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HomeMy WebLinkAbout202 21ST ST - Building Permits CITY OF COSTA MESA eon BUILDING DIVISION )•• Alm 77 FAIR DRIVE, COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714)754-5626 wnm`o PERMIT NUMBER: BX11-00116 PERMIT TYPE B_MISC STATUS: ISSUED APN: 42614101 DATE ISSUED: 04/27/2011 Zoning: ISSUED BY: RMD JOB ADDRESS: 202 21ST ST CM Suite/Unit: Vicinity: ROOF Primary Occ: Const Type :?? SQ. FT: 190 Valuation: 59,800.00 SCOPE OF WORK: • INSTALLATION OF 190 SF ROOF MOUNTED PHOTOVOLTAIC SOLAR PANELS 3.22 KW WITH MISC EL EQUIP, DISCONNECTS, INVERTER. OWNER: BLACK, GARRY L Address:: 202 E 21ST ST Unit City/State: COSTA MESA,CA Zip Code: 92627-2126 Phone: APPLICANT: ELLISON, PAUL Address: Unit: City/State: Zip Code: Phone: 949-683-9861 CONTRACTOR: SWAN SOLAR License No. 909987. • Address: 24512 BRIDGER RD Unit: City/State: LAKE FOREST, CA Zip Code: 92630 Phone 949-309-3409 Cell: ARCHITECT: License No. Phone ENGINEER: License No. Phone FEE SUMMARY Building Plari Check: $117.81 Building Permit: $181.25 Electrical Permit: $62.10 SMIP Residential $0.98 SMIP Commercial $0.00 Bldg Std Admin Fund $1.00 TOTAL FEES $363.14 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibited all hours-Sundays and the following Federal Holidays: New Years Day, Memorial Day, Independence Day,Labor Day,Thanksgiving Day and Christmas Day 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 INTIDALS 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 X rj- 241--/I kora by "�- 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Faclory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site v 204 Final Demolition 250 Final Building/Occupancy ') 3 ' ZU-/I RGy 19/ WORKERS'COMPENSATION DECLARATION: Owner ID verified by driv,,.„license. ❑Yes ❑No I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires: ❑ 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: �1 ,, 4l�S person is required to descend,will be made in connection with work authorized fU t1'CS� ) / by this permit,and that no building structure,scaffolding,falsework,or demolition lCarrter._:_-r C� or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp (This section need not be completed a the preemut is valued at one hundred ddtars(St00)aless.) 2 Arta Sec.341,Title 8,California Administrative Code). Policy NumJber: -76 0000 57_06/o/ ❑ As owner-builder, I will not employ anyone to do work which would ❑ 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 . ornia, and agree that if I should become sub'-. • the work- • e --tion provisions of Section 3700 of Applicant's Signature Date the Lab• gym• with these provisions. i �i2 7, Division of Industrial Safety Permit Number: (L1W.FloriIs rg tom' (ate HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: •• ING: 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? ❑Yes 0 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 fort- and effect. a registration form for acutely hazardous materials? 0 Yes 0 No - 11 Class:#-LCT (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by y7 each business which at any one time has on hand a quantity of acutely ac! 'ignature L••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). ❑ I 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)? 0 Yes 0 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 0 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? 0 Yes ❑No issuance,also requires the applicant for such permit to file a signed statement uested that he or she is licensed pursuant to the provisions of the Contractors (Section 65850.2fu i the onnlifornia Govemment Cold requires b buildingnt tpemi s). License Law(Chapter 9(commencing with Section 7000)of Division 3 of the information be furnished applications fa non-residential permits). 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? 0 Yes 0 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 sale. If, however, the building or improvement is sold within one year of control officer). 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 ❑ 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 0occupancy of any building authorized by ilii •-r=iri1 •. •- Signature Date 4r� A 7`7, 3057-46(3/07) - ' (AWIa.Authonzed Applicant CITY OF COSTA MESA 1 4 �q BUILDING DIVISION: c q->"'�. F i ^^h. I DEVELOPMENTSERVICES DEPARTMENT PERMIT NUMBER o PERMIT E05-00498 (714)754-5273 • Fax(714)754-4856 ••www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA-MESA,CA 92626 ELECTRICAL PERMIT Job Address: 202 21ST ST Status: ISSUED Suite No Applied: 05/24/2005 Vicinity: Issued: 05/24/2005 Parcel Nunmber: 42614101 �q Applicant: MC CULLOUGH, DOMONIC ��\ISSUED BY: Aar) J Address: - • Phone: Zip Owner: BLACK, GARRY L . Address 202 E 21ST ST, " Phone: , COSTA MESA,CA Zip: 92627-2126 Contractor: KIEGGO CONSTRUCTION INC � . Address: P.O.BOX 10714 • - • Phone: (949)294-0902 COSTA MESA,CA Zip: 92627 License:773135 , SCOPE OF PERMIT ' TEMPORARY POWER POLE - ` REF#B05-00146 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 kvaRw $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 2 . 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 , -J 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, 12121-92) •EXPIRATION: This permit shallautomatically expire and-become void If work isnot commenced.within 180 days,or if work is-suspended or abandoned for a period of 180 days. INSPECTIONS: In.order for thee.work authorized:under this-permit to be considered legal,.such work must.comply with all applicable codes, and all requiredlnspectlonsand:fInaI-approval,must:be-obtained..Failure to'obtaininspectionsand•final'approval will result inthe-expiration of this permit. FOR'INSPECTIONS CALL: (714)75445626 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 rk'for which this permit is issued. gageeve and will maintain workers'compensation Insurance,as required by section 3700 of th Labor Code,for the performance of the work for which this permit Is issued. My workers'compensation Insurance carrier and policy number are:a .1 ) -/ Cartier. J (b5 -70(i j '- 2ooce- ifIit}'IE Foy, €_cam')Num.:., O5 / 0 — 200 ((lits section need not be completed if the permit is valued of one hundred dollars($700)or less.) ❑ I certify that in the performance of the Work for which thii perrnit 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 abor Code,I shall forthwith comply with these prove • plRemr Dare. O S ABNIN FAI tlR TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOyEBSG,CRIMINr1NPE TIES AN CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5100,000),IN ADDrON 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 provisions of Chapter 9(commencing with Section 7000)of Division 3 of usi4ess and Professions Code,and my license Is in full ContrSigpatd e: C-1--71—",),, ri/'y(/-1 L75 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 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: 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 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 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 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? 