Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 / Refrig Sys<100 k BTU $0.00 0 - Domestic Incinerator $0.00. 0 Ref rig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems • Gas Piping $0.00 0 Up to 3 hp/100 k BTU $0.00 0 Factory Fireplace $10.65 1 3 To 15 hp/500 k BTU $0.00 0 Hood w/Meeh Exhaust $0.00 ' 0 ' 15 To 30 hp/1,000 k BTU - $0.00; "0 VAV Box $0.00 0 30 To 50 hp/1,750 k BTU $0.00/ 0 Vent Fan/Single Duct , : , $0.00. 0 _ ' Over 50 hp/Over 1,750 BTU - -$0.00 0 Appliance $0.00 - 0-- Boilers 7 Fire Dampers ' $0.00 0 - Up to 3 hp • ' ",$0.00 0 Smoke Dampers $0.00 0 3 To 15 hp - $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers< 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $34.15 COMMENTS /SPECIAL CONDITIONS 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 f 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: 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 rk for which this permit is issued. Iihave 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 w rs' mpen on Insurance carrier and policy number are: CO � (Carn'er:ti &D( Policy Number: l'/y6a9oopo S 3 (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) O I certity that in the performance of the work 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 alifornia,and 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 the isio // rApplicart Signatire: 1Dae 3 9 =Z-6--0/ 'WARNING.FAILURE TO SECURE WO ERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOI I ARE(S100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that4 am lice .• und• 'ons of Chapter 9(commencing with Section 7000)of Division 3 of.the.Busin s d Prgt%t io s Code,and my license is in full force and effect.It N/ �� Class y I� ^ff'�� ContractorsSIn----Th / i Date: CONSTRUCTION LENDING AGEN Y: ❑ 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). Lender's Name: Lenders Address: Signature: j 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).): 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 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 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: 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 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 en RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑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? 0 Yes jNo (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 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? 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 AND AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. . •f Leg.L ner(s) Vii6 to / Sign-Si ��� ^d/• 'u ,." ed'Appl ( Da -----,, CODES INSPECTION TYPE DAa' INTRIALS CODES INSPECTION TYPE PATE JNTRIALS 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 BIocldRetaining Wall �` , 212 Final Fire Prevention -)q 202 Final Factory Fire Place ./ "02' I7 (' ee 220 Final Planning Approval 203 Final Sign (L 222 Final Site 204 Final Demolition 250 Final Building/Occupancy M6 CITY OF COSTA MESA a - BUILDING DIVISION F ,. DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER o•y PERMIT '`boaaro e# M01-00170 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT • Job Address: 169 21ST ST Status: ISSUED Suite No D • Applied: 04/02/2001 Issued: 04/02/2001 Vicinity: ' / Parcel Number: 42619317 ISSUED BY: .) v Applicant: RENZ, RUSS - Address: - - - - Phone: 714-577-0771 - .- - _ - ' Owner / INFINITYYHOMES CM I, LLC _ Address:/ CLIFTON JONES III / \yN CERRITOS',-CAS' Phone: 5629244491 > , ', •. / ; 10945 SOUTH STREET,#301 Zip: 90703 - ��� *A Contractor-,/SENTRY MECHANICAL, INC. ' _ • ' Address: • 540 S JEFFERSON', _ ,AA • CA 'Phone: 714-577-0771 _ ' 7' - 'PLACENTIA, CA - ' „ Zip: 92870 , , , License:631049 - 1 SCOPE OF PERMIT - INSTAL HEATING AND.AIR CONDITIONING IN NEW SFR. - '\ ./ , REF: B00-00987.CONTRACTOR IS DOING HEATING AND AIR CONDITIONING ONLY. i ' -' i ' ., FEE SUMMARY - _ - Quantity - , , Quantity? ISSUE FEE , i, $23.50' -- - - ' Repair/Alt Absorbtion Unit / ;$0.00 • 0 . / ' Inst FAU <100 k.BTU $0.00 -0 - - - ` Repair/Alt Refrigeration Unit I� /$0.00 of Inst FAU>100 k BTU $18.20 1 Ventillation System '.., $0,00 0 RepairhAlt,Cooling/Heat $0.00. 0 Evaporative Cooler - ',: $0.00- -0 /,.//1 Inst/Rep; Recess.Wall Htr $0.00 0 Commercial Incinerator I'(/ . $0:00_ ,0 /, Refrig Sys<100 k BTU - ' $0.00 0 Domestic Incinerator 7�� '$0.00` 0 Refrig-Sys>100 k BTU; $0.00 0 - :. Compressors/Absorption Systems !�'� ( ' / lI Gas Piping`, .. , $0.00 0 _ ' Up-to3 hp/100 k BTU $0.00 /0 Factory Fireplace °. - $0.00 0 • - 3 To'15 hp/500 k BTU / $0.00 0 / Hood w/Mech Exhaust ' 4 $0.00. 0 7.15 To 30.hp/1,000,k BTU - ,� " $0.00, •'0 VAV Box \ A � $0.00 0 )_ -30 To 50 hp/"1,750i BTU ,'/ �. $0.00'/ 0 Vent Fan/Single Duct / . . N$0:00 0 ,.Over 50 hp/Over 1,750 BTU / ' v, $0.00 0 Appliance ��� <0 $0.00-'.-'\,-..,,.'0, - Boaers ,� , /�<�� Fire Dampers � $0 00 ,0�: Up to 3 hp �� ( 2 �2$0:00 0 Smoke Dampers � /$000 0 - - -3 To"15.h =-� / vA�' 4�°$27.15 1 Inst or Relocate Appl Vent: A � $0.00� 0 - - - „ "c`---15'to 30M04- `" <AV 2 \Ci ,v." $0.00 0 Air Handlers< 10000cfm� ` -$0.00 . 0 .- 30 to 50 hp - � , $0.00 0 Air Handlers> 10000cfm \- .�50.00.>0 , ' ; Over-50 hp - ,`\ ,� / ,2 , $0.00 0 Floor Furnace ''$0.00 -0 \ / % • -Other Mechanical-Fee - i-f� Floor or Suspend Heater `50:00-,0 _ -, A Investigation.Fee -,,,/,',„„---i $0 .00 Plan Check Fee $0.00 Reinspection-Fee` - - $0.00 -- ~ TOTAL CALCULATED FEES $68.85 COMMENTS/SPECIAL CONDITIONS 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(6/00) U / 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 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'c pensation Insuranep carrier and policy number are: ( - - Cone-hundred Cartier. G0 os l4'L..(~ L (, C (r I -L h ( 1. V h Q Policy'Number: -W'�L 0 Q Cin - 00 -(This section need not2e completed it the permit is valued at one undred dollars($100)or less.) ❑ 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 to become subject to the workers' compensation of California and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with t 1 ovislons. \ Applicant Signature: L . . //.�Q 1 1—Date` ^� ^--{) I WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COV GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(S100.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that am ken e44,,U der provisio s of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect'lia a .S l ci 4 Class a C " .1() ,Contractors Si ,•gne e l \t--�e ,u/s1 Date: y.-�-.'n CONSTRUCTION LENDING AGENCY: O 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).): ❑ 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 property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). O 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: ❑ 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 e 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 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? 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_pPermit 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? ❑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? 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 AND AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Wign ure Of Legal Owners Date (A A\A 1 � ___n r Auth zed A 9 3 -0 ' Data- _ CODE INSPECTION TYPE air 1[QIgALS CODE I INSPECTION TYPE �j PAU =IIDRALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical l' O 'O n ail 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 250 Final Building/Occupancy 4`, R $ 9 CITY OF COSTA MESA o .�p BUILDING DIVISION > • u„n AI Q' DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER �7 /s i88QQ PERMIT 0'Rmso P00-00669 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No D Applied: 12/01/2000 Issued: 12/01/2000 Vicinity: UNIT D Parcel Nunmber: 42619317 ISSUED BY: Applicant: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS, CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 License: 317026 • Arch / Eng: Address: Phone: Zip: License: SCOPE OF PERMIT PLUMBING PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT D). INSTALL 2 BATHTUBS, 1 DISHWASHER, 1 EXPANSION TANK,5 GAS OUTLETS, 1 WASHER, 1 PRESSURE REGULATOR, 1 SHOWER, 1 KITCHEN SINK, UP TO 4 VACUUM BREAKERS,4 WASH BASINS, 3 WATER CLOSETS,8 1 WATER HEATER. REF: B00-00987 FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $9.80 1 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $19.60 2 Pressure Regulator $9.80 1 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $12.30 1 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $39.20 4 Dishwasher $9.80 1 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $29.40 3 Drain, Roof $0.00 0 Shower $9.80 1 Water Heater/vent $12.30 1 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $9.80 1 Sink, commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $6.15 1 Sink, kitchen $9.80 1 Water Softener $0.00 0 Gas(Over 4 outlets) $1.10 1 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 ' TOTAL CALCULATED FEES: $202.35 NOTICE: The work authorized by this permit sGOOMWEMT'$ASBECtiAle CebiDjT4@0S 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 pe/rmit.' FOR INSPECTIONS CALL: (714)754-5626 //! 2446-46(6/00) ///" . , 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 sell-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the �—wo>kf r which this permit is issued. -[�-'Fhave 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=cc pensation Insurance carrier and policy number are: ____ ( _ �^ Carrier:_-(-$N�'4-"1 LF Policy Number. �--rl L,e. l (This section need not be completed it the permit is valued at one hundred dollars($100)or less.) ________.,....A ❑ 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 to become subject to the workers' compensation laws of California,and agree that it I , ould become subject to the workers'compensation provisions of Sect on 37 of the Labor Code,I shall forthwith comply with these •r. .ions. / OD -Applicant Signature: A 4 c/_ J Jr).. IDate-`// Li 9 .WARNING:FAILURE TO SECUR9 RKERS'•• ATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI AL PE ALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLCARE($100,.. ADDITION T•r(TAT 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.lic.• :d under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Busine s a d rofaessions Code,and my license is in full force an—__d aect. c.# D• - lass# � Contractor's Signature: - !WI Date:�- • I CONSTRUCTION LENDING • ENCY: , ❑ 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). 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 fora 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 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 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 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 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? LJ Yes LJ No (Section 65850.2 of the California Govemment 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 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? 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 AND AUTHORIZATION 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. . •na tOf Legal Owner(s) Date if Or Authorized Applicant.- (Date CODE IJ MON TYP-�rllDATE INTRIAL$ CODE II INSPECTION TYPE DAFT MAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing ''3.oA as 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 250 Final Building/Occupancy O MF CITY OF COSTA MESA ( 4 a' BUILDING DIVISION >4�.-, DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER V PERMIT „E01-00333 Irbkrommooe r (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No D Applied: 05/01/2001 Vicinity: UNIT D Issued: 05/01/2001 Parcel Nunmber: 42619317 Applicant: INGRAM, STEVEN ISSUED BY: Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 Owner INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS, CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: ELITE ELECTRIC Address: 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 License: 418242 ! SCOPE OF PERMIT ELECTRICAL PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES'(UNIT D). INSTALL NEW ELECTRICAL THROUGHOUT RESIDENCE& 1 LIGHT,2 OUTLETS,& 1 SWITCH IN GARAGE. REF:B00-00987 FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 , Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $120.68 2155 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 , Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $1.10 1 up to 50 kva/kw $0.00 0 , Recept Outlets $2.20 2 up to 100 kva/kw $0.00 0 Switches $1.10 1 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 .0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $148.58 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS 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, andel! 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(Wee) 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 ork for which this permit is issued. riarI 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. L--My-Workers'compensation Insurance carrier and policy number are: -Garner: 3 Policy Number: _(Th/s'section need not be completed if the permit is valued at one hundred dollars($100)or less.) J ❑ I certify that in the pe •• :rice of the.