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 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. SIg r 1 ner(s) C Date I ` -• ''i d/Or7Auth .Lymt�,� J Z atH nS SU"., ., CODE r 'INSPECTION TYPE ' WI " - INTITIALq - ' 900E! INSPECTION TYPE ' " - GATE IDLs • 1616 Fixed'System Final Fire Prevention • 206 Final Mechanical • ' 1266 Pool Spa Final 208 Final Plumbing ! /�/�pr�/y..t"�:y 200 Final Re-Roof 210 '' Final Eledirical J/(2.57Ptc eg V 201 Final Block/Retaining Wall 212 Final Fire Prevention �I 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 i .1 /44 BUILDING DIVISION ' $ E " i DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER f t .g•..,: I PERMIT 605-007 28. (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.muILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 202 21ST ST Status: ISSUED Suite: Applied: 05/06/2005 Vicinity: Issued: 05/06/2005 Primary Occ: R3 Type of Construction: V-N Parcel Number: 42614101 Zoning: �� Applicant: UN ifr„� . Address: ISSUED BY: _ ' Phone: • Zip: Owner: BLACK, GARRY L Address 202 E 21ST ST . Phone: COSTA MESA,CA Zip: 92627-2126 - Contractor: SWAN POOLS OF SOUTHERN CALIFORNIA Address: 24512 BRIDGER RD Phone: (949)859-8466 • LAKE FOREST,CA , Zip: 92630 License: 440333 Arch : " . Eng: Address: Address: -Phone: Phone: Zip: License: License: SCOPE OF PERMIT CONSTRUCT A 270 SF IN-GROUND GUNITE POOL AND DETACHED SPA AT:THE SIDE YARD OF AN EXISTING SFD. FEE SUMMARY Plan Check: $261.20 Calc Valuation: $26,000.00 Permit: $401.55 Claim Valuation: . $26,000.00 SMIP Res: $2.60 , • SMIP Com: $0.00 Other: $0.00 - • Inspection: $0.00 - . Total: $665.65 PLANNING & ZONING , SETBACKS - ' MAIN STRUCTURE Front 23-0 Rear 23-0 Left 7-0 - - - Right 20-0 ACCESSORY Front :0-0 -' Rear 0-0 Left 0-0 . • Right ' 0;0 PARKING Existing: -0 . Required: 0 • Proposed: , 0•- ' NOTES: i NOTICE: The work authorizedby 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,�w// is suspended or abandoned for a period of 180-days. W 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 finalapprovalmust be obtained.Failure to obtain inspections and final approval will result In-the expiration of this permit. FOR.INSPECTIONS CALL: (714)754-5626 2448.48(8/00) DECLARATIONS fl L J WORKEpS'COMPENSATION DECLARATION: • • z 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 �+s•-7 for which this permit is issued. . e • I have and will maintain workers'� sation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this Permit is issued. �f My wo a s'co pensa• nsurance rrier and policy number are: 5 / l�,g /Carrier: -' bei (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' compensatio cos o alifomia,and agree tha ' I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comp) ;,rhes pr ' ' n J– Applic nt.Signatu/re: - 'IjaCi —It WARNING:FAILURE TO SECURE W ERS'COMPENSATION COVERAGE IS uM.AW FIX AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE(S1oo,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 Icense provisiohapter 9(commencing with Section 7000)of Division 3 offh ,Bt7sinw6Ild Professions Code,and my license is In full force arM'e eNct'rLIcRYT-� b,�.�� Class a l:�'j Contrac�fs;Sign_atyre: ,}1 /� /(�/ - Date: 5—'l1,'- J� 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.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 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.). 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 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: 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 It 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 65B50.2 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 Fa 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-describ d propertyrfor inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. tj Bipna Ot gaga Owner($ s D / �� •Utl ter. An Autho „ MIDala`�•J CODE t. INSPECTIONTYPE - , '"'OATE I$TITIN. ' ' cQQU- -INSPECTIONTYPE ' ` ' ' ' ' ' PATE RCM 1616 Fixed System Final Fire Prevention ' i.. 206 Final Mechanical 1266 Pool Spa Final �`� Oto 208 Final Plumbing 200 Final Re-Roof _ - _ _ 210 Final Electrical . 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final-Factory Fire Place " - • 4 '' 220 Final Planning Approval • • • • 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupandy ,lI it - IIII 10600 Pioneer Boulevard,Suite 0 • Santa Fe Sprin s,California 90670 • 562)903-0032 • Fax(562)903-353a ACCREDITED — HMI 1.11111 IIIIIIIIIIIIIIIIIIIIIII I ( III TEST SPECIMEN AND COMPRESSIVE STRENGTH DATA SHEET PROJECT NAME: Black INSPECTION FIRM OR CLIENT: Luiz Inspections PROJECT ADDRESS: 202-21st Street INSPECTOR'S NAME: Richard Luiz Costa Mesa,CA INSPECTOR'S LICENSE NO.: On File PERMIT NUMBER: B05-00728 SET IDENTIFICATION NUMBER: - CAST DATA(ATTACH DATA SHEET OF OTHERS WHEN AVAILABLE) CAST DATE 8/16/05 DESCRIPTION Concrete Grout I Monar Sholcrele Masonry Pnsm (Other GUNITE CONTRACTOR Swan SPECIFIED Pc-PSI 2,000 CEMENT TYPE V SUBCONTRACTOR Arco CAST BY Art ADMIXTURE N/A ENGINEER -Lacher NO.OF SAMPLES 1 WATER ADDED N/A CONC.SUPPLIER -N/A TOTAL YDS.PLACED N/A SLUMP N/A PLANT N/A TICKET NUMBER N/A AIR CONTENT N/A Mix DESIGN NO. 4 1/2- 1 CAST TIME N/A AIR/CONC.TEMP. N/A LOCATION IN BLDG.: -Bottom of The Swimming Pool NOTES: NR=Not Reported Test specimens were cast using grout square box. Results relate only to the tested specimens. COMPRESSIVE STRENGTH DATA DATE SPECIMENS RECVD. 8/25/05 EQUIPMENT USED Forney MLT REPORT DATE 9/13/05 SN OF EQUIPMENT 04149 TECHNICIAN NAME C. Henriquez-Supervisor CALIB.I REGAL.DATE 9-04/9-05 SPECIMEN AGE AT TEST TEST SPECIMEN DIMENSIONS-IN.' AREA LOAD Fac BREAK IDENTIFICATION TEST DATE TIME 1 2 3 4 _ SQ.IN. LBS. PSI TYPE' NUMBER DAYS 6e__ 7 _.____.__8 Nnl 3.365 3.2033.367 3.207 10.79 E12101A 28 9/13/05 10:22am -- - -- - -- .- ----- 49,220 4,562 c 5.703 5.707 5.704 5.706 (1.74( 1 Specimen dimensions 1 -4=width and length of each face at midheighI:4 through 8=specimen height at midwidih. `Break type designation per ASTM C39 Figure 2:a=Cone,b=Cone end Split.c=Cone and Shear,d=Shear,a=Columnar COMPLIANCE WITH SP6CI D STRENGTH/COMMENTS:Complies 1 THORIZED Arlin 2� 2-08 V] ..Q g J-Ii-2 °\–ter—Qs ;VP,,..:,,:,,. .1,c , RICHARD LUIZ 5071 LOYOLA AVENUE WESTMINSTER, CA 92683 c y��� Reportxof Special Inspection Project Name & Address k �+`�` ue--i 20Z —2-1-=----a----7:~ >.\-'1;• tr v[SA Fe;emit Namb41 QG2Z d]2-%J Inspection Type(s) Gunite Inspection Date(s) —((.0 —O5 [ ) Periodic ( XXX ) Continuous Describe Inspection Made, including Locations: Inspection of the swimming @ the above address on S—((p "OC-- Lis: Tests Made: ( c60‘..)Nll _ c..11-1^".1 L „ 4ft)4 'rQ T IL 6 Total Inspection 'lime Each Day: • Date -16-oS Hours I IWZ _ist hems Requiring Correction, include uncorrected items previously listed omm.n.s: I SOZ� V S�a/l) — ��tG Rico 1>41-e ICrb fra12_, G:. S pal uct u7 t TV- To Inc best of my knowledge, the work inspected w>,'as in accordance with the Building Dcpartmen. 22pros'co design drawings, spec' Ica hie and applicable workmanship provisions of the U.5.0 ' :sebo pt as noted ave Signcd: .1 Dale 4 Zc D I , C, B . 0. if Print Full Name: Richard T. Luiz Registration No. 1075691-49 Concrete F'oRm S: : ,. 28 pr v ,_ e w-0-6- e\-20--05— I DEPUTY 1 INSPECTIuN SERVICE INC. I • DEPT. OF BLDG. & SAFETY 25121 DE SALLE ST, LAGUNA HILLS, CA 92653 CITY OF Costs--1445.).5.4 1 - 800 - DEPUTY 1 = 1 - 800-337 - 8891 COUNTY OF Cog SPECIAL INSPECTION REPORT (9/ �[ ms`s_ Building Permit No. 00'5" Job. No. Date - ` Job Indentification/Address C Ly 15(4"c l< Pk-S-I 202_ -zi SnST•/ G 149 General Contractor/Address lc-I €-GC> CoN 5 7 Sub - Contractor/Address ---- e4-\/R.- Sim t Tlf- Structural Engineer I Address c r 'P-0 "t (-- A-l-{-ar IA Arch. REINFORCED CONCRETE MASONRY HI-TENSILE BOLTING CHEMICAL ANCHORS PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE OTHER WELDER RECEIPT NUMBER WELDER 1 RECEIPT NUMBER DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED G,-2-4,i -o 5- . D&5r&R-c , I natatnav o F 57R a:-'— T7 s —4Lr .A4*Z9 '. (3J cr. P 13•s wi/cc ti cwt& — 41- 16%,\--t57; Wv'(Sf€ "T"4 t-� 0 !30 (-..vt �z. : C`J c_ - H-D' s t-) 'lc" Wasizei CO * (moi) cr. A'13`S w/' f�wr3t0 - Coon. P FED- 9/51> - I wt Mc tt l4 t Pt-css °✓rSi wtp Soh t.