- ark 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 • Californi:, agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with th::: proms Applicant Slgnatu :: r_Date: i�^ t- 0 ( WARNING;.FAILU• To s URE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOL1A-E($100003),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that'am licensed un•-..revisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect.Uc.N. � - Class 0 '1 Contractors Signature.: � ,Date: f" / —y')/ 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). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I em 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 CMI 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 ere 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. 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: ❑ 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 0 No (Section 25505 of the California Health and Safety Cafe 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 et 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). .._._...o _ ._..__-tRs-Ma a .__.____ . 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazaMous 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 Na ---...__W 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application apermlt 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 U No (Section 65850.2 of the California Govemment Code requires that the requested Information be furnished on applications for non-residential building permits). ea .._ _..___....__ 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___.❑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? 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 AND AUTHORIZATION.OF ENTRY:f 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. •-: - - - • :r s) Date ed Applicant, ( Date BODE w INSPECTIONTYPE RAIL MOE& ;ODE! INSPECTIONTYPL RAIL ILLS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing C p q 200 Final Re-Roof 210 Final Electrical 19#2. /�,5&(,A. • 201 Final Block/Retaining Wall 212 Final Fire Prevention Ay, 202 Final Factory Fire Place - 220 Final Planning Approval eget 203 Final Sign 222 Final Site 204 Final Demolition • - 250 Final Building/Occupancy 0 CITY OF COSTA MESA _, 49 BUILDING DIVISION F „' 1, DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 4jj : PERMIT E00-01139 itberoR'te (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No I Applied: 11/30/2000 Vicinity: Issued: 11/30/2000 Parcel Nunmber: 42619317 Applicant: LYLE COOTER ISSUED BY: ` 1 4 Address: Phone: 800-863-2525-SHAWN Zip: Owner: INFINITY HOMES CM I, LLC is \ Address CLIFTON JONES III ^1...\9>"1- t(fJ CERRITOS,CA Phone: 562 924 4491 S 10945 SOUTH STREET,#301 Zip: 90703O Oe' Contractor: SR BRAY CORP/DBAPOWER PLUS TEMP UTILITY SERVICES Address: 1372 VALENCIA AV Phone: (800)863-2525 TUSTIN,CA Zip: 92660 License: 523596 SCOPE OF PERMIT TEMP POWER POLE AND 5SUBPOLES AND TRAILER HOOK-UP. • FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $18.20 1 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 0 Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0 Switches $0.00 0 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to lhp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $23.50 1 TOTAL CALCULATED FEES $126.70 Intermed Pole $61.50 5 COMMENTS/SPECIAL CONDITIONS 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(6/00) DECLARATIONS I 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: /�/ G 0-" -9 / Policy Number: /S S 57 /2 C/ (This section need not be tihpleted if the permit is valued at one hundred dollars($100)or less.) ❑ 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 to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'-compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. D --oxo Applicant Signature: �✓ Date: /AL( �v ✓ WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINPYPENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060F THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that t am licensed under provisions of Chapter 9(commencing with Sectiorr7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect.Lic.# 2 ' - r'1 6 / Class# / „(J Contractor's Signature: . - Date: ?v 2.- CONSTRUCTION LENDING AGENCY: CCCC ❑ 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). Lender's 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 for a permit subjects the applicant to a'civila penalty of not more than five hundred dollars($500).): ❑ Fo I,as owner of the prroperly,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 orLher-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 driver's license. ❑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: El 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,Califomla 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? ❑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? ❑Yes ❑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). .... .i ._. . 3 Does orr willllthe 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 ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this[implication a2ermit 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 u 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? ❑Yes ❑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 AUTHORIZATION 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signal Of Legal Owner(s) Date And/Or Authorized Applicant / '�/1 j �y y��/ / Date CODE# INSPECTION TYPE GATE ' INTRIALS CODE# INSPECTION TYPE PAIS MALI 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 250 Final Building/Occupancy 4L0 Itt 9 CITY OF COSTA MESA ; qq�CC BUILDING DIVISION .� :Jrr �r8 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER v.: � ' l PERMIT 4P"' E01-00838 a�ran (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No K Applied: 09/26/2001 Vicinity: Issued: 09/26/2001 Parcel Nunmber: 42619317 • Applicant: JONES, CLIFF ISSUED BY: Address: Phone: 562-924-4491 Zip: Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 X� ��g�\�/' Sit CII‘ Address: . Phone: Zip: License: SCOPE OF PERMIT ELECTRICAL CONDUIT FROM HOUSE METER TO FEED TWO LIGHTS AT ENTRY WAY PYLONS TO COMPLEX. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 • up to 10 kva/kw $0.00 0 Lighting Fixts $2.20 2 up to 50 kva/kw $0.00 0 Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0 Switches $0.00 . 0 over 100 kva/kw $0.00 0 Non Res Appl , $0.00 • 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $18.20 1 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $43.90 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS 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 for which this permit Is Issued. ❑ I have and will maintain workers'compensation in -: e•,: ..uired by section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. My workers'compensation Insurance carrier a d policy num.:r are: Carrier: Policy Number: (This section need not be camp: :•If the�•:•rmit is valued: one• .red dollars($100)or less.) ❑ I certify that in the•' ormanc p' 'ark for w ' this •ermit is Issued,I shall not employ any person in any manner so as to become subject to the workers' compensation la, •of Calif. ree th. if I sho •become subject to the workers'compensation provisions of Section 3700 of tth eeLLabbor Code,I1 shall forthwith comply with the a pro g /COIL/0/ ,ApplicanPSignature:- 1 i Date: WARNING:FAILURE TO SECU-• WORKERS'•.4ENSATI •r•Or, IS UNLAWFUL AND SHALL SUBJECT Al EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,...),IN ADDM•••• •• E COST• COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'$FEES. LICENSED CONTRACTOR I. ARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect.Lic.# Class k Contractor's Signature: Date: 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: 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 for a pern-4' subjects the applicant to a civil penalty of not more than fi • •.•dred dollars($500).): ❑ I,as owner of the property,or my employees with wages a 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 ' ense 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, • ovided that such improvements are not Intended or offered for sale.If,however,the building or Improvement is sold within one year of co.•: • 'o. Xowner-builder have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the. ..en - EXCLUSIVELY CO. RACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The co .cto ' : •.^ 'cies not app, to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pu :.ant • e ontr: tors 'cense La -.). ❑ I am. •m• .nder sec. i Business and Professions Code for this reason: C :Slgnetn ••.^- /-lra� Date: CJ(49/0/ Owner II •:nfied by'river Icon s. ■ es t• No Driver's License No. Expires: Verification of Ownership• ( .':of d.. ent,i.e.-property tax bill or deed): DIVISION OF INDUSTRIALS: ' TY PERMIT CERTIFICATION: ❑ I hereby ce ify t : o 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 at 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,Califomla 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 Califomla 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 0 N (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? D Yes 2 No (Section 85850.2 of the California Govemment 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? ❑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 Califomla Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If'yes",attach certificate of compliance from t : .•.ropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I yarttty that under •-natty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials a d&Emissions. Signature: Date: CERTIFICATE OF s P • C'' AUTHORIZA P•NOF ENTRY:I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree . cam. wi;L:1'� .to laws and ordinances relating to building construction,and authorize representative of the City of Costa Mese to enter upon Ire above-descri..d prop. 1 spec?' n - I' to occupy or allow occupancy of any building authorized by this mit u final atom. CSlgnatu%; • -Legal Owner(s --tet /�1 •�'f) Date •r Authorized Applicant Date CODE I . ' 1.•. I: PATE MALI CODE t INSPECTION TYPE DAM g/TiTIAL£ 1616 Fixed S :•• . 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 250 Final Building/Occupancy • 9 CITY OF COSTA MESA BUILDING DIVISION Y• �„r.,l �I DEVELOPMENT SERVICES DEPARTMENT P MIT NUMBER 4. 'Pea `/a PERMIT E01-00708 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No K Applied: 08/09/2001 Vicinity: NEW ELECTRICAL METER PEDESTAL Issued: 08/09/2001 Parcel Nunmber: 42619317 • Applicant: JONES, CLIFF ISSUED BY: Address: 10945 SOUTH ST ' UNIT 301 , ' Phone: (562)924-4491 CERRITOS,CA' ' I 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 SCOPE OF PERMIT ELECTRICAL PERMIT FOR INSTALLATION OF NEW METER PEDESTAL FOR"INFINITY HOMES". FEE SUMMARY Quantity _ Quantity ISSUE FEE $23.50 .. Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 0 Recept Outlets $0.00 0 up to.100 kva/kw $0.00 0 Switches $0.00 0 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment ' $0.00 0 Res Appl $0.00 • 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $30.50" 1 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a - $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus(mech ride or lights) 50.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 .. 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $54.00 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS • 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 peimit' FOR INSPECTIONS CALL: (714)754-5626 V 2446-46(6/00) 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 s:- •n need not be complete• the pe •it/s valued at one hundred dollars($100)or less.) •r Y./Iicertity that in the pe••rm�he ork for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' f compensation law. •f C�.:f^• n' agree hould become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with th:.':pro•. -. //�� p- Applicant Signatur-. Date:- -(�S /�'� _WARNING:FAILUR •• ,r ERS'CO PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($1..... DITION TOTHE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRA +DECLARATION: I hereby affirm that I em licensed under provtslons•,•;" • encing with Section 7000)of Division 3 of tha'BusineSs and Professions Code,and my license Is in full force and effect.Lic.s " a . a ii�� Class A- .S Contractors SignaN�e`— �I I Date: f{cr7rci CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a constr olio -':ing 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 for a perms: 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 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.). O I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑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: 0 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). O 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 then 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? ❑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 L]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 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 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 AND AUTHORIZATION 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 laws a,. 