-r ePo et-.6-2-rt T — (-17 csu, rrovf 2rt r Rests Nero rhe— L[ � HOURS SAMPLES IDATE Peg. OT Time In Time Out I Grout Mortar Concrete Block Density G - - - -- Prisms All inspections based on a minimum of 4 hours&over 4 hours-13 hours, minimum.Any inspection extending past the noon hour will be billed as 8 hour minimum.In addition,any inspection extending past an 8 hour pe- riod,or Saturday inspection will be billed at time and a half. 4 ATTORNEY'S FEES - If any action at law or in equity is brought to enforce or interupt the terms of this Contract, the prevailing party shall be entitled to reasonable attorneys fees,costs and necessary disbursements in addition to any other relief to which such party maybe entitled. . SPECIAL INSPECTION REPORT Inspector's Name: b Inspector's Signature: I.D. No. t tt 3s11-`4, has n filed and it states that the above work to the best of his/her knowledge complies with the provisions of the Uniform Building Code and meets approved plans and specificatio Respectfully Subm' ed, Approved by: Project Superintendent By. Larry Carter l C �OS.) 9 CITY OF COSTA MESA BUILDING DIVISION f •, ..1I DEVELOPMENT SERVICES DEPARTMENT PERRMJT NUMBER 4. 00114 PERMIT /P05-00575 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 202 21ST ST Status: ISSUED Suite No Applied: 07/27/2005 Issued: 07/27/2005 Vicinity: • Parcel Nunmber: 42614101 ISSUED BY: _(;:t. Applicant: LISA ZOSCAK Address: 32244 PASEO ADELANTO#A Phone: (949)493-9548 SAN JUAN CAPISTRANO,CA Zip: 92675 Owner: BLACK, GARRY L Address 202 E 21ST ST Phone: COSTA MESA,CA Zip: 92627-2126 Contractor: AQeAPt fi# A61€S Address: 3 - cc/` V Phone: (949)499.954&- 0'49) K S ,CA Zip: n2&5 License: - 441Z7„ y (4a 333 SCOPE OF PERMIT INGROUND POOL AND SPA REF B05-00728 , FEE SUMMARY Ak1T 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 $60.75 1 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) $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) .$30.25 1 VIOLATION $0.00 Gas Service 50.00 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: 5114.50 • / / 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. i / 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) . 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 irk for which this permit Is Issued. I ave and will maintain workers'compo -:tion insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. :rs co •:nsatlo• rT3j urance ca .r and policy number are: ' `-1cari PSig e, rtir 'POmumber section need not be completed if the permit Is valued at one hundred dollars($100)or less.) ❑ I certify that in t e pe.y ance 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• :11fomla,and agree gat if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith cora. ' .the-• • Is••s. 'e� Ap•'%nl Signal e: 101 •MND: IRE TO-E • WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHAH SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED ( ••c+t D DOLLARE($100,.•7,,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 the :m titans:d - er rp�AsJ�gC• •ter 9(commencing with Section 7000)of Division 3 of Ih 'moss •d Prof: I• and my license is In full force and -j►'i �J �/ S CI _ A} Jr FP' II , - r CON' • • ON LENDING At CV: ❑ 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 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,fatsework,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 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 Safely Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one 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 hes 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). _.._ se _._..._ hazardous m_.t._ . 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely 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 apgermit 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 IJ 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). __._._......._.alit..__......___.__.__ _ _ _ ._..._i_.. 7 if a permit from the South Coast s Descry ed Management District or other et pollution 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 ❑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 prop. y for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. • ature• Le•al O n' (s) ' Date LAO 4 And/0 CC' .. ',,•man ate l ;ODE t ILSPECTION TYPE PATE MAO CODE! INSPECTION TY Pt DAIS ItinnaL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical �n /� 1266 Pool Spa Final 208 Final Plumbing {2-ZZ-4f SO f 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 CITY OF COSTA MESA BUILDING DIVISION >•lev. r.,,,. , 8 DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER i PERMIT P05-00528 (714)754-5273 • Fax(714)754.4858 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 202 21ST ST Status: ISSUED Suite No Applied: 07/06/2005 Issued: 07/06/2005 Vicinity: ISSUED BY: Parcel Nunmber: 42614101 Applicant: PAUL ELLISON Address: 24512 BRIDGER RD Phone: (949)859-8466 LAKE FOREST,CA Zip: 92630 Owner: BLACK, GARRY L Address 202 E 21ST ST Phone: COSTA MESA,CA Zip: 92627-2126 Contractor: SWAN POOLS OF SOUTHERN CALIFORNIA Address: 24512 BRIDGER RD Phone: (949)859-8466 LAKE FOREST,CA Zip: 92630 License: 440333 SCOPE OF PERMIT REROUT SEWER LINE FOR NEW POOL. REF#B05-00728 • WORK TO INCLUDE: 1 SEWER CONNECTION. FEE SUMMARY AMT QTY - AMT QTY AMT OTY 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 $24.65 1 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 S0.00 0 Gas(Over 4 outlets) $0.00 0 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe 50.00 0 Spa(private) $0.00 0 VIOLATION $0.00 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)754-5828 2446-48(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 pedonnance of the work for which this permit Is Issued. riga d 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. �TAwwoorkers'co Ion IInsuurrance c/��I'er°J� try number are: /�+ Carrier. 1bi'I t- T v r" P rreVlu`mtiar!"-'s/7577 7 e/o S �tfTsecctlon need not be completed U the permit is valued of one hundred dollars($100)or less.) C in I certify that in the performan of the wo or whi - i Is permit Is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Cal 00• a, :.• nth: ' should become subject to the workers'compensation provisions of Sect n 3 of the Labor Code,I shall forthwith comply with these awl _ b ,r� APPIIcanFBipnehae;,�- � � Date Lam, A)if•JI" E TO SE •E WORKERS'COIAPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYE ,sly,I P TIES AND CML FINES UP TO ONE HUNDRED F SAND DOLLARE(SIM•.•),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 de jroj4 ns� hapter 9(commencing with Section 7000)of Division 3..0 slness and Professions Code,and my license is In full force'aWd�eHect„ - s. `'1-c' J .--- CONSTRUCTION 1 gne>ure1r� 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,CMI Code). Lenders Name: Lenders 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 toe dull penalty of not more than five hundred dollars($500).): o 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 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 Safely Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has al any ono 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). ._... l_.. _ _ ._........_.._.__ �__.. 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. _.__....__..r......__.._.__ _._....._...._— 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 akermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 101 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... W ill any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? Cl Yes ❑No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health end 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--ii-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: Dale: 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 property for inspection purposes.I agree not to Jr- py or allow occupancy of any building authorized by this permit until final inspection. Sign— ::.i.. 747DDaattg,� ) ;ODE I INSPECTION TYPE 263 g1TITAI& ;g2EE IN$PECRON TYPE ME INEVAL6 1616 Fixed System Final Fire Prevention - 206 Final Mechanical 'y 1266 Pool Spa Final 208 Final Plumbing 11-10-0(.. J 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retalning Wall 212 Final Fire Prevention _ 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 260 Final Building/Occupancy Jr 3 q CITY OF COSTA MESA 1 BUILDING DIVISION F • •._,' , DEVELOPMENT SERVICES DEPARTMENT PER IT NUMBER 1re IN k Pita PERMIT "p�+oamm44. OS-00146 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 202 21ST ST Status: ISSUED Suite: Applied: 01/26/2005 Vicinity: Issued: 04/04/2005 Primary Occ: R-3 Dwellings/Cong Res<10 Type of Construction: V-N Parcel Number: 42614101 Zoning: Applicant: HOLDSWOR, MICK ISSUED BY: Address: Phone: 714 299-9792 Zip: Owner: BLACK, GARRY L Address 202 E 21ST ST Phone: COSTA MESA,CA Zip: 92627-2126 Contractor: KIEGGO CONSTRUCTION INC Address: P.O. BOX 10714 Phone: (949)294-0902 COSTA MESA,CA Zip: 92627 License: 773135 Arch : Eng: STEPHEN K AHUNA Address: Address: 25101 VIA PORTOLA Phone: Phone: 949-495-3214 LAGUNA NIGUEL,CA Zip: License: 92677 License: 34264 SCOPE OF PERMIT 2,011 SF ADDITION TO EXISTING SFD(647 SF 1ST FLOOR AND 1100 SF 2ND FLOOR).ALSO ADD 176 SF COVERED PORCH AT REAR, 118 SF COVERED DECK,85 SF BALCONY AND A 744 SF ATTACHED GARAGE.INCLUDES 2 OUTDOOR FIREPLACES-ONE AT 1ST FLOOR AND ONE AT 2ND FLOOR DECK. REMOVE AND REPLACE ROOF STRUCTURE OF EXISTING 1010 SF STRUCTURE.ALSO INCLUDES DEMOLITION AND COMPLETE REBUILD OF'NON-PERMITTED 89 SF OF EXISTING SFD.ALSO INCLUDES AFTER-THE-FACT CONVERSION OF 175 SF EXISTING GARAGE TO HABITABLE WORK-OUT ROOM. REPLACE ALL GLAZING IN EXISTING STRUCTURE WITH DOUBLE PANE GLAZING. CONVERT 2 BEDROOM, 1 BATH SFD TO A 3 BEDROOM,3.5 BATH SFD. ZA-03-86/MM-03-56 FEE SUMMARY Plan Check: $1,111.86 Calc Valuation: $227,002.38 Permit: $1,710.55 Claim Valuation: $0.00 SMIP Res: $22.70 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $2,845.11 PLANNING &ZONING NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord.No.92-28,§1, 12.21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 • 2446-46(WOO) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 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 end policy number are: Cartier: AMC-2w CA-I.� �.-�o�O(L-rA/&- Policy Number: 65'.oc4 (..— to c el- /Ms 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 laws of Califomi ee that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall fdrthwlth 1 comply with these provisi /� Applicant Signature: • Date: 1- 114- AP ._ '-R j WARNING:FAILURE TO SECURE W Con '1..eMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($10),000),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 I am licensed u er provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Busines and Professions Code,and my license is in full force and effect.Lic.M = Zi 3 5 Class M 1 Contractor's Signature: _&141,C)- Date: ef-r1 ,4-P24,— -ioa 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 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 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,end 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 Cr 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 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,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 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 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 appermil 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 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 ❑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. M / Signa re Of Legal Owner(s) Date erhm A.d/th Authorized Applicant Date ' LODE Y INSPECTION TYPE PATE MALE CODE! INSPECTION TYPE M EE INTMALS 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 t • 204 Final Demolition 250 Final Building/Occupancy =t--"Y Went, PPV t S NEWPORT-MESA UNIFIED SCHOOL DISTRICT N2 5436 CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES PURSUANT TO AB 1600 AND AB 181 To: (Y) City of Costa Mesa District Receipt No. ( ) City t of art Beach , 00' ( ) County of Orange Plan Check No �f�J Applicant' k I Cc4 o C"m 1 2J c---it c “Th. 1 L. c Address: I5-gai — C7/49 zMorowl G4 `AJ S , EOL-7,1 i 11�(-&N'1o�7 ��.� c a Telephone Number: "l 4 1 — Co 4- 2 - i o 4{- 6 Tract/Parcel and Lot Number(s): Location of Project: Q-C 2 a‘cT f LoS 7/4- n._.C:_-"ThA 1 1 , 0-4 # Number of Square Feet of: Ll(i0 1 1 JX�y/ 31 O Residential Space 14 x`$11.84 Total Commercial and Industrial Space x $ .30 Total Commercial/Industrial Project is: (Check One) Warehouse Motel Preschool R & DBank 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 This 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. aper" �•ed Re. - . the The above representation as to square footage is true. Applicant ees that if it is later determined that such representations are not true,then this certificate shall automatically terminate and the appropriate City/County shall be notified. Date: �'�'r{ AP�t.. c2 c^�-L7� A l rN • CITY OF COSTA MESA .fit P.O. BOX 1200 • 77 FAIR DRIVE • CALIFORNIA 92628.1200 0� / C\. t` : — L:i DEVELOPMENT SERVICES DEPARTMENT January 6, 2005 Gary Black 202 21st Street Costa Mesa, CA 92627 RE: ONE-YEAR TIME EXTENSION FOR MINOR DESIGN REVIEW ZA-03-86 202 21St STREET, COSTA MESA Dear Mr. Black: The review of the time extension for the above-referenced project has been completed. The application has been approved, based on the following project description and findings, subject to the conditions set forth below: PROJECT DESCRIPTION The subject site is located on the northeast corner of Orange Avenue and 21st Street. It is developed with a single-story, single-family residence. On December 4, 2003, Minor Design Review ZA-03-86 was approved for a 1,197 sq.ft., 2nd floor addition to a single-story, single-family residence. The property owner changed architects and was unable to submit required plans to begin the plan check process before the project expired on December 4, 2004. Staff has reviewed the proposal and determined that it is still in conformance with all applicable development standards and the residential design guidelines. The second story floor area is approximately 50% of the first floor area (1,197 sq.ft./2,392 sq.ft.) and is well integrated with the configuration of the existing house. The proposed construction also incorporates offsets and projections for an interesting building mass. Privacy impacts on adjoining residences are minimized since the 2nd floor overlooks the driveway of the property to the rear (north) and there are mature trees on the adjacent property to the right (east) to minimize views from the proposed addition into the neighbor's backyard. Building Division(714)754-5273 • Code Enforcement(714)754-5623 • Planning Division(714)754-5245 CAV,71A\]LA-A9c . Tnn/]1A\74A S'1A.1 . .........•-,, t,m87.