't or•'.=• : relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection u • f,:e not to o• upy or allow occupancy of any building authorized by this permit until final inspection. u - % eiali al Owner(s) �a Date �� ` / ulho,, ,. tc,- t o -.__ CODE# JNSPECT1ON TYPE IMM INTRIALS CODE IBSPECT1ON TYPE PATE LfIIIDNLS 1616 Fixed Syste in. e P ,vention 206 Final Mechanical 1266 Pool Spa Fine 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 41- /6.-.9Z- 6Z"� 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 250 Final Building/Occupancy f CITY OF COSTA MESA \, ) o, *- BUILDING DIVISION > -f r,,,- r DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F t r� / PERMIT -' oamip`"`' P01-00569 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No F Applied: 09/20/2001 Issued: 09/20/2001 Vicinity: ISSUED BY: tal7y=_., Parcel Nunmber: 42619317 Applicant: JONES, CLIFF Address: - Phone: 562-924-4491 Zip: Owner: INFINITY HOMES CM I, LLC , Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 0 10945 SOUTH STREET,#301 Zip: 90703 _f�t Contractor: OWNER BUILDER DA's r"lit Address: Phone: Zip: License: 000000 Arch / Eng : Address: Phone: Zip: License: SCOPE OF PERMIT GAS LINE FOR FUTURE OUTDOOR USE. FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 - Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 . Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain.Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 - Sewer Private Line $0.00 0 Water Closet(Toilet) $0.00 0 Drain, Roof $0.00 0 Shower $0.00 0 Water Heater/vent $0.00 0 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $6.15 1 Sink,kitchen $0.00 0 Water Softener $0.00 0 Gas(Over 4 outlets) $0.00 0 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $29.65 COMMENTS I SPECIAL CONDITIONS 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: 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(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 for which this permit Is issued. ❑ I have and will maintain workers'•••••:nation 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 In-•ranc:carrier and policy number are: Carrier: Policy Number: (This section need not be corn•eted if th-permit is valued et one hundred dollars($100)or less.) ❑ I certify that in the o he work 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 pe -fee Nnia =rid agree t :t 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 Slgnatur= a ..//.dict. Date: 6^//.01)/0 J WARNING:FAILURE TO SE URE r KERS'•• -ENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($1••000), 'ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.ft Class# Contractor's Signature: Date: 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). 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 pem+: subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I.as owner of the property,• • .mptoyees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec. 7044,Business and Prof: sions •..e: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 th 'ugh his o 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• completio ,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 th' •• ,am = CLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The••• a cense -w does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license p . ane Contr. tors License Laws.). ❑ I am a imp '..c. .APS Business and Professions Code for this reason: � f�) Signature. falM r Date: C(j1 L-90/C) Owner ID ven led., drive 'dense. • 'es 0 No Driver's License No. Expires: Verification of Ow.ership; 511 • CITY OF COSTA MESA 4� ►D BUILDING DIVISION >allt'',��,,"' ' ''''�A 1 DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER PERMIT E01-00335 41-400 to' WWI (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No F Applied: 05/01/2001 Vicinity: UNIT F Issued: 05/01/2001 Parcel Nunmber: 42619317 Applicant: INGRAM, STEVEN ISSUED BY: Address: 9415 BELLEGRAVE AVE . Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor r ELITE ELECTRIC Address: . 9415 BELLEGRAVE AVE Phone: (909)681-5811 RIVERSIDE,CA Zip: 92509 License: 418242 SCOPE OF PERMIT ELECTRICAL PERMIT_FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT F). INSTALL NEW ELECTRICAL THROUGHOUT RESIDENCE& 1 LIGHT,2 OUTLETS,&1 SWITCH IN GARAGE. REF: B00-00990 , FEE SUMMARY • Quantity Quantity ISSUE FEE. $23.50 Temp Dist System/Lighting $0.00 0 . Temp service test ' $0.00 Busway/100 ft $0.00 0 . Res.a/c package $0.00 Standing.Section $0.00 0 New Res(1-2 units) $137.09 2448 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa - - $0.00 0 up to 10 kva/kw $0.00 0 -� Lighting Fixts . , $1.10 1 up to 50 kva/kw $0.00 0. Recept Outlets N $2.20 `2 - up to 100 kva/kw- " $0.00' '-0 / Switches `- $1.10 1 - - over 100 kva/kw" $0.00 ' 0 / / . Non Res Appl $0.00 0 Low Voltage Equipment $0.00 ,0 Res Appl $0.00 0 Low Volt Wring System/Ckt $0.00 0 Service to 200a - $0.00 0 Misc.Conduit $0.00 . 0 Service to 1000a $0.00 '0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 • Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 .0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $164.99 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS • 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 I 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 7/ 2446-46(WOO) 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 for which this permit is issued. yAcshave 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. L- -`My workers'compensation Insurance carrier and policy number are: Carrier.— 7 Policy Number: ,(This section need not be completed if the permit is valued at one hundred dollars($100)or less.) O 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 to become subject to the workers' compensation laws of Califor fd nd ree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these pro - i — ApplicantSignatuier-n t Date: 2 5— — ( — O( tWARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE MST 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 provi .f Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect/Lic.## \ � Class# Contractor's Signature: ' _ Date: S- • 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). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that 1 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.). ❑ I,as owner of the properly,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 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: 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 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 ❑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? li 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? ❑Yes ❑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? 0 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 AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize represehtatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. • e Or wner(s) Date €7-1€7-1 —,_o And/ r. Shorized Applicant L. Date CODE x INSPECTION TYPE PALEINTRIAI$ CODE I INSPECTION TYPE PaIE INTIRALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing /O ��1 200 Final Re-Roof 210 Final Electrical / Z p - 1' 0"-.. '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 ' • 250 Final Building/Occupancy a; '01 MF CITY OF COSTA MESA BUILDING DIVISION 04( ).• I IthadailirEI IJ _ DEVELOPMENT SERVICES DEPARTMENT PER T NUMBER 4• PERMIT 00-00990 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.usNG PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDIJob Address: 169 21ST ST Status: ISSUED Suite: F Applied: 06/30/2000 Vicinity: UNIT F Issued: 11/22/2000 Parcel Number 42619317 Zoning: Applicant: JONES, CLIFF ISSUED BY: Address: 10945 SOUTH ST#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 : WILKINSON ASSOCIATES Eng: STRUCTURES WEST Address: 17932 SKYPARK CI#A Address: 3430 E FLAMINGO RD#240 Phone: (949)852-8596 Phone: (702)435-1307 IRVINE,CA LAS VEGAS, NEVADA Zip: 92614 License: 89121 License: SCOPE OF PERMIT CONSTRUCT NEW 2-STORY SINGLE FAMILY RESIDENCE WITH ATTACHED GARAGE FOR"INFINITY HOMES"(UNIT F)- 1268 SQ FT 1ST FLR, 1080 SQ FT 2ND FLR,&442 SQ FT GARAGE.ALSO,44 SQ FT FRONT&REAR PORCHES. FEE SUMMARY Plan Check: $1,082.74 Calc Valuation: $219,796.84 Permit: $1,665.75 Claim Valuation: $0.00 SMIP Res: $21.98 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $2,770.47 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. I 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 thhis peermit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(6/00) DECSARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: 1 , ❑ 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: Cartier: /" Policy Number: (This s:- on need not be complete• I pe s valued of one hundred dollars($100)or less.) t —I.certify.that in the p:-•rm:nc,of r-wo •for which this permit Is issued,I shall not employ any person in any manner so as to become subject to the workers' _compensation la .of C:if• la - •agr': that If I ubject to the workers'compensation provisions ofction 3700 of the Labor Code,I shall forthwith comply with ih:-e pro -'•ns '7' Applicant Sgnatu : �,/ ( (Date:42Z c WARNING:'FAILURE TO SE TRE WORKE": '• PENSATION COVERAGE IS UNLAWFUL AND SHALT SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOL.ARE(S103...9.IN A" •'TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST.AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: *, I hereby affirm Mall=II�psg,upde(-prpvjsfd • •f Ch (co 'mencing with Section 7000)of Division 3 of,the.Busin and Professions Code,and my license Is In full force and effect.Lic.M `!!///Y(/G(� Class p Contractors'SIgnnaature: di./ rJ// Date //7'Z J CONSTRUCTION LENDING AGENCY: "-O- ❑ I hereby affirm that there is a construction - g agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's 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 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.). ❑ 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 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: 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,lalsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title B,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 California Health and Safety Code been fully complied with? ❑Yes ❑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? Yes 8 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? ❑Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air 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 AND A ••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 with all stat�•i an• city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspe •ores.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ;, e•f Leg: Owner(s) Date -And/Or•ut • .•Applica L_Date---_ _ .– CODE I INSPECTION TYP DATE INTIIULS CODE INSPECTION TYPE DEE MALE 1616 Fixed System - F - "revention 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 250 Final Building/Occupancy 4 7-0.2.. bc. 4 ., . . . . Th p 3607i NEWPORT-MESA UNIFIED SCHOOL DISTRICT CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES PURSUANT TO AB 1600 AND AB 181 To: ( %) City of Costa Mesa District Receipt No. ( ) City of Newport Beach ( ) County of Orange Plan Check No.B00-00990 Applicant: INFINITY HOMES COSTA MESA Address: 10945 SOUTH STREET STE 301, CERRITOS, CA 90703 Telephone Number: 562/ 924-4491 Tract/Parcel and Lot Number(s): TRACT 15995 Location of Project: 169 EAST 21st ST UNIT F ,_ COSTA MESA, CA Number of Square Feet of: Residential Space 1354 SF x $1.84 Total $2491.36 Commercial and Industrial Space x $ .30 Total Commercial/Industrial Project is: (Check One) Warehouse _ Motel _ Preschool R & D _ Bank _ Auto Repair Movie Theater _ Neighborhood Shops _ Hospital Mini-storage _ Racquet/Health _ Large Office Heavy Industrial _ Hotel _ Office Bldg. Regional Shops _ Medical Office _ Restaurant Light Industrial _ Office Park _ Fast Food This project is exempt because i his certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Government Code sections 53080 and 65995. The Building Permits for this square footage in this proposed development may now be issued by your jurisdiction. Checks are to be made payable to Newport-Mesa Unified School District. By: BONNIE KUBOTA Authorized Representative The above representation as to square footage is true. Applicant agrees that if it - later determined that such representations are not true,then this certificate shall automatically terminate and the appyv./county shall be notified. NOV 22 2888/2:82 PM 2186132 \\\ / RCPT#:QTN:81 81123232 Date: �/�ZZ'OrT � � 112345 • ROBIN B. HAMERS 234 E. 17TH ST.. SUITE 205 & ASSOCIATES, INC. COSTA MESA. CA 92627 CIVIL ENGINEERS • PLANNERS • SURVEYORS (949)549-„92 FAX(949)5413-6516 December21, 2000 City of Costa Mesa Building Dept. 77 Fair Drive Costa Mesa, CA 92628 RE: 169F 215t. St., Costa Mesa . Lot 6, Tract No. 15969 Attention: City Building Inspector This letter is to certify that the