•_ ..e ZA 03-86 January 6, 2005 Page 2 FINDINGS 1. The information presented substantially complies with Section 13-29(e) and 13- 29(9)(14) of the Costa Mesa Municipal Code in that: a. The proposed development and use is compatible and harmonious with uses on-site as well as those on the surrounding properties. The project meets or exceeds all residential development standards and design guidelines. b. Safety and compatibility of the design of the buildings, parking areas, landscaping, luminaries, and other site features including functional aspects of the site development such as automobile and pedestrian circulation have been considered. c. The project is consistent with the General Plan. d. The planning application is for a project-specific case and does not establish a precedent for future development. e. The proposed development is substantially compatible and harmonious with existing and/or anticipated development on surrounding properties. This includes site planning, landscaping, appearance, scale of structures, location of windows, and any other applicable features relative to a compatible and attractive development. The second floor addition is well integrated with the existing floor plan and consideration is also given to the effect of proposed development on the light, air, and privacy of adjacent properties. The proposal incorporates projections and offsets for an interesting building mass. Privacy impacts will also be minimized by the driveway and tree buffers between structures/properties. 2. The project has been reviewed for compliance with the California Environmental Quality Act (CEQA), the CEQA Guidelines, and the City environmental procedures, and has been found to be exempt from CEQA. 3. The project is exempt from Chapter XII, Article 3 Transportation System Management, of Title 13 of the Costa Mesa Municipal Code. CONDITIONS OF APPROVAL Ping. 1. Street address shall be displayed on the fascia adjacent to the main entrance or front door in a manner visible from the public street. Numerals shall be a minimum 6" in height with not less than ''/z' stroke and shall contrast sharply with the background. 2. All new and existing construction shall be architecturally compatible with regard to building materials, style, colors, etc. Plans submitted for plan ZA 03-86 January 6, 2005 Page 3 check shall indicate how this will be accomplished. 3. The conditions of approval and ordinance or code provisions of minor design review ZA-03-86 shall be blueprinted on the face of the site plan as part of the plan check submittal package. 4. Grading, materials delivery, equipment operation, and other construction-related activity shall be limited to between the hours of 7 a.m. and 8 p.m., Monday through Friday, and 8 a.m. to 6 p.m. Saturday. Construction is prohibited on Sundays and federal holidays. Exceptions may be made for activities that will not generate noise audible from off- site, such as painting and other quiet interior work. 5. The applicant shall contact the Planning Division to arrange for a Planning inspection of the site prior to the release of occupancy/utilities. This inspection is to confirm that the conditions of approval and code requirements have been satisfied. Eng. 6. Maintain the public right-of-way in a "wet-down" condition to prevent excessive dust and promptly remove any spillage from the public right-of- way by sweeping or sprinkling. CODE REQUIREMENTS The following list of federal, state and local laws applicable to the project has been compiled by staff for the applicant's reference. Any reference to "City" pertains to the City of Costa Mesa. Ping. 1. Approval of the zoning action is valid for one (1) year and will expire on December 4, 2005, unless building permits are obtained and construction commences, or the applicant applies for and is granted an extension of time. A written request for an extension of time must be received by Planning staff prior to the expiration of the zoning action. 2. All contractors and subcontractors must have valid business licenses to do business in the City of Costa Mesa. Final inspections will not be granted until all such licenses have been obtained. Bldg. 3. Comply with the requirements of the California Code of Regulations, Title 24, also known as the California Building Standards Code, as amended by the City of Costa Mesa. 4. Prior to or concurrent with the submittal of plans for building plan check, the applicant shall prepare and submit documentation for compliance with the State Water Resources Control Board (SWRCB) Water Quality Order 99-08-DWQ; National Pollutant Discharge Elimination System (NPDES) Permit No. CAS000002 for Storm Water Discharges Associated with Construction Activity (General Permit); the California Regional Water Quality Control Board (RWQCB) Santa Ana Region Order No. R8-2002-0010 and NPDES Permit No. CAS618030; and, the City of Costa Mesa Ordinance No. 97-20 for compliance with NPDES Permit for the City of Costa Mesa. Such documentation shall include a Water Quality Management Plan (WQMP) identifying and detailing the ZA 03-86 January 6, 2005 Page 4 implementation of the applicable Best Management Practices (BMPs). Fire 5. Provide approved smoke detectors to be installed in accordance with the 2001 Edition of the Uniform Fire Code. Eng. 6. At the time of development submit for approval an off-site plan to the Engineering Division and grading plan to the Building Division that shows sewer, water, existing parkway improvements and the limits of work on the site, both prepared by a civil engineer or architect. Construction access approval must be obtained prior to building or engineering permits being issued by the City of Costa Mesa. Pay offsite plan check fee to the Engineering Division. An approved offsite plan and fee shall be required prior to engineering/utility permits being issued by the City. 7. A site access permit and deposit of $500 for street sweeping will be required by the Engineering Division prior to the start of any on- or off- site work. 8. Submit required cash deposit or surety bond to guarantee construction of offsite street improvements at time of permit per Costa Mesa Municipal Code Section 15-32, and as approved by City engineer. Cash deposit or surety bond amount to be determined by the City engineer. 9. Obtain a permit from the Engineering Division at the time of development and then construct P.C.C. driveway approach per City of Costa Mesa standards as shown on the offsite plan. Location and dimensions are subject to the approval of the Transportation Services Manager. A.D.A. compliance is required for all driveway approaches. 