foundation forms were surveyed for line and grade on December 18, 2000, and are in substantial conformance with the approved grading plan and site plan for the above project. Lit Robin B. Hamers R.C.E. 31720 ��QROFESS70�q cc. Infinity Homes \�Q�6O�N 8. H9 yj eF ¢ RCE31720 m * EXP. 12/31/2004 4. Tq' CIVIL %�Q- F-F CALIFo. cs Printed on Recycled Paper. , INSULATION CER's_.ICATE IC-1 169—F 21st Street Costa Mesa Number and Street City Orange Amber Way—#15969 F County Subdivision Lot Number Description of Installation 1. ROOF Material Brand Name Thickness (inches) Thermal Resistance(R-Value) 2. CEILING Batt or Blanket Type Batts Brand Name Certainteed • Thickness (inches) 10 Tr Thermal Resistance(R-Value) R-30 Loose Fill Type Brand Contractor's min installed weight/ft2 lb Minimum thickness inches Manufacturer's installed weight per square foot to achieve Thermal Resistance(R-Value) 3. EXTERIOR WALL Frame Type A. Cavity Insulation Material Fiberglass Brand Name Certainteed Thickness(inches) 3 1 /2" Thermal Resistance(R-Value) R-13 . B . Exterior Foam Sheathing Material Brand Name Thickness(inches) Thermal Resistance(R-Value) 4. RAISED FLOOR Material Fiberglass Brand Name Certainteed Thickness (inches) 6 1 /4" Thermal Resistance(R-Value) R-19 5. SLAB FLOOR/PERIMETER • Material Brand Name Thickness (inches) Thermal Resistance(R-Value) Perimeter Insulation Depth(inches) 6. FOUNDATION WALL Material Brand Name Thickness (inches) Thermal Resistance (R-Value) Declaration I hereby certify that the above insulation was installed in the building at the above location in conformance with the current Energy Efficiency Sta. ards for residential buildings(Title 24, Part 6,California Code of Regulations)as indicated on the Certificate of Comp i e, wh e pplicab e. • (,L Ill 6/26/01 OJ Insulation Co. , Inc. Item #s ignature, Dat 1 Installing Subcontractor(Co. Name)OR General Contractor(Co.Name)OR Owner Item #s Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Item #s Signature, Date Installing Subcontractor(Co.Name)OR General Contractor(Co.Name)OR Owner Revised March I, 1996 • FINAL GRAVING CERTIFICATION Project Address: 169 21st Street Costa Mesa Lot Number: H Permit Number: G00-00026 By Civil Engineer: I certify to the satisfactory completion of grading in accordance with the approved plans, specifications, local and state codes. All drainage devices required by the'grading permit, grading plan and grading ordinance have been installed. Adequate provisions have been made for drainage of surface water from each building site. The minimums are: • 2% Fall from structures within 5 feet from exterior walls. 1% Fall for asphalt surfaces and landscaped areas. 0.5% Fall for concrete surfaces to approved disposal areas. The final monuments as shown on the recorded tract map were set. All final grading eleva- tions are within ± 1/10 of the desigQed elevations. Supervising Civil Engineer !a) 1 eu l Reg. No. 31720 (Signature) • Date 11/19/01 ErFESS/04,qB.Hgy7F _5.9 4Z- cc C 17. /3./ 004 fC Il PF C/11.. STAMP and SIGN 189,-46 ��MF CITY OF COSTA MESA 4 i9 BUILDING DIVISION Y%J� .4r DEVELOPMENT SERVICES DEPARTMENT PERM NUMBER 4. Ira PERMIT ly Imo y'yi �`�o M01-00213 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No F Applied: 04/24/2001 Issued: 04/24/2001 Vicinity: UNIT F Parcel Number 42619317 ISSUED BY: Iv ii Applicant: PETERS, RANDY ' Address: 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA Zip: 91702 Owner: INFINITY HOMES CM I, LLC Address: CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 ' 10945 SOUTH STREET,#301 Zip: 90703 Contractor: , OJ INSULATION INC , - . Address: ' 600 S VINCENT AVE Phone: (626)812-6070 AZUSA,CA Zip: 91702 , License:465709 SCOPE OF PERMIT INSTALL MECHANICALFIREPLACE FOR NEW SINGLE FAMILY RESIDENCE(UNIT F). REF: B00-00990 . FEE SUMMARY • Quantity -- - Quantity ISSUE FEE $23.50 - Repair/Alt Absorbtion Unit Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU . $0.00 0 Ventillation System $0.00 0 Repair/.Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00. 0 i , Inst/Rep.Recess Wall Htr $0.00 0 Commercial Incinerator '$0.00' 0 Refrig Sys<100 lc BTU. $0.00 0 - - Domestic Incinerator . $0.00/ 0 . ' Refrig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems Gas Piping $0.00 0 Up to 3 hp/100 k BTU $0.00 0 Factory Fireplace , $10.65 1 3 To 15 hp/500 k BTU .$0.00, 0 Hood w/Mech Exhaust $0.00- - 0 ' 15 To 30 hp/1,000 k BTU , $0.00' , 0 VAV Box , '$0.00 0 30 To 50 hp/1,750 k BTU $0.00/ 0 Vent Fan/SinglDuct ' / $0.00 : 0 _ Over 50 hp/Over 1,750 BTU '$0.00 0 Appliance ' , , ,$0.00 0 Boilers Fire Dampers _ $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers . , '$0.00 ' '0 3To15hp - - - , ' $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp - $0.00 0 Air Handlers< 10000cfm \ . $0.00 0 - 30 to 50 hp , $0.00 0 Air Handlers> 10000cfm $0.00 . 0 Over 50 hp . - $0.00 0 Floor Furnace $0.00 . 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 ' Reinspection Fee $0.00 TOTAL CALCULATED FEES $34.15 COMMENTS/SPECIAL CONDITIONS • 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 2 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(6/00) \/ 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 ork 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 wo coE[�;pensatl Insurance rrler and policy number are: /yry�/n� (Cama: Policy Number: 6(i 2709 3 (This section need not be comped it the ermit is valued at one hundred dollars($100)or less.) l_O —7 ❑ 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 to become subject to the workers' compensation laws aliforni a agree at if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with thes r sions. '7 ApplicanLSignature: Data: 4/�j'Q/ tWARNING:.FAILURE.TO SECURE WO s'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,0001,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licen e �1d.5r_Er9yi ns of Chapter 9(commencing with Section 7000)of Division 3 of.the.Busines andel rofessi r04,Code,and my license is in full force and effect.Lie.4 Y r'j C(l"�//�� / Class 4 1 /Er �,/L� Contractor'ss g tura:`?ii((/ n.1/7 / A Date: �/ Cy CONSTRUCTION LENDING AGENCY: LjA/� ❑ 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). 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.). ❑ 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.). O 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,Am 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? ❑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 0155 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? ❑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 flan 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 a_aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LI No (Section 65850.2 of the Califomia 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? ❑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? 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 AND AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Iir ensu' • WV'•. onzed Applicant CODE r INSPECTION TYPE PATE' "-- ' I[IIIIIdLS CODEr INSPECTIONTYPEpA1E ©� IrjTRIALS 1616 Fixed System Final Fire Prevention _ 206 Final Mechanical I /'i'•'{Wf- 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 - 250 Final Building/Occupancy ' M- 9 CITY OF COSTA MESA 4 BUILDING DIVISION F • ,rt1 DEVELOPMENT SERVICES DEPARTMENT PERM NUMBER . 4. �c%a I PERMIT Ibkbp„, 044. M01-00172 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No F Applied: 04/02/2001 Issued: 04/02/2001 Vicinity: Parcel Number 42619317 _ - ISSUED BY: Vw Applicant: RENZ, RUSS - 7' - - Address: "� - . Phone: 714-577-0771 , J 2X7-1- /j Zip: - • Ownei - -INFINITY/HOMES.CM I, LLC ' /, Address:/ \CLIFTON'JONES III ' : CERRITOS,;CA'' Phone: 562 924 4491 10945 SOUTH'STREET,#301 Zip: 90703 \\. Contractor: /SENTRY MECHANICAL, INC. ' • A�` / • r Addreess I 540"S JEFFERSON. - = ��`, CA Phone: 714-577-0771 " , , PLACENTIA,CA / • - Zip: 92870 , • ' License:631049 • . . 7 SCOPE OF PERMIT . - . , INSTAL HEATING AND,AIR CONDITIONING IN NEW SFR.- / ' / `, REF:B00-00990.CONTRACTOR IS DOING HEATING AND AIR CONDITONING ONLY. I" FEE SUMMARY , Quantity- . +. , , . , - , - Quantity, ISSUE FEE $23.50/ - -'- — - -�- Repair/Alt-Absorbtion Unit .�,/$0 00 0. Inst FAU'<100 k.BTU''` $0.00'.0'- -. Repair/Alt Refrigeration Unit V - $0.00 0; / Inst FAU >100 k BTU. , $18.20. 1 Ventillation System 2/;$0:00_ --0 11' Repair/,Alt-Cooling/Heat $0.00 0 Evaporative Cooler /('/$0.00 .-��0 ,',Ii Inst/Rep. Recess.WaIIHtr $0.00 0 Commercial Incinerator /2/1 $0:00.., 0 % / Refrig Sys<100 k BTU t:' $0.00 0 Domestic Incinerator2/' $0 00" o. f' Refrig Sys>100 k-BTU. \ $0.00 0 - : , .t.•"Compressors/Absorption Systems "'-1/.// , / r '/�/ Gas Piping�, A $0.00 0 Up to.3 hp/100 k BTU $0.00 /0' r Factory Fireplace .. ; - $0.00 0 , 3 TO-15 hp/500 k BTU $0 00 ,/,0/ Hood w/Mach-Exhaust 1 10.00, 0 ;15 To 30,hp:/.1,000 k BTU -i C $009','2 0 VAVBox \"I\. ,-/- 7`$0:00-` 0 '-„.30To50 hp/17507kBTU "jam , v, $0.007 /0 Vent Fan/Single,Duct / ” -, `$0.00 �-0 / ,:Over 50 hp/Over 1,750 BTO„27 $0.00 0 Appliance ��A ) $0:00�0� -C _ , Boilers ,�.�✓' �,'// Fire Dampers s �� < , 1 $0.00\0$,„z„-,, " -.„ - Up to 3 hp f� \--Y..- 0.00 0 Smoke Dampers � v, / '$000 o-,:-.:,,--:-,,,,,,, ,� o3 To15,hpr 7 $27.15 1 Inst or Relocate Appl Vent*, _ --T-"15 to30hp, \ //,-\c,-/ i $0.00 0 Air Handlers< 10000cfm\ `‘;$0.60/i -o - ;- - 30 to 50 hp - \ j '�> $0.00 0 Air Handlers> 10000cfm $000 / '0 - - Over 50 h ' �' '� / J _ P ', .-\ .- /�� $0.00 0 Floor Furnace ��-$0:00 0 w V I 'Other MechanicalFee _-/V Floor or Suspend Heater /----$0.00:-.--0 - ' ,, -_Investigation Fee ,7,2 $0.00 ; - -. - ' Plan Check Fee 7/ / $0.00 Reinspection Feed�- $0.00 ' - — —v TOTAL CALCULATED FEES $68.85 COMMENTS/SPECIAL CONDITIONS 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- f-7 required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration.of thispermit" FOR INSPECTIONS CALL: (714)754-5626 / 2446-46(6/00) 1.114Wil;Tijf•1dE 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 T� work for-which this permit is issued. Djhave 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.w(�y,(rkers' pensation InsuranceT� carrier and policy number are:`` _ [,� L DI0700 'G G Ca e_ L-0-0-6)Wtr h L 1'1. S C V h.0 Policy Number:. (This section need not be completed i e permit is valued at one hundred dollars($100)or less.) ` - - -'i ❑ 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 to become subject to the workers' compensation laws of Califomia, .nd agree that' I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith I=mply with the-' -visions. I '� Applicant v'- . /a , .� Las. Date:-_ 9--..-7 --Ci I WARNING:FAILURE TO SECURE WORKERS'COMP SATION COVERAGE 4 NLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($1W,0110),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37o6 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that•I am.licenssg under pr visions of Chapter 9(commencing with Section 7000)of Division 3 of.the Business-and Professions Code,and my license is in full force and effect.Lic:#-( --e-D/ [Class#--1 L -1 Co;iracrols Si t Fri Date: -y-j-c. 1 V" (1-11T6 VVV 4 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). 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.). ❑ 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.). O I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's 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,Grp 2,Art 2,Sec. 341,Title 8,Califomia 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 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 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? U Yes U 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? ❑Yes ❑No (II"yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have ell of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? 0 Yes ❑No 8 Of"yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penally 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 AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. C� \ /S pture Of Legal Owners Date (�1K - 1 -V I end/Or Auth Ized Applicant .. rDate-- COM A INSPECTION TYPE PAIL' IMRUL@ CODE1 INSPECTION TYPE AT MLS 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 250 Final Building/Occupancy • S CITY OF COSTA MESA _� 40.g BUILDING DIVISION Fr 41 DEVELOPMENT SERVICES DEPARTMENT PERMIT BER J• ni PERMIT ,.F P00-00672 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT • Job Address: 169 21ST ST Status: ISSUED Suite No F Applied: 12/01/2000 Issued: 12/01/2000 Vicinity: UNIT F Parcel Nunmber: 42619317 ISSUED BY: Applicant: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: GOLDEN WEST PLUMBING INC Address: 1247 NORTH BATAVIA Phone: (714)997-9991 ORANGE,CA Zip: 92667 License: 317026 Arch/ Eng : Address: Phone: Zip: • License: SCOPE OF PERMIT PLUMBING PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT F). INSTALL 3 BATHTUBS, 1 DISWASHER, 1 EXPANSION TANK,5 GAS OUTLETS, 1 WASHER, 1 PRESSURE REGULATOR, 1 SHOWER, 1 KITCHEN SINK,UP TO 4 VACUUM BREAKERS,4 WASH BASINS,3 WATER CLOSETS,8 1 WATER HEATER. REF; B00-00990 FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $9.80 1 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $29.40 3 Pressure Regulator $9.80 1 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $12.30 1 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $39.20 4 Dishwasher $9.80 1 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain,Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $29.40 3 Drain,Roof $0.00 0 Shower $9.80 1 Water Heater/vent $12.30 1 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $9.80 1 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) 56.15 1 Sink,kitchen $9.80 1 Water Softener $0.00 0 Gas(Over 4 outlets) $1.10 1 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 _ , TOTAL CALCULATED FEES: $212.15 NOTICE: The work authorized by this permit sCOMMftN1S laSREGIAls 6ONQjTAQ96S 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 .