10. Obtain a permit from the Engineering Division, at the time of development and then remove any existing driveways and/or curb depressions that will not be used and replace with full height curb and sidewalk at applicant's expense. Trans 11. Remove existing drive approach on 2151 Street and construct a new drive approach approximately 10 ft. east to align with new driveway leading to 2-car garage. Comply with minimum clearance requirements from property lines and any vertical obstructions for residential drive approach. Parks 12. Existing parkway trees shall remain. SPECIAL DISTRICT REQUIREMENTS The requirements of the following special districts are hereby forwarded to the applicant: Sani. 1 . It is recommended that the applicant contact the Costa Mesa Sanitary District at (949) 631-1731 for current district requirements. School 2. Pay applicable Newport Mesa Unified School District fees to the Building Division prior to issuance of building permits. ZA 03-86 January 6, 2005 Page 5 Upon receipt of this letter, your project has been approved, subject to the above- listed conditions. A copy of the conceptually-approved site plan is enclosed. The decision will become final at 5:00 p.m. on January 13, 2005, unless appealed by an affected party or a member of the Planning Commission or City Council, including filing of the necessary application and payment of the appropriate fee. If you have any questions regarding this letter, please feel free to contact the project planner, Wendy Shih at 714-754-5136 between the hours of 1 p.m. and 5 p.m., Monday through Friday. • Sincerely, . MICHAEL ROBINSON Zoning Administrator Enclosure: Conceptually-approved plans cc: Engineering/Development Services Fire Protection Analyst Water District (--\/ Building Division • PLANNING APPLICATION SUMMARY Location: 202 21st Street Application: ZA-03-86 Request: Minor design review for a second-story addition to a single-family residence. SUBJECT PROPERTY: SURROUNDING PROPERTY: Zone: R1 North: R1 Single-Family Residence General Plan: Low Density Residential South: R1 Single-Family Residence Lot Dimensions: 78 ft.x 100 ft. East: R1 Single-Family Residence Lot Area: 7,800 sq.ft. West: R2-MD Existing Development: Single-story, single family residence. DEVELOPMENT STANDARD COMPARISON Development Standard Required/Allowed Proposed/Provided Lot Size: Lot Width 60 ft. 78 tt. Lot Area 6,000 sq.ft. 7,800 sq.ft. Density: Zone 1 du/6,000 sq.ft. 1/7,800 sq.ft. General Plan 1 du/5,445 sq.ft. 1/7,800 sq.ft. Building Coverage: Buildings NA 31% (2,392 sq.ft.) Paving NA 13% (1,050 sq.ft.) Open Space 40% (3,120 sq.ft.) 56% (4,358 sq.ft.) TOTAL 100%' 2n0 to Floor Ratio': 80% (guideline) 50% (1,197 sq.ft./2,392 sq.ft.) Building Height: 2 stories/27 ft. (max.) 2 stories/23 ft. Setbacks (house): Front 20 ft. 20 ft. Side (Iett/righ2 10 ft./5 ft. 18 ft./5ft. Rear(1' fl/2 fl) 10 ft./20 ft. 10 ft./16 ft." Interior 2n" Floor Side Setback': 10 ft. average(guideline) 22 ft. average Parking: Covered 2 2 Open 2 2 TOTAL 4 4 Driveway Width: 10 ft. 13 tt. NA=Not Applicable or No Requirement CEQA Status Categorical Exemption: Class 3 Final Action Zoning Administrator Residential design guidelines. Minor Modification (MM-03-56) for 4 ft. encroachment into rear setback requirement. • X /*/94 CITY OF COSTA MESA Pwin .O;‘, . BOX 1200 • 77 FAIR DRIVE • CALIFORNIA 92628-1200 t. a: i flu DEVELOPMENT SERVICES DEPARTMENT December 4, 2003 Gary Black 202 21St Street Costa Mesa, CA 92627 RE: MINOR DESIGN REVIEW ZA-03-86 202 216t STREET, COSTA MESA Dear Mr. Black: The minor design review for the above-referenced project has been completed. The application has been approved, based on the following project description and findings, subject to the conditions set forth below: PROJECT DESCRIPTION The subject site is located on the northeast corner of Orange Avenue and 21' Street. It is developed with a single-story, single-family residence. The applicant proposes to expand the first floor area and a 1 ,197 sq. ft., 2"d floor addition. The project will result in 2 bedrooms, 2 bathrooms, a kitchen, dining room, living room, family room and laundry on the 1st floor and 2 bedrooms, 2 bathrooms, a study, and a deck upstairs. Minor Modification MM-03-56 is approved for a 4 ft. encroachment into the rear setback (20 ft. required; 16 ft. proposed) for the 2' floor addition. ANALYSIS • The proposal conforms to all development standards and the residential design guidelines. The second story floor area is approximately 50% of the first floor area (1 ,197 sq.ft./2,392 sq. ft.) and is well integrated with the existing house configuration. The proposed construction also incorporates offsets and projections for an interesting building mass. Staff has conducted a site inspection and determined that the addition would not negatively impact the surrounding properties or aesthetics of the neighborhood. There are many 2-story structures within the vicinity so it would not appear out of Building Division(714)754-5273 • Code Enforcement(714)754-5623 • Planning Division(714)754-5245 . I - ZA-03-86 December 4, 2003 Page 2 place or obtrusive. The proposed addition provides an 18 ft. side setback (10 ft. required) from Orange Avenue and the 2nd floor portion is set back further from 21'' Street than the 15t floor to provide visual relief as viewed from the street intersection. Privacy impacts on adjoining residences are minimized since the 2nd floor overlooks the driveway of the property to the rear (north) and the windows are also offset from the 2-story structure to the rear. There are also mature trees on the adjacent property to the right (east) to minimize views from the proposed addition into their backyard. FINDINGS 1 . The information presented substantially complies with Section 13-29(e) and 13-29(g)114) of the Costa Mesa Municipal Code in that: a. The proposed development and use is compatible and harmonious with uses on-site as well as those on the surrounding properties. The project meets or exceeds all residential development standards and design guidelines. b. Safety and compatibility of the design of the buildings, parking areas, landscaping, luminaries, and other site features including functional aspects of the site development such as automobile and pedestrian circulation have been considered. c. The project is consistent with the General Plan. d. The planning application is for a project-specific case and does not establish a precedent for future development. e. The proposed development is substantially compatible and harmonious with existing and/or anticipated development on surrounding properties. This includes site planning, landscaping, appearance, scale of structures, location of windows, and any other applicable features relative to a compatible and attractive development. The second floor addition is well integrated with the existing floor plan and consideration is also given to the effect of proposed development on the light, air, and privacy of adjacent properties. The proposal incorporates projections and offsets for an interesting building mass. Privacy impacts will also be minimized by the driveway and tree buffers between structures/properties. 2. The project has been reviewed for compliance with the California Environmental Quality Act (CEQA), the CEQA Guidelines, and the City environmental procedures, and has been found to be exempt from CEQA. 3. The project is exempt from Chapter XII, Article 3 Transportation System Management, of Title 13 of the Costa Mesa Municipal Code. ZA-03-86 December 4, 2003 Page 3 CONDITIONS OF APPROVAL Ping. 1 . Street address shall be displayed on the fascia adjacent to the main entrance or front door in a manner visible from the public street. Numerals shall be a minimum 6" in height with not less than 1/2" stroke and shall contrast sharply with the background. 2. All new and existing construction shall be architecturally compatible with regard to building materials, style, colors, etc. Plans submitted for plan check shall indicate how this will be accomplished. 3. The conditions of approval and ordinance or code provisions of minor design review ZA-03-86 shall be blueprinted on the face of the site plan as part of the plan check submittal package. 