- fora 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(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 for which this permit is issued. ��f_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 carder and policy number are: i (Tater.-roll" F1l.tr. Policy Number. -0N. (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) t — ❑ 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 to become subject to the workers' compensation laws of California.and agree that if I hould become subject to the workers'compensation provisions of Sectio 3700 of the Labor Code,I shall forthwith comply with these pr•vi'•ns. c------- Applicant -----Applicant Signature:- A ALFA" A✓ 1 rDate:—/ci CO WARNING:FAILURE TO SECURE ERS'COM' NS ON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO I PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLARE($100,0001,I ••DITION TO Er•-T OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am)icensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the.Business and Professions Code,and my license is in full force and effect.Lic.# /17 r / Class u._=1 Contractor's Signature:--- "A ../. /.iA (Date:—/7 S Q I �- - CONSTRUCTION LENDING AGE• Y: OF ❑ 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 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.). ❑ 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 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,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 Safely 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 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 ❑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 ppermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ID Yes LJ No (Section 65850.2 of the California Govemment 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? ❑Yes ❑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? 0 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 AUTHORIZATION 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. re Of •al Owner(s) Date A ,A4 ' r /..:' /2/COD An$:'f thorized Applicant. . (Date _ _ _ - _ CODE 1 . ' •ll�' � PLIl. INTmALS Min ytsPEc110N TYPE PATE mu. 1616 Fixed System Final Fire Prevention 206 Final Mechanical 4 1266 Pool Spa Final 208 Final Plumbing /210 200 Final Re-Roof 210 Final Electrical 201 Final BIocldRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site .04 Final Demolition 250 Final Building/Occupancy 0 '(cam r CITY OF COSTA MESA • BUILDING DIVISION >• ; ,. DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER F PERMIT `�e F00-00286 (714)754-5273 • Fax(714)754-4856 • www.ci.costa- FIREa.us SUPRESSION PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 169 21ST ST Status: ISSUED Suite: F Applied: 11/02/2000 Vicinity: UNIT F Issued: 04/11/2001 Parcel Number: 42619317 Zoning: ISSUED BY: ± S)4 Applicant: MARTINEZ, MONA LISA Address: 1787 POMONA RD SUITES D&E Phone: (800)915-3473 CORONA,CA Zip: 91720 Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: FIRE SPRINKLER SYSTEMS Address: 1787 POMONA RD SUITES D&E Phone: (800)915-3473 CORONA,CA Zip: 91720 License: 684600 SCOPE OF PERMIT FIRE SPRINKLER PERMIT FOR NEW SINGLE FAMILY RESIDENCE FOR"INFINITY HOMES"(UNIT F). INSTALL 26 FIRE SPRINKLER HEADS. REF: B00-00990 FEE SUMMARY Plan Check: $39.07 Calc Valuation: $1,700.00 Permit: $60.10 - Claimed Valuation: $1,700.00 Other: $0.00 - Total: $99.17 • • i . • 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(6/00) 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 ?30work for which this permit is issued. •1 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_� nInsurance carrier and policy number are: "Carder: _Io2st L v11A tcy.Number: _(This section ed not be completed if the permit Is valued at one hundred dollars($1 00)or less.) ❑ 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 to become subject to the workers' compensation laws of California,and agree that If I should become subject to the workers'compensation provisions of Section 370 of the Labor Code,I shall forthwith comply with these p •visions. Applicant Signature: ''ji'.vdLi / JQ Air \ __Date: '`T/' fi III ' WARNING:FAILURE TO SECURE •: ERS'COMPENSATION COV: •WFUL AND SHALL SUBJECT AN EMPLOYER TO GRIMINL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED '- _THd1CAND DOLLARE($100,000),IN ADDITION TO THE COST OF'•'t'-ENSATION,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 un pr sions 0 hapter 9(commencing with Section 7000)of Division 3 of.the Business a Prof ssions Code,and my license is in full force and effect:Ucl i t7 ?et( Class a— 1( Contractor's Signature: !.� � '7g - -i7�_ Date: /// �C7 1 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). 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 end 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 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,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 Califomia 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 end 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 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 Califomia 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 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 ❑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? 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 AND AUTHORIZATION.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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ,T/T Sigpatyye Of Leg I- s) 1////Ute (` v nd r A�th ze Applicant ate CODE I INSPECTION TYPE 2676' INTOIAL$ CODE. INSPECTIONTYPE 267E INTITIALS 1616 Fixed System Final Fire Prevention I)-6 'D 1 /, Y - 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical v� 201 Final Block/Retaining Wall 212 Final Fire Prevention J I-Co•'o( }wit 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition - 250 Final Building/Occupancy rf�' Souths _st Inspection and Te" ting, Inc. Y ! / 10826 South Norwalk Blvd., Santa Fe Springs, CA 90670 424 ,,/(I (562) 941-2990 • (714) 526-8441 • Fax (562) 946-0026 ( "'� SWIT JobiNo. Date REGISTERED INSPECTORS'S DAILY REPORT YL5-2/6 '/-K-6 / TYPE OF 0 Reinforced Concrete 0 Structural Steel Assembly 0 Quality Control INSPECTION ❑ Post Tensioned Concrete 0 Fire Proofing 'Other-Gutty+ REQUIRED 0 Reinforced Masonry ❑ Asphalt JJ Job Address t / ity �1 07eAe9F rIE if) mfr Job Name - 1 i Permit No. Issued By 1.t r Tarim r-t" No4 4-S -TE"r- >/ Lc1a_i Type of Structure / Architect .. //WA/ O,Y/G.r- r/4!, ;- `0 .//.1:,,. zu fl A s Material Description(type,grade.source) Engineer 1 % i`1 .0 I[, Me .-SAfi t ; 1 DEPUTY 1 INSPECTION SERVICE INC.I DEPT. OF BLDG.& SAFETY 25266 VIA ENTRADA LAGUNA• NIGUEL, CA 92677 CITY OF COi /Y1“14 1- 800 - DEPUTY 1 = 1- 800 - 337 8891 COUNTY OF SPECIAL INSPECTION REPORT Building Permit No. 542°-"I/gggr Q91. 913 Job No. Date Z - / S- D / Job-Identification/Address ZCIr 51 tc1 tf, -Empr cwi ss 1 G7 2lSr3 C9574 Mc S Al General Contractor/Address\_ Fi f÷0 44 i5, Sub - Contractor/Address E+ t= w6l 0int6 Structural Engineer/Address SIR uc-r+..tRE5 (JJLST TYPE OF WORK REINFORCED CONCRETE MASONRY HI-TENSILE BOLTING PRESTRESSED CONCRETE WELDING X GYPSUM CONCRETE WELDER RECEIPT NUMBER WELDER RECEIPT NUMBER Gt45T1-Vo Ca2eg- ' " ' LA Cry 'cczr DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED (14) T - 5172.1cr, -ry t 57-L. fgot e5 - 8 x 6x 7/3" (? 4-075 - ( 'l , 7 9 w&GDEn f:/LC. P.9A1 r#LL AcotinI/7 06, .ory sot 1--"D A le4c-a �NT21'>e - n't Pe-e-ff P5 t.4r c crOt5 c SPrPirfrcAno,,✓s P ?Al I;r. � . Lo / - ch`„> - &2o 9 y -4 - ,,rniir 17- /Oo 921 Ltj r - - :.(nlr'r-(7 - goo 9j car 9 - 4AI7J -- 000 498 FCA 670 V v fL.EC72c7Dc HOURS SAMPLES Date Reg. OT Time In Time Out Block Grout Mortar Concrete Density 2//5/0I SOU ( 3 a Prisms All inspections based on a minimum of 4 hours&over 4 hours-8 hour minimum.Any inspection extending past the noon hour will be billed as an 8 hour minimum.In addition,any inspection extending past an 8 hour period,or Saturday inspection will be billed at time and a half. 'ATTORNEY'S FEES- If any action at law or in equity is brought to enforce or interpret the terms of this Contract, the prevailing party shall be entitled to reasonable attorney's fees, costs and necessary disbursements in addition to any other relief to which such party maybe entitled. , SPECIAL INSPECTION REPORT (1-dA Name: L.�+Q'e Y 6412 it& Inspector's Signature 1,414/ I.D. No. 0 C- 9,531 has been filed and it states that the above work to the tjest f his/tier knowledge complies with the provisions of the Uniform Bui/rding Code and meets approved plans and specifictions. U 1 / / y Respectfully Submitted, i /I._t Approved by: / 1-4,1;')/ ,".7 Vi1f/ By: G.�—' Project Superintendent Gary Rutherford O 9 CITY OF COSTA MESA �. 66 BUILDING DIVISION >: r .4r DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 1• t si.nsa i PERMIT ` ro,� B01-01000 eI se (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.usNG PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDIJob Address: 169 21ST ST Status: ISSUED Suite: Applied: 06/28/2001 Vicinity: REAR OF RESIDENCES Issued: 06/28/2001 Parcel Number: 42619317 Zoning: Applicant: JONES, GAIL ISSUED BY: / Address: Phone: 949-645-4338 Zip: Owner: INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS,CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor: ante/ "" r Address: Phone: Zip: License: Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT TRASH ENCLOSURE PER CITY SPECS FOR A 9 HOME COMPLEX: REF:TRACT 15969.APPROVED UNDER ORIGINAL PLAN CHECK FOR HOMES. FEE SUMMARY Plan Check: $0.00 - Calc Valuation: $1,500.00 Permit: $54.00 Claim Valuation: $1,500.00 SMIP Res: $0.00 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 • Total: $54.00 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(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 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 carder and policy number are: Carrier: Policy Number: (This section need not be completed if the permit Is valued et one hundred dollars($100)or less.) ❑ 1 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 to become subject to the workers' compensation laws of Califomla,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARE($1%,000),IN ADDfTION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class# Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: O 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 penally 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).): 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.It however,the building or improvement is old 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 exemp/ der s . Business and Professions Code for this reason: / Signature: i/ ( i -0 Date: CO/.,Sr rD Owner ID verif:d by drivers license. Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of docu nt,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 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? ❑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 ❑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 a plication akermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Li Yes LJ No (Section 65850.2 of the California Govemment 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 ❑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 AUTHORIZATION 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. / '// ` i ignatur f zgz I Owner(s ' D to ( / AUDI And/ Authorio pPlicant ate CODE» INSPECTIONTYPF ' Mg INT6IALS CODE INSPECTION TYPE RAM 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 41446-02-- .� // / �,__,. 204 Final Demolition 250 Final Building/Occupancy / wn"VZ" i 4t,- MF CITY OF COSTA MESA BUILDING DIVISION >:f ] DEVELOPMENT SERVICES DEPARTMENT PER T NUMBER aaiver:1 /" PERMIT B01-01001 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite: Applied: 06/28/2001 Vicinity: REAR OF RESIDENCES Issued: 06/28/2001 Parcel Number: 42619317 Zoning: Applicant: JONES, GAIL ISSUED BY: Address: Phone: 949-645-4338 Zip: Owner INFINITY HOMES CM I, LLC Address CLIFTON JONES III CERRITOS, CA Phone: 562 924 4491 10945 SOUTH STREET,#301 Zip: 90703 Contractor OWNER-BUILDER Address: Phone: Zip: License: 0 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT 333 L.F. BLOCK WALLS BETWEEN RESIDENCES FOR A 9 HOME COMPLEX.APPROVED UNDER ORIGINAL BUILDING PERMITS FOR HOMES. REF:TRACT 15969. FEE SUMMARY • Plan Check: $0.00 Calc Valuation: $6,660.00 Permit: $139.25 Claim Valuation: $0.00 SMIP Res: $0.67 . SMIP Corn: $0.00 - Other: $0.00 Inspection: $0.00 Total: $139.92 • 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 fora 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(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 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 the permit is valued et one hundred dollars($100)or less.) O 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 to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($106,006).IN ADDITION TO THE CfST 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 provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class k Contractor's Signature: _ Date: CONSTRUCTION LENDING AGENCY: O 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).): 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 property who bultds or Improves thereon,and who contracts for such project with a contractor(s) license purs ant to the Contractors License Laws.). ❑ I am exe , rider;•c. Business and Professions Code for this reason: Signature: // •, 6 ea Date: (c7e ii/01 Owner ID veri led by driver's license. ❑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: ❑ 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,talsework,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 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? ❑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? ❑Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes D No (Section 65850.2 of the California Govemment 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? ❑Yes ❑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 end Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION 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 laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. N� A /sig, Lk.Of Leal Owner(s) - --- -- // Oate , LL r//Jl ._ n I r(i And/pr u orized Applicant • Date SODEN INSPECTION TYPE + RAIL INTITIALS CODER INSPECTION TYPE PATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Root 210 Final Electrical 201 Final Block/Retaining Well ti-arc_DL 6,441.` 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition _ _ 250 Final Building/Occupancy • 4 05111 6 CITY OF COSTA MESA BUILDING DIVISION F �,;z ►.I DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER p •, PERMIT J q.(, C00 0002c (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 GRADING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite: Applied: 06/30/2000 Vicinity: TRACT 15969 Issued: 09/28/2000 Parcel Nunmber: 42619317 • Zoning: ISSUED BY: Applicant: CLIFTON S JONES III Address: 10945 SOUTH ST#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 Eng: ROBIN B HAMERS &ASSOC Address: 234 E 17TH ST#205 Phone: (949)548-1192 COSTA MESA, CA Zip: 92627 License: SCOPE OF PERMIT CUBIC YARDS PRECISE GRADING FOR 10 NEW SFD(TRACT 15995). 2000 _ FEE SUMMARY Plan Check: $44.00 Calc Valuation: $82,458.00 $0.00 Permit: $209.00 Other: $0.00 $0.00 Inspection: $0.00 $0.00 • Total: $253.00 PLANNING &ZONING 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(6/00) • 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: i>. Policy Number: (This se ' n need not be comp:ted if t :permit is valued at one hundred dollars($100)or less.) [certify that in the performs• e o e work 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 of ..if.rni.,. d agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these • • i-o _ /yy�- '�7 (( -Applicant Signature: .- /..re se- Date:'- • ( -.C--Q— Cf-D -WARNING:FAILURE T• 0' VERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(S1.... -DDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that I am licensed under pr. apter 9(commencing with Section 7000)of Division 3 of the Busine nd Professions Code,and my license is in full force and effeci Liao-W,..� � Class 1-.1 f Contractor's Signature:-.-.-_ agar: -- Dete: &8 -co (((( � _ CONSTRUCTION LENDING AGENC : ❑ I hereby affirm that there is a con tion lending 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'Lo 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.). ❑ 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. ❑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,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? 9 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? ❑Yes ❑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 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? 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? Yes 0 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 ❑No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .. ir Quality Management Dist 7 If a permit from the South Coast res prescri ed by gement District or other airpollution control district3 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 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 COMPUANCE AN• .,:`' -TON 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 . state laws : d'city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for'• .ection purp•.-5.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. atu • ofer(s) C Date k An. •d Authorized Applicant 2 DatCd S CODE I INSPE :•N TYPE DATE IML@ CODE I INSPECTION TYPE PAIS (NTMAL$ 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 C_f--10`.4Y— 6-‘444- 204 Final Demolition 250 Final Building/Occupancy aCITY4`p Fs OF COSTA MESA BUILDING DIVISION >•4 , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F t t PERMIT vlit- fi; B00-01616 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.C.UILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 169 21ST ST Status: ISSUED Suite: Applied: 10/09/2000 Vicinity: PERIMETER BLOCKWALL FOR 9 UNITS Issued: 10/09/2000 Parcel Number: 42619317 Zoning: Applicant: JONES, CLIFF 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 CONSTRUCT 713 LF OF RETAINING/GARDEN WALL UP TO A MAXIMUM OF 8.5 FEET HIGH AROUND THE PERIMETER OF TRACT FOR"INFINITY HOMES". . FEE SUMMARY Plan Check: $326.85 Calc Valuation: $35,650.00 Permit: $502.85 Claim Valuation: $o.00 SMIP Res: $0.00 SMIP Com: $0.00 Other $0.00 Inspection: $0.00 Total: $829.70 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 fora 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: • ❑ I have and will maintain a certificate of consent to sell-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 sion need not be COMMIX-•if t a permit is valued at one hundred dollars($100)or less.) uaetr -I-certify that in the part• ..ante o the work for which this permit is Issued,I shall not employ any person in any manner so as to become subject to the workers' 1/4.---compensation law nia and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith ' comply with the : . .. �•L p� ,,..1 �AppliCant Signature' Dat=: /O i / G'v ,WARNINGr FAILURE TO i ERS' NSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN'EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(SI W,"', '�DDtTION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. 6 LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisi• pier 9(commencing with Section 7000)of Division 3 of.the-Busineessd Professions Code,and my license Is in full force end effect.Lic.e �27n 0 S' (Class# Co�tractors•Slgnalure:_m ; n/ ('Data /O— 9--'C CONSTRUCTION LENDING AGENC • ❑ I hereby affirm that there is a construc ion lending 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.). ❑ 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 • Drivers 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 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 ❑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 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? 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 akermit for such construction or modification L! from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes U No (Section 65850.2 of the California Govemment 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 Califomia 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? 0 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 • r , ORIZATION 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 . state law :nd city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property 1• n n purp• =s,I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ft'•.• urer =•alp •-.+ ,.,•Date_ Ahd/r. •Fmz=d •ppli antes— —.. _ [Date CODE• INSPECTION 263 REELS CODE! INSPECTION TYPE PSIS 1I41II1D15 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 well 7//�O/D 2— 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy • 05151114 CITY OF COSTA MESA BUILDING DIVISION > , , , DEVELOPMENT SERVICES DEPARTMENT PER T NUMBER F t Pita a . ' PERMIT 00-01363 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ccaU�LDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 169 21ST ST Status: ISSUED Suite: Applied: 09/05/2000 Vicinity: Issued: 09/05/2000 Parcel Number: 42619317 Zoning: Applicant: JONES, CLIFTON Address: 10945 SOUTH ST ISSUED BY: 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 1033 SQ FT SINGLE FAMILY RESIDENCE. 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 2446d6(NW) 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 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'compensationInsurance ' r and policy number are: Carrier: Policy Number: (This s on need not be complete. ' pe it is valued at one hundred dollars($100)or less.) C . _I.cenify the in the•• orm - ce of •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 I• s of ,,- for . x.agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with t• se • - '• ( Applicant Signature. /(�. or WARNING:FAILURE TO S-r URE W• 'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(VI•,OpO),ITION 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 Ilam licensed under pr•visi• (commencing with Section 7000)of Division 3 of theBusin d Professions Code,and my license is in full force and effect.Lic.# ' — I + ,J A - Class# . • Contractor's'Signature: Gr' %-<' CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a constructio - ling 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.). ❑ 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 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 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? 0 Yes LJ No (Section 65850.2 of the California Govemment 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 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? 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 AND A t •-I • '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 stat' .ws and city •rdinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspect. • noses.'1•a•ree not to occupy or allow occupancy of any building authorized by this permit until final inspection. �S';n: • e j.r.t ••wners ���aDate •nd/OPA • '•Applicant--^------r—, - r Date CODE r INSPECTION TYPE PATE INiIiIAL$ COPE• INSPECTION ME PAIL INiTRAL$ 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 tL iG•OL 4441 250 Final Building/Occupancy • 4`0 'f - CITY OF COSTA MESA BUILDING DIVISION N-c„ .� . DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER J 1.114 lLa . PERMIT s`OkPonar03..0P00-00484 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 169 21ST ST Status: ISSUED Suite No Applied: 09/05/2000 Issued: 09/05/2000 Vicinity: Parcel Nunmber: 42619317 ISSUED BY: Applicant: JONES, CLIFTON 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: Phone: Zip: License: SCOPE OF PERMIT CAP EXISTING SEWER LINE FOR DEMOLITION OF EXISTING RESIDENTIAL HOMES. FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0 Dishwasher $0.00 0 Sewer Cap for Demo $9.80 1 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $0.00 0 Drain, Roof $0.00 0 Shower $0.00 0 Water Heater/vent $0.00 0 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas(Over 4 outlets) $0.00 0 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $33.30 COMMENTS I SPECIAL CONDITIONS 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 fora 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-p FOR INSPECTIONS CALL: (714)754-5626 --------- 2446-48W0a) 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 sell-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 -b'/y OwBgo 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. {�(/pfgf4Srkerscompensation Insurance carrier and policy number are: e' Policy Number: ' itThritiction need not be completed If fh: a: if is valued at one hundred dollars f$100)or less.) -- 1,certify the in the perto • • : f the •rk 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 -alifo J�and:•ree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these• ovisio• Applican(Signeture:— -� / 'e Date:-- WARNING:FAILURE TO SECUR • -S'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CWIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN'•DITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed underJprovisions• C • ommencing with Section 7000)of Division 3 of the Busine nd Professions Code,and my license Is In full force and effect.Lic.it 7790 C Class ContractoYs Signature:- - t 1Date:— %'S'c° 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 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.). El I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. El 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(38)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? ❑Yes ❑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? El 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 a plication 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? DI Yes U 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? ❑Yes ❑No (If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia 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? El 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'AUTHO DATION 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 laws nd city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for •: pu ses.