4. The applicant shall contact the Planning Division to arrange for a Planning inspection of the site prior to the release of occupancy/utilities. This inspection is to confirm that the conditions of approval and code requirements have been satisfied. Eng. 5. Maintain the public right-of-way in a "wet-down" condition to prevent excessive dust and promptly remove any spillage from the public right-of- way by sweeping or sprinkling. CODE REQUIREMENTS The following list of federal, state and local laws applicable to the project has been compiled by staff for the applicant's reference. Any reference to "City" pertains to the City of Costa Mesa. Ping. 1 . Approval of the Zoning Action is valid for one (1 ) year and will expire at the end of that period unless building permits are obtained or the applicant applies for and is granted an extension of time. 2. All contractors and subcontractors must have valid business licenses to do business in the City of Costa Mesa. Final inspections will not be granted until all such licenses have been obtained. Bldg. 3. Comply with the requirements of the California Code of Regulations, Title 24, also known as the California Building Standards Code, as amended by the City of Costa Mesa. 4. Prior to or concurrent with the submittal of plans for building plan check, the applicant shall prepare and submit documentation for compliance with the State Water Resources Control Board (SWRCB) Water Quality Order 99-08-DWQ; National Pollutant Discharge Elimination System (NPDES) Permit No. CAS000002 for Storm Water Discharges Associated with Construction Activity (General Permit); the California Regional Water Quality Control Board (RWQCB) Santa Ana Region Order No. R8-2002-0010 and NPDES Permit No. CAS618030; and, the City of Costa Mesa Ordinance No. 97-20 for compliance with NPDES Permit for the City of Costa Mesa. Such documentation shall include a Water Quality Management Plan (WQMP) identifying and ZA-03-86 December 4, 2003 Page 4 detailing the implementation of the applicable Best Management Practices (BMPs). Fire 5. Provide approved smoke detectors to be installed in accordance with the 1997 Edition of the Uniform Fire Code. Eng. 6. At the time of development submit for approval an off-site plan to the Engineering Division and grading plan to the Building Division that shows sewer, water, existing parkway improvements and the limits of work on the site, both prepared by a civil engineer or architect. Construction access approval must be obtained prior to building or engineering permits being issued by the City of Costa Mesa. Pay offsite plan check fee to the Engineering Division. An approved offsite plan and fee shall be required prior to engineering/utility permits being issued by the City. 7. A site access permit and deposit of $500 for street sweeping will be required by the Engineering Division prior to the start of any on- or off- " site work. 8. Submit required cash deposit or surety bond to guarantee construction of offsite street improvements at time of permit per Costa Mesa Municipal Code Section 1 5-32, and as approved by City engineer. Cash deposit or surety bond amount to be determined by the City engineer. 9. Obtain a permit from the Engineering Division at the time of development and then construct P.C.C. driveway approach per City of Costa Mesa standards as shown on the offsite plan. Location and dimensions are subject to the approval of the Transportation Services Manager. A.D.A. compliance is required for all driveway approaches. 10. Obtain a permit from the Engineering Division, at the time of development and then remove any existing driveways and/or curb depressions that will not be used and replace with full height curb and sidewalk at applicant's expense. 11 . Applicant is informed 21s' Street is under a "no Open Cut" moratorium until December 7, 2003. Open cutting the street pavement during the moratorium period shall require special resurfacing requirements. Trans 12. Remove existing drive approach on 21" Street and construct a new drive approach approximately 10 ft. east to align with new driveway leading to 2-car garage. Comply with minimum clearance requirements from property lines and any vertical obstructions for residential drive approach. Parks 13. Existing parkway trees shall remain. SPECIAL DISTRICT REQUIREMENTS The requirements of the following special districts are hereby forwarded to the applicant: Sani. 1 . Developer shall contact the Costa Mesa Sanitary District at (949) 631- 1731 for current district requirements. ZA-03-86 December 4, 2003 Page 5 School 2. Pay applicable Newport Mesa Unified School District fees to the Building Division prior to issuance of building permits. Upon receipt of this letter, your project has been approved, subject to the above- listed conditions. A copy of the conceptually-approved site plan is enclosed. The decision will become final at 5:00 p.m. on December 11 , 2003, unless appealed by an affected party or a member of the Planning Commission or City Council, including filing of the necessary application and payment of the appropriate fee. If you have any questions regarding this letter, please feel free to contact the project planner, Wendy Shih at 714-754-5136 between the hours of 1 p.m. and 5 p.m., Monday through Friday. Sincerely, ,I R. MICHAEL ROBINSON Acting Zoning Administrator Enclosure: Conceptually-approved plans cc: Engineering/Development Services Michael McBride Fire Protection Analyst 918 Acacia Ave. Water District Huntington Beach, CA 92648 ,/ Building Division • • ` CITY OF COSTA MESA BUILDING DIVISION )„l-' :.fir DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F t ^^jL • PERMIT 4414,,0,i„mV05-00276 (714)754-5273 • Fax(714)754-4856 • www.ci,costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 202 21ST ST Status: ISSUED Suite No Applied: 04/04/2005 Vicinity: Issued: 04/04/2005 Parcel Nunmber: 42614101 Applicant: HOLDSWOR, MICK ISSUED BY: Address: Phone: 714 299-9792 Zip Owner: BLACK, GARRY L • Address 202 E 21ST ST Phone: COSTA MESA,CA Zip: 92627-2126 Contractor: KIEGGO CONSTRUCTION INC Address: P.O. BOX 10714 Phone: (949)294-0902 COSTA MESA,CA Zip: 92627 License:773135 SCOPE OF PERMIT REF:1305-00146-2,011 SF ADDITION TO EXISTING SFD(647 SF 1ST FLOOR AND 1100 SF 2ND FLOOR).ALSO ADD 176 SF COVERED PORCH AT REAR, 118 SF COVERED DECK,85 SF BALCONY AND A 744 SF ATTACHED GARAGE.INCLUDES 2 OUTDOOR FIREPLACES-ONE AT 1ST FLOOR AND ONE AT 2ND FLOOR DECK.REMOVE AND REPLACE ROOF STRUCTURE OF EXISTING 1010 SF STRUCTURE.ALSO INCLUDES DEMOLITION AND COMPLETE REBUILD OF NON-PERMITTED 89 SF OF EXISTING SFD.ALSO INCLUDES AFTER-THE-FACT CONVERSION OF 175 SF EXISTING GARAGE TO HABITABLE WORK-OUT ROOM. REPLACE ALL GLAZING IN EXISTING STRUCTURE WITH DOUBLE PANE GLAZING. CONVERT 2 BEDROOM, 1 BATH SFD TO A 3 BEDROOM,3.5 BATH SFD. ZA-03-86/MM-03-56 ELECT.PERMIT IS FOR 50 FIXTURES,30 SWITCHES,30 OUTLETS 8 200 AMP.SERVICE UPGRADE. 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 $43.90 50 up to 50 kva/kw $0.00 0 Recept Outlets $29.30 30 up to 100 kva/kw $0.00 0 Switches $29.30 30 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 • 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 2446-06(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 carrier and policy number are: .. Cartier: AneetcAi, L%a--C)161 Ci C Policy Number: 4(o .��'vIt-I — Zoog (This section need not be completed it the permit is valued at one hundred dollars($100)or lass.) ❑ I certify that in the performance of the work for which this permit is Issued,I shell not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agre that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall tdrthwlth comply with these p�r v^isior}g " Applicant Signature: 1_`�if�-( i Date: C-1-n-( AOa- L 4o o'i 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($100,CCO),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3106 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under pro> lons 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.Lie.4 "4-3 /J class a Contractor's Signature: M e•---) Date: 41L=( 4PdtC. Zo 3 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 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 properly,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.). ❑ 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? ❑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 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 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? Yes IJ 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 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 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. ure Of Legal Owner(s) , � Date (V L" L i � -f-1'�IA-i L �,�' And/O,Authorized Applicant Dalai CODE# INSPECTION TYPE PAIL INTRIALS CODEC In$PECTION tYPE pAIF UfIB1SL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 17:1-CC li 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 Q` 9 CITY OF COSTA MESA BUILDING DIVISION . %1,.;a.nr 1 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER b. PERMIT I� � )//M05-00160 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,(COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 202 21ST ST Status: ISSUED Suite No Applied: 04/04/2005 Issued: 04/04/2005 Vicinity: Parcel Number 42614101 ISSUED BY: Applicant: HOLDSWOR, MICK Address: Phone: 714 299-9792 Zip: Owner: BLACK, GARRY L Address: 202 E 21ST ST Phone: COSTA MESA,CA Zip: 92627-2126 Contractor KIEGGO CONSTRUCTION INC Address: P.O.BOX 10714 Phone: (949)294-0902 COSTA MESA,CA Zip: 92627 License:773135 SCOPE OF PERMIT REF:B05-00146-2,011 SF ADDITION TO EXISTING SFD(647 SF 1ST FLOOR AND 1100 SF 2ND FLOOR).ALSO ADD 176 SF COVERED PORCH AT REAR, 118 SF COVERED DECK,85 SF BALCONY AND A 744 SF ATTACHED GARAGE. INCLUDES 2 OUTDOOR FIREPLACES-ONE AT 1ST FLOOR AND ONE AT 2ND FLOOR DECK.REMOVE AND REPLACE ROOF STRUCTURE OF EXISTING 1010 SF STRUCTURE.ALSO INCLUDES DEMOLITION AND COMPLETE REBUILD OF NON-PERMITTED 89 SF OF EXISTING SFD.ALSO INCLUDES AFTER-THE-FACT CONVERSION OF 175 SF EXISTING GARAGE TO HABITABLE WORK-OUT ROOM.REPLACE ALL GLAZING IN EXISTING STRUCTURE WITH DOUBLE PANE GLAZING. CONVERT 2 BEDROOM, 1 BATH SFD TO A 3 BEDROOM,3.5 BATH SFD. ZA-03-86/MM-03-56 MECH.PERMIT IS FOR: 1 FAU,2 VEN FANS, 1 AC UNIT.' FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU $14.80 1 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 $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 $0.00 0 30 To 50 hp/1,750 k BTU $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. • INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(6/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintaiQ workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Cartier: {lcMjaajacrn L$c.oQ M[c2p__ Policy Number: %bc9- 2otn (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit is Issued,I shell not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these lrovision 4• Applicant Signature: �FIL71 'R Date: ,H AGi"ti -2 of C WARNING:FAILURE TO SECURE W PSNSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provision, of Chapter 9(commencing with Section 7000)of Division 3 of the Business and psgfassions Code,and my license is in full force and effect.Lic.k R—3 7 3 J Class A Contractor's Signature: Date: 4---t-$ Alt4r-4---. -I m o rts— CONSTRUCTION LENDING AGENCY: ❑ I hereby affimi 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.). ❑ 1.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.). ❑ 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 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 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). B Will any part of the facility to be constructed under this permit bo 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: Dale: 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. M &�tgn Lure Of Legal Owner(s) Date 4-7(4 AG S_ mco—•) 1ttdTTRid Applicant Date CODE INSPECTION TYPE PAIS INIEtAL5 CODE I INSPECTION TYPE ^ @PAT_E 1616 Fixed System Final Fire Prevention 206 Final Mechanical 12'- 5-0 5 NiaN 1268 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`, 'F 9 CITY OF COSTA MESA BUILDING DIVISION > • v DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER ft IPPICa PERMIT vP05-00229 etberontuso (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 202 21ST ST Status: ISSUED Suite No Applied: 04/04/2005 Issued: 04/04/2005 Vicinity: Parcel Nunmber: 42614101 ISSUED BY: Applicant: HOLDSWOR, MICK Address: Phone: 714 299-9792 Zip: Owner: BLACK, GARRY L Address 202 E 21ST ST Phone: COSTA MESA,CA Zip: 92627-2126 Contractor: KIEGGO CONSTRUCTION INC Address: P.O. BOX 10714 Phone: (949)294-0902 COSTA MESA,CA Zip: 92627 License: 773135 SCOPE OF PERMIT REF:B05-00146-2,011 SF ADDITION TO EXISTING SFD(647 SF 1ST FLOOR AND 1100 SF 2ND FLOOR).ALSO ADD 176 SF COVERED PORCH AT REAR, 118 SF COVERED DECK,85 SF BALCONY AND A 744 SF ATTACHED GARAGE.INCLUDES 2 OUTDOOR FIREPLACES-ONE AT 1ST FLOOR AND ONE AT 2ND FLOOR DECK.REMOVE AND REPLACE ROOF STRUCTURE OF EXISTING 1010 SF STRUCTURE.ALSO INCLUDES DEMOLITION AND COMPLETE REBUILD OF NON-PERMITTED 89 SF OF EXISTING SFD.ALSO INCLUDES AFTER-THE-FACT CONVERSION OF 175 SF EXISTING GARAGE TO HABITABLE WORK-OUT ROOM.REPLACE ALL GLAZING IN EXISTING STRUCTURE WITH DOUBLE PANE GLAZING. CONVERT 2 BEDROOM, 1 BATH SFD TO A 3 BEDROOM,3.5 BATH SFD. ZA-03-86/MM-03-56 PLUMB.PERMIT IS FOR:2 BATHTUBS, 1 DISHWASHER, 1 GAS SYSTEM 1-4 OUTLETS, 1 LAUNDRY TUB/WASHER, 1 SHOWER, 1 SINK,7 WASH BASINS,8 4 WATER CLOSETS. 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 $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 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 carrier and policy number are: TpA Carrier: s ME2a. CAL, UGHO 'U 2Lx- Policy Number: (A3 FS 4-I - 7-00 C (This section 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 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 provlsio 'I Applicant Signature: Date: `-t"i(-4 Prima' Zuc. WARNING:FAILURE TO SECURE 'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND OVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5100,0001.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 provsiS 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.Lit.# ^�� Class k 1' ? Contractor's Signature: .. °' . Date: 4Tl-1 402_%` Zo Aa •'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).): ❑ 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,end 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 et 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)? Dyes ❑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 2555 344 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? Yes 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 In 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 penally of perjury that t have read this application and state that the information given S correct. I agree to comply with all slate 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. ' lure Of Legal Owner(s) Date al-44 ` ? r Authorized Applicant Date CODE I INSPECTION TYPE OIL IWTITIAI& CODE INSPECTION TYPE DATE 18I1TIELE 1616 Fixed System Final Fire Prevention 206 Final Mechanical �1 ( _� 1266 Pool Spa Final 208 Final Plumbing )4g 'C�)-05 -Fri 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 J'.. y. ♦ ..,...,- .....-..,Y., 3.•.v new. ti�..� - ., n. .. _ • PACIFII MAST INSPECTION SERVIC i, INC. ' 9161