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. • - o• er(s) ry Date Aye • thorized Applicant__ � Date CODEC 1•. $•. DATE INIRIALS CODE INSPECTION TYPE PATE IMMS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 11 .Y,,� 1266 Pool Spa Final 208 Final Plumbing - O(',4. 10 1di 10-TO 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 250 Final Building/Occupancy PROJECT ADDRESS: 169 21ST ST UNIT: CITY OF COSTA MESA — BUILDING PERMIT PERM NO: M 060418 OWNER'S NAME: JACOBY NED L TR ADDRESS: 375 231th ST A PERMIT NO: M 060418 PLAN CHECK NO: N GOVT: N SUPP: N NEWPORT BEACH, CA 92660 CONSTRUCTION TYPE: 5—N PERMIT TYPE: MEC PURPOSE: OTH ARCH/ENGINEER: REG.NO.: JOB DESCRIPTION : REPLACE WALL FURNACE SQ FT: ADDRESS: UNIT: CLAIM VALUE: CALC—VALUE; GROUP OCC; R-3 / PERMITTEE: ABC HEATING & A/C ( 714 ) 540-0972 ADDRESS: 2951 GRACE LN COMMENTS: WALL FURNACE CHANGE OUT IN THE FRONT UNIT ONLY! COSTA MESA CA 92626 *****Sr***+ESr*+E**x***Sr*SE*SE***SESESE************SrSESETE*FE***+E*************SE*****+ESr**Sr*** LICENSED CONTRACTOR DECLARATION: I hereby atlirm 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 full force and effect, SETBACKS CITY UC).: 006041 STATE Uc.:133298 �pss: 20 Dat�/E • ep — 92 signature: /_/ MAIN BUILDING ACCESSORY BUILDING WORKERS'COMPENSATION DECLARATION: I hereby affirm that Ihave acenificate of con oseU insure orapennicate of workers' FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN Compensation Win�a(}certified copy thereof(Section 3800.Lab.81 /01 /93 LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT; FT IN POLICY NO.: 4 J 7 EXP.DATE: V cOMmANY: REPUBLIC INDEM PARKING RE • PROV: PARCEL: 42619317 ZNE; REF NO: ' "] Certified copy is hereby furnished. (A Certified coi. filed with the ly Building Division. PLANNING N TES> _,? -Z?-9t, / /' > -- Dal App . /✓/ i *************************************iE***************************************** EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (this section need nal bey.- Meted if the permit is for one hundred($100)or less). DEVELOPMENT SERVICES REQUIREMENTS I certify that in the performance of the work for which this permit is issued,I shall n x employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. ZONING APPROVED BY DATE: Date: youSshoul BUILDING APPROVED BY : DATE: NOTICE:IL after making this declaration. should become subject to the Workers'Compensation provisions of the Labor Code.you must forthwith comply with such provisions or this permit shall be deemed revoked. ' CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED BY: /i�� S DATE. �� which this permit is issued(Section 3097.Gv.CI ************************* R * E *i ********** **** **1E******7k** LENDER: *********************************************** ****************************** ADDRESS: LEGALIZATION;N F E E S U MMA R Y STRUCTURAL SEGMENT:N OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING (Section 7031.5 Business and Professional Code: My city of county which requires a permit to construct,alter,Improve,demolish,or PERMIT 9 00 repair any structure.prion to its issuance.also requires the applicant for such permit to file a signed statement that he/she is licensed 5t SMIP/NON—RES pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business PLAN and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.My violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dotars($500). ISSUE FEE 15 , 00 I. as owner of the property or my employees with wages as their sale compensation, will do the wont, 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 TOTALS----> 9 . 00 15. 0 0 0 . 00 24 , 00 24 . 00 . 00 does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through his or her own employees,provided that such improvements are not intended on offered for sale.If,however the building or REVENUE DIVISION TOTALS--> COLLECTED: 24 . 00 OVER/SHORT: , 00 imforptheepurrpose of sale(. one year of completion,the owner will have the burden of proving he/she did not build or improve BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK I.as owner of the propel,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business 2 4 0 0 ❑ and Professions Code: The Contractors'State License Law does not apply to an owner o1 property who builds or improves thereon and who contracts for such projects with a contractor(s)license pursuant to the Contractors'State License Law).l am aware ******************************************************************************* that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL F E E BREAKDOWN ❑ I am exempt under Section: 8.&P.C. lor this reason: TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST Date: Owner: MEC 1 INST/RELOC RECESSED WALL HEATER 9. 00 9 . 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]on any future building occupant wtywiI not(circle one)need to comply with said state codes and the requirements for a permit for construction or modification from the Air Duality Management District.Residential construction applications are exempt from these provisions. Dale: _ 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. DaI / GSignal Driver's license or Social Security N: 164 '46 White—Building:Green—Code Enforcement:Canary—AoolicanC Pink—Revenue:Goldenrod—Assessor CONSTRUCTION AND PLANNING • POO SPA APPROVALS Permit# Date Inspector APPROVALS Permit # Date Inspector 1. Temporary Electrical Service.or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6, Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 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. Structural Floor System i 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 'I Rough Plumbing c 65. Electrical-Final 15. Rough Electrical-Conduit ' System-Final 66. Solar !I 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 I - '• APPROVALS Permit # 21: Ducts, in Structure I ..`.. 70. Underground Hydro 22. Ducts, Ventilating .., t• , 71. Product Piping 0 Gds 0 0il • ipe.Rou h &Test I ' 23.,Ga { P 9 i .72. Underground Flush 24. Roof Framing . 73."Undergrnd.Storbge'Tank 0 Gas 0 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& SidingI 77. FIXED SYSTEM FINAL • 29. Insulation I - 78. FIRE PREV. FINAL 30. Drywall Nailing • I HEALTH DEPT. REQUIREMENT I • ! 31. Plaster Brown Coat . i 1 t; 79. FINAL INSPECTION 32.. Electrical Power Meter-Final • .I .1 80. FOOD CERTIFICATE ISSUED 33. Final Electric j r ( - Notes: _t 34. Final Heating & Air Conditioning izl�ti r.�o�' 35. Final Gas Pipe-Test j 36. Hood or Canopy L ; ,I 37. Final Factory Fireplace I ' 38. Final Plumbing .i • 39. Water Service-Final Ii: ' vl. 40. Gas Service-Final : j 41. Solar Domestic•Final • I i :I • . •• 42. Backf low Preventer , 1 43. Backf low Irrigation - 44. Landscape Irrigation System . 45. Sound Attenuation 46. Handicap Regulations . 47. FINAL STRUCTURE & BUILDING 1 I "1 • 48. FINAL PLANNING • I 49. Electric Release to Edison 1-'1 Jr� 50. Gas Release to Southern California Gas CO I 1211 51. CERTIFICATE OF OCCUPANCY •'� No. Date This is to certify that insulation has been installed in conformance with the current energy regulations, California Administrative Code, Title 25, State of California, in the building located at: SITE ADDRESS DUPLEX APARTMENT/165-169 21st Street, Costa mesa EXARIOR WAILS Manufacturer 0 C F Thickness/Type 3i" R-Value 11 CEILINGS • Batts: Manufacturer 0 C F Thickness/Type 6" R-Value 19 Blown: Manufacturer Thickness/Type R-Value Wt./Bag Sq.Ft. Covered R-Value • FLOORS (Cantilevered) Manufacturer 0 C F Thickness/Type 3i" R-Value 11 SLAB ON GRADE Manufacturer Thickness/Type R-Value Width of Insulation Inches • FOUNDATION WALLS Manufacturer Thickness/Type R-Value GENERAL CONTRACTOR Atlas Builders LICENSE # BY TITLE DATE KING TO'JWSU `TION CO TRACTORS, INC. LICENSE # 221615 C-2 BY TITLE Production Manager DATE 8/19/76 CITY OF "OSTA MESA PA1._. FEES NP 181 / Fee Payment tt7Receipt Project Address ppfdQ- 1 • `I�T Sr Park Area U A. P. No. 1 1 -OG2--21 Building Permit No. 41972-- Owner's Name 3.—C A tAcs / Aca Y Mailing Address I cos- • 2.4 r S[-' FEE Single Family * No. of Units @ S455.20 = Multiple Family ** No. of Units Z @ S321.32 = Co4Z• (o4 Total Fee �ft-)75). ` Cn42•�q Planning Department Approval fietq S— ?R �7 By et✓/�Q. J Applicant's Signature v * City Ordinance 72.44 •• City Ordinance 72-45 *** City Resolution 74424 1(G JQ1J White-Planning;Canary-Planning;Pink-Finance;Goldenrod-Applicant CMF 0174-26 u A {t IKANtsi.IACUM .,..._ 5-28-76 JOB ADDRESS 169 East 21st Street1. It. BUILDING PERMIT NO. 41972 1/44IGENFRAL CONTRACTOR Atlnc Rid 1dnrc DESCRIPTION of WORK n"ple,r mint I- garagp AI 11s-067-71 LOT TRACT FIRE ZONE VALUE $ 50,800.00 INSPECTIONS Signature Date TYPE V GROUP I & J ZONE R-2 .��.ki`qqqSOIL c?-4 b'I�.71 SUBCONTRACTOR PERMITS ISSQED GAS Date I Number I Signature WATER f . 7� lambing HOUGH PLUMBIN }L'� S.: JIL •'_' A,- 6- R•7G (,923(0 ..'"--- PROP. PROP. SWR. LINE 0 HOUSE CON. SPRINKLING SYSTEM /��/yy�� p MISCELLANEOUS I'." '� 4-3. ROUGH HEATING AND AIR CONDITIONING TEMPORARY SERVICE OR POLE UNDERGROUND ❑ POWER [.4. ANC/ -W1.7f./' ROUGH WIRING 'C# 7-71L01/ Heating and Vent. TRENCHES 0FORMS n STEEL REINF. [Ta....**. A f Ad ggiaS, A '�-1�-Z. /at/ -- FLOOR FLOOR SYSTE^M +'/ / I�,e� 4.1 ,-/-e-c, 7-�5'.b �„�L97," BOND BEAM L STEEL REINFORCE n / (meq tat* ,_/ant, 7 I/--74 f"270 SHEATHING ' / Le •'i ! . an • eitacw awe. 7-14 1-76. 1270 FRAME AND FLASHING ^A ,L • /` Q ••• . • J -- ` ,-,,a_,..;,,-,,a_,..;, ^' LATHING — IN 7 Gus or — IC- ' -{I"1� P' TER, BROWN COAT 1e LC- € '/ I S ,TURAL. FINAL ^ Electric HEATING, VENT., REFRIG. AND A.C., FINAL <A c _je..'/ ('t • P.p.a^Q, G.'�_7! gese'A ,e ' PLUMBING, FINAL AND GAS TEST M k//1b 4.b^y/pa V• " b i Ci ELECTRIC, FINAL 4- /[� • BUILDING, FINAL s"� f J/y4 SPECIAL REOWREMENTS 7� /I' 7I . �` 9 4/ 7� qjY ?R-7 , 00i771 d** 189.00 COSTA MESA BUILDING-SAFETY DEPARTMENT P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 APPLICATION FOR STRUCTURAL PERMIT For Applicant to Fill in Completely — link Only /�� 2 RECE�VF DATE RECEIVED DAA I ` BUILDING T ADDRESS pt /�/� ��.,,,III r OWNER Jery ,(IES J4CO8Y A.P. NO. PERMIT NO. MAIL // BUILDING ADDRESS ADDRESS TEL. TRACT I LOT BLOCK CITY NO. CONSTRUCTION NEW ADD ALTER (REPAIR (MOVING DEMOLISH LENDER BRANCH OWNER ADDRESS VALUE ARCHITECT TEL. USE $ OR ENGINEER NO. FIRE ADDRESS ZONE TYPE GROUP APPROVED CONTRACTOR BY DATE ADDRESS ZONE INO.OF USE OF NEW TEL. PLANS BUILDING CITY NO. f STATE CITY YARDS APPROVED YARDS APPROVED gLIC. NO. LIC.NO. MAIN BUILDING ACCESSORY BUILDING W SIZE NO.OF BLDGS. (FROM C/L STREET) 0 OF LOT I NOW ON LOT FRONT FT. FT. Q USE OF v).. EXISTING BLDG. R.SIRE FT. FT, to FSeparate permits are required for L.SIDE FT: FT. G electric,plumbing and heating work. REAR FT. FT. c_ USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN& �S MAIN BLDGS. ACCESS.BLDGS. ..1 VAR.# DATE a G� \L ��///��� IGQQ C.U.P.# APPROVED ) .p fie t APPROVED �/C/ ` ` iAP DATE lY. 0. • O I hereby acknowledge that I have read this application and state n IX that the above information is correct and agree to comply with m L all laws regulating building construction, and I shall not employ i. WZ any person In violation of the workman's compensation laws of .S. the State of California. m 3 I hereby certify that I am properly licensed as a contractor under SQ. FT. N the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m Chapter 9, and that such licenses are In full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FE Y: am exempt from theprovisions of the State of California Business co p VALUATION PERMIT FEE $ ` .Da < and Professions Code,Division 3,Chapter 9. n m PLAN CHECK $ e — 'c Signature ofo Permittee $ TAX 4/0 $ 4 U U Authorized Agent TOTAL PAID $ 4,0)0 nY 12-76�,".F^OO 563" "�` ~99.O6 44.102 /OSTA MESA BUILDING-SAFETY DEPARTMENT P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 APP CA ION FOR STRUCTURAL PERMIT For Applicant to Fill in Completely—Use Ink Only RE( V DATE R/ECEIV7E/D D IS E'B/, I BUILDING �/ / 6, 2,/ __ �l — b+ 17 -�•y-/F3 L ADDRESS Cy ani L OWNER JE7i- 3 )i- C U/3 7' A.P. NO. fl lil X--24 PERMIT NO. MAIL .42.`--\ 4T ( BUILDING I�9 ' �f I ' ADDRESS ('�/4 ' c / — `'/ .TEADDR�EtS�_S1{ rVtj ` �J�/ CITY /� Csi S7^ NO. CONSTRUCTION ^"CTW%! . edT2 2.,. BLOCK CONSTRUCTION 0 • )v / NEW ADD ALTER REPAIR MOVING OFMOLISH LENDER 0 ����(((( 5C BRANCH OWNER t ) EA-1J1�2� jA,"a pn✓ ADDRESS w/��ft j t! ARCHITECT TEL. USE �j ft $ (l OR ENGINEER NO. - - r FIRE T ADDRESS ZONE TYPE TROUP,J,/ 1 APPROVED CONTRACTOR 4 7-4.,..9-J -aU/ _.Z)e-'7L .S BY / DATE ADDRESS .L04-j 4A-1,7 Feet?' '6 L 0/,O• ZpQpI�� NO.OF USE OF NEW/Z. Vl�rt ' TEL. '-VJ (PLANS.. BUILDING�./Awn Gi CITY C, �L7 NO. ) )/y 3 1\ rTr r .E.. STATE •' CITY YARDS APPROVED YARDS APPROVED LIC. NO. [.1 ' ¢4-4 LIC.NO. -) C. L' MAIN BUILDING ACCESSORY BUILDING W SIZE NO.OF BLDGS. (FROM C/L TREE ) �+ L OF LOT 7 / 5 x 5 0 d./SI NOW ON LOT 7 FRONT 1C FT. g . FT. Q USE OF en ` EXISTING BLDG. ' C` D/ c S ( 'd"'T/,* R.,IQE �j' FT.b FT. CO 15 E-, Separate permits are required for L.SIDE 5 FT. FT. electric,plumbing and heating work. 7/ WREAR FT. FT. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN& MAIN BLDGS. ACCESS.BLDGS. J.77 VAR.# DATE C/ 4.4:,re 1./f:.i .sr-1 -- C.U.P.# APPROVED 'C / 6,47_,z. C ' Q / r DUPL.-CSC ��/�.�/fc c /} , APPROVED�I^ DATE 5-2-8 -,C5 W .OLD FOR Si-ECU-.L REQUIREMENTS. QI hereby acknowledge that I have read this application and state 'a 0: that the above Information is correct and agree to comply with N co 6i all laws regulating building construction, and I shall not employ Z any person in violation of the workmen's compensation laws of HQ-CCI. T 'm` El the State of California. // 7 SO. FT. II Y / cO�O w I hereby certify that I am properly licensed as a contractor under the State of California Business and Professions Coda, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m Chapter 9, and that such licenses are In full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from the provisions of the State of California Business y VALUATION PERMIT FEE $ and Professions Code,Co/�`Division 3,Chapter 9. 00 n PLA Permittee Signature of V.X�1/✓i�( / l.OiG�CJ� q�/$ 501 �� TAXN CHECK $ �'� o //t� �J h .3 SL- _ U Authorized Agent (2--1 :4<i ex„.. X�R��J ` TOTAL PAID $ �+r W. o 6 • OWNER HEMMENDINGER, Richard - SOUDER-, Morris & Marie. DATE n-14-57 IOB ADDRESS 169—B E. 21st. St. BUILDING PERMIT NO. 591j3 A CONTRACTOR ROitlar!t hBlldrs. • VALUE $ 7,536.00 3.4..N-N X17 LOT 2142 TRACT .FIRE ZONE DESCRIPTION OF WORK Residence Matt gar. 1UP I Sr J TYPE V ZONE R14 PLAN NO. 5951 INSPECTIONS DATE SUBCONTRACTOR PERMITS ISSUED DATE NUMBER Trenches/•s, Forms Steel WSW Floor Sys m / Steel Reinforce �aC,�hi�mney Re-Rod Bornd''Beam7// � iQ/,0 Frame and Flashing cal , ,.% '9 Lathing, Ini ilWAfr Out "Maiglirrira=1 Plaster, brown coat -,417 - Underground soi // W/G Pipe TestM 2-/••— —7 Top Out //-14-57 Furnace tic Mgl 17'12 ,as' .'T, r 02. ♦: Y Gas Vats Si P rarALSainfeinnia r Rough Plumbing AIMS 'd!9 ri7 Fr • . � a/ 0 Cesspool Septic Tank / ENIENF5PINNA Prop. Swr. Line House Con. 0 _____ ra2Lo 3 0 '' -i Sprinkling System —W Homing �Tj Final a �49 bin. Fixtures Final 4q S _/qr_- ' —ina howl Gas Test // 1H.S • -sq-Cie iiinfrat Construction 'ole . niairi Underground Power w�� Rough Wiring 7a•.�/ - ,-a K�l Aby�/ i7I�1.=aglanai ab + Fixtures, Final �s71 r, t —I/`a_\ OCCUPANCY nn*s- lit--sy-.Ciel Form 210-5M-1-57 / 59143 ., 5951 FEE RECEIVED COSTA MESA BUILDING DEPARTMENT • '° - v. s - s V (-L- P.O. AFINANCE DEPT. COSTA MESA,. CALIFORNIA rrffTT nn ����TT�� �A�F��`pp FOR APPLICANT TO FILL IN APPLICATT MMFPeg FM MIT ADDRESS /G 98,62/QST, — c/ BUILDING COSTA MESA, CALIFORNIA FOR OFFICE USE ONLY RECEIPT NO. 'a DWNEIRichard Hemmendinger & Morris & Marie Souder s /Gf' 43 MAIL // RECEIVED BY DATE RECEIVED DATE ISSUED__ ADDRESS 2510 Westminister Ave. L j ri , 57 CITY Costa Mesa TNO.L] 8-9388 ADDRESSEL. /V / �� ZI it ARCHITECT LIC. OR NEER . COSTA MESA. CALIFORNIA FIRE 3 ADDRESS ZONE 2ONEUNSNS NO. / OU CITY LIC. P ..-2___TEr,E 7.- CONTRACTOR RLnnmar B1� 1i1deTg NO. 6336 W ADDRESS 2 Nnwpo7t Blvd TN .L3 $- 3 8 BPPRov 7'141,,K FATE 1/7 S 7 LEGAL LOT f • -i c DESCRIPTION �jNO. /24/271 BLOCK TRA �J �f�(� A.P. NO. /t O CLL :7..�� 17 ✓ �+ N�R 1Y IED SIZE ••�� ( / rvo.of aLDcs. CITY O 05'S�+EA1 Hk sSA OF LOT ii Ll X � t / Now oN LOT ItAiti. _ ++ E. USE OF ' ;tie O.. EXISTING BLDG. V SU8JEC8 '1, ,c4.(yen .. J SETBACK LINE FROM � r (' Dar CENTER OF STREET/ / �I�„ REAR YARD pLJ..I A l I fanr SIDE YARD RIGHT 7 7 LEFT J✓ PLAN )_6yj;. DESCRIPTION OF WORK NEW X ALTERATION ADDITION REPAIR /y MOVING DEMOLISH BUILDING C/ ROOF �/ SIZE illi ROOMSOF // STORIES EXTERIOR WALL ROOF ,� � , COVERING fry COVERING USE OF NEVA, BUILDING 'j'y70 Bedroom Dwell Ing With ��� ,J i e 12 x 20 Att. Garage / J/ az yo 3 / I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS S T AND AGREE TO COMPLY W=-.1- C ITY ORDINANCES AND 'flE L4TING B LOING CO TION. VALUATION ,yT SIGNATURE •F PERMIT FEE S a_y PERMITTEE L .GL/ / SST 4 .- PLAN CHECK S l O - s l AUTHORIZED AGENT TOTAL FEE S 3o Vµ� OWNER HEMMENDINGER, Richard - SOUDER, Morris & Marie DATE 11-4-57 — JOB ADDRESS 169-A E..._21st St. BUILDING PERMIT NO. 59.12 �.GF,(1ERAL CONTRACTOR ROmar$ldrs• VALUE $ 7,500 tlA--P. No.LL1// LOT 242 TRACT g,FIRE ZONE DESCRIPTION OF WORK Residence with att gar, "UP I & J TYPE V ZONE R 4 PLAN NO. 5950 INSPECTIONS DATE SUBCONTRACTOR PERMITS ISSUED / DATE NUMBER Trenches','�x*Forms Steel /4041 Floor Syskm Steel Reinforce Chimney Re-Rod ,,��/ Bfi am .n -R J• n0tif 1 Frame and Hashing U '• 7/ /ajfj,S Lathing, In ( %', Out a.• '. 2f 7 s Plaster, browti coat - 4A'%6 r/-/',51 Underground soit4f%4-4 WIG PipelTest(///S r2_-/9-37 Top Out //'/e' t? , Furnace AHC. /2-/9-.57 '.- 9 . // '-/7-47 /a/07 d.," . Gas VentsSystew N- //pl 441,-,,,-4 -2- //-57 /25-4,7 - Rough Plumbing AIMS f -q- , f ) . Ryut -4- /1-/7'-s7 /a/07 Cesspool Septic Tank /_ Prop. Swr. Lind- House Co'f' Stekr. it i I/r1- 43.--m......4--11. / I- f t U'7 _� 'o"' ;PO Sprinkling System I Hosting Final /V//fS aand-r/' O Sing Fixtures, Final *ALS .1.yy-fl' I L...nl Gas Test /,-/ MAK [Z-/S'-5'8' ` 4 Construction Pole I ' I Underground Power p �• f Rough Wiring 76,Z-/ >7 o . (-u.�;/. Ppa.._ --(ion. // -/7 17 S7.,9( J��`jL��'� Fixtures, Final , //,� u I OCCUPANCY Alm( %iy-,.l-r _ Form 210-5M--1-57 59142 . f . V 3. 5950 FEE RECEIVED COSTA MESA BUILDING DEPARTMENT / 0 " V 8-5-7 v 0.-- P. ^P.O. BOX AL FINANCE DEPT. • COSTA MESA. CALIFORNIA los.E MM ��pp FOR APPLICANT TO FILL IN APPLICCITY A i IVEN 'FOR PERMIT ADD BUILDIRESS NG j674 C �'" 2/ sr j3 BUILDING COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY RECEIPT NO. cTCNO� OWNER Richard Helmnendinger & Morris & Mare Souder J / MAIL ADDRESS 2510 Westminister Ave. i E. sr TE RECEIVED l71so y/s , CITY Costa Mesa 1-II LI 8-8335 ADD EESS /6 ? /9- t -LI st ORCHITENE LIC. OR F" NEER COSTA MESA. CALIFORNIA NO. FIRE ADDRESS ZONE ZONE NO OF TYP ROUP ets CONTRACTORRomar Builders° TY Noo . 6336 /2 C =L^rv5Y ADDRESS . . S \ : ' .. t B1vd.NO.L 8-9388 ABPYPROV nett( DATE �i47j LEGAL LOT ri CORRECTIONS DESCRIPTION NJ NO. 2242 BLOCK A.P.NO.// c L/ /, a—/7 ~ a sm SIZE NO.OF !LUGS. y�(j}, PPP' i OF EL x3�� NOW ON LOT A��y D P'Wit in EXISUSE TING BLDG. -F CITY Q�- S'I�A I�_'"_ 1-1_r%P+1.'i+tir Obi-.1'_ CENTERSETBACK OFLINSTREETEFROM /7o, i �J REAR YARD /D SUBJECT, 1J' V:a'1Gi-E}Ei4:Aga SIDE YARD • RIGHT 7 / LEFT 5---- DESCRIPTION �/iJ'j//'/j�J / �� DESCRIPTION OF WORK BY7`A�' . Dll`I+E1.!f. .� TFFH • ..••.f.-:+es.•—% NEW X ALTERATION ADDITION REPAIR MOVING DEMOLISH BUILDING l 2. NO.OF SIZE ` ROOMS Ce, STORIES EXTERIOR WALROOF COVERING A COVERING f �ij USE OF NEW ,t1-..c_-fC.~ BUILDING Two Bedroom Dwelling with 12 x 20 Att. Garg. o'y.z- '� / Ii s1 I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND �O y ^ .� STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL CITY ORDINANCES NO ST WS REGULATING BUILDING CONSTRUC- TION. /y VALUATION -- SIGNATURE/S) //� ��� � PERMIT FEE $ �O PERMITTE �•/ 7 \..5---3 (� PLAN CHECK $ /0$ /, AUTHORIZED AGENT TOTAL FEE $ 30 'd.( OWNER HEMMENDINGER, Richard - SOUDER, Morris & Marie DATE 11-14-57 _ JOB ADDRESS 169 E 4421st St. BUILDING PERMIT NO. 591414. 11 �E R CONTRACTOR Romer B}idrs. VALUE $ 9.2614.00 i o. LOT 2142 TRACT fig T.9.FIRE ZONE DESCRIPTION OF WORK Residence w/att gar. G JP I & J TYPE V ZONE Rh PLAN NO. 59147 INSPECTIONS DATE SUBCONTRACTOR PERMITS ISSUED _ DATE NUMBER Trenches Forms Steel ///14W5 •/_ Floor System Steel Reinforce Chimney Re-Rod Bend-Beam 4:24,40 felk.p_ /glia/.r9 Frame and Flashing U Chit'/y/ao/d- Lathing, In Cit.-Out (2"/,r// - a-77 S-1 Plaster, brown'coat 6-A4,1 /-/i-' ' Underground soil Mft S' WIG Pipe res yfq'p- 4.-5'9 Top Out /"t9-s7 �o Furnace &WS '2.-r9-5-7f' ( . dwn.F2t2. //-/tj=4-7 /R/o6 .---- Gas Gas YenteJj'X ,. 7/. -.n4 at - "-rt /et�'44L ./Rough Plumbing Ann' z_/r/-67. ,�_ RI //-/t-n /2/O4, / _ Cesspool Septic Tank Prop. Swr. Line House Coll/ St. Swr. rr y'}/y-p (jp.,,, ..L.1 taut/in 13 O to Sprinkling System / F ig Final Mfsc a-e v-4-S 1 4 F_ Aug Fixtures, Final Ala2.. e/-CP Final Gas Test /t/ /tf/f.$ a- v-S i' - Construction Pole Underground Power �� i p / Rough Wiring Lr ) I�Si-`Il .4n.(c Jain-,- C-- 1/f,ir`/ 3-'/1.y. Fixtures, Final it) •) -(1-13( •OCCUPANCY Min 1-/v-sr Form 210-5M-1-57 / 5914. } 5947 FEE RECEIVED . `COSTA MESA BUILDING DEPARTMENT , s,5-1 J c P.O.BOX 317 FINANCE DEPT. COSTA MESA. CALIFORNIA IC�(Y OF COSTA MESA FOR APPLICANT TO FILL IN APPLICATION FOR PERMIT ADBUILDI DRESSNG/67e /S.,..577r _ A BLLAI_DING COSTA MESA. CALIFORNIA FOR OFeICE USE ONLY RECEIPT NO. N RMIT N m OWNER Richard Hemandinger-Morris & JR.riA Smith:r . � �y MAIL RECEIVED BY DATE RECEIVED DAT IB D_ ADDRESS 2510 Westminiater Ava. P 7& - #—S7 «(y/) 7 TEL. BUILDIN CostaG! CITY Mesa NO.TIT 8-833 . ADDRESS ARCHITECT LIC. OR ' NEER NO. COSTA MESA. CALIFORNIA FIRE ADDRESS ZONE ZONE NO.NF TYPE GROUP p CITY LIC. PL S �/ CONTRACTORRQTII� Builders NO. 6336 PI TEL. APPROVE /��� I ADDRESS NO. BY J eria DAT/�Ef�er/ LEGAL DESCRIPTION NOT $ BLOCK �// TRA T // t {�IE�"'�I�.�!/`Rppe//a++�pIE�TC�(TIO"" A P. NO. // e. eL ? ^ / / / 1 1.I 1 R V 1! E D OF LOT �/ /X 3 CJ 6.1 SI NOWOF ON LOT BLOT NOW 1 CITY OF COSTA MESA USE OF O;I'T• EXISTING BLDG. SU BJ EGI I Lc. . DEPT. RE �, SETBACK LINE FROM L//y / CENTER OF STREET QD REAR VARA/ 7.---- j{ �(� 1 a 7 f �� ; BY GG'f' DAT u C SIDE YARD RIGHT 69 S LEFT PI ynl T4rH DESCRIPTION OF WORK l NEW X ALTERATION ADDITION REPAIR MOVING DEMOLISH BUILDINGNO.OF SIZE A/O �� ROOMS STORIES / EXTERIOR WALL ROOF COVERING ��.....�� COVERING USE OF NEW BUILDING 3 RiAronm Dwelling /O /q ? with Att. Garg _ sej I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL CITY ORDINANCES ANO ST RE LATINO BUILDING CONSTRUC- TION. �Ai VALUATION / SIGNATU' . OF /// ' `- ,/ J PERMIT FEE S R„Z C,� PER MITT , f ? a& Lr/� PLAN CHECK S /07S AUTHORIZED AGENT TOTAL FEE S � VDT OWNER SOLIDER. Morris & REPJMENDINGER. R.M. DATE 10-23-57 JOB ADDRESS 169 E. 21st St. BUILDING PERMIT NO. 5904 GENERAL CONTRACTOR Owner . VALUE $ • 1;11,–. qy6 2 T`7 LOT 242rpACTligt8 FIRE ZONE DESCRIPTION OF WORK Demolition - Residenc - IUP I TYPE V ZONE 114 PLAN NO. 9 • PERMITS ISSUED INSPECTIONS DATE - DATE NUMBER Trenches Forms Steel Floor System Steel Reinforce Chimney Re-Rod Bond Beam Frame and Flashing Lathing, In Out Plaster, brown coat Underground soil W/G Pipe Test —' Top Out 'MIMI.real FAr� Furnace M� �n.F a�. Gas Vents —aa�Iyj%f� Rough Plumbing =IIIMMIIIISI Cesspool Septic Tank - idelPallirall Prop. Swr. Line House Con. St. Swr. --'ffilla_— Sprinkling System —linailaii - Heating Final —�dTl_-' r bin! Fixtures Final --`7at— k .. Gas Test / r712_ Construction 'ole In.11.1111 Underground Power Rough Wiring Fixtures, Final OCCUPANCY Form 210-5M—t-57 5904 ! a w 5930 r EE ' RECEil'ED 'COSTA MESA BUILDING DEPARTMENT F��ANCE DEPT. `� P.O. BOX 317 COSTA MESA, CALIFORNIA CITY OF COSTA MESA FOR APPLICANT TO FILL IN APPLICATION FOR PERMIT • BUILDING ADDRESS /�Q E ..isT Sr BUILDING COSTA MESA. CALIFORNIA " FOR OFFICE USE ONLY ��..yy�� C /�/ RECEIPT NO. `PERMIIT NO. OWNER 1070iANI:S UU�chin i. �Iwl.eir`ry--I- l l / d T MAIL (5 RECEIVED BY- / DATE RECEIVED DATE ISSUED ADDRESS /G? ( 240 ST ,e /0-0'3-57 //7 -,-7J-`, / /� y //Aqq / - TEL BUILDING CITY IIl%* ilz-, E, /. f NO.A 36/7 ADDRESS ARCHITECTE-1NE �! NO. COSTA MESA. CALIFORNIA OR NEER LIC. FIRE ADDRsSS ZONE� e CITY LIC. ONl! /V NOPL. TYPE GROUP // CONTRACT0a-Owl 9/.. NO. J ` `L"(�//// TEL. APPROVED ADDRESS NO. BY DATE — LEGALnun // / CORRECTIONS DESCRIPTION NOT ,nn / --7.- BLOCK T A X11 fir/ ��• <.P, NO./! X .—° & .;Z....- / l T • �� SIZE 'NV3 A-K NO.OF SLOGS. ri ®� �� OF LOT x 3 's-7NOW ON LOT 1 D USE OF p� NISTING BLDG. /�'� CITY OFPSTA MESA SETBACK LINE FROM PLN G DEPT. CENTER OF STREET REAR YARD STIR IFCT TO HI DR DFPT RFC, SIDE YARD • RIGHT LEFT DESCRIPTION OF WORK BY L/'/�i DATF/6 -air, I , L...i T.C:Id.....- NEW ALTERATION ADDITION ��// REPAIR MOVING /A DEMOLISH BUILDING 1/ t NO.OF SIZE �fL 74 ROOMS 9 STORIES / EXTERIOR WALL ) ROOF COVERING LD C! WOO/qpm/ USE OF NEW �._. BUILDING AL1..... V // oSiAih[ e I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING BUILDING CONSTRUC- TION. VALUATION 0-0 PERMIT FEE $ d, SIGNATURE OF ieti PERMITTEE ��—� ,/fie _ _ / PLAN CHECK S $ /IlN/yUi(/ AUTHORIZED AGENT TOTAL FEE $ a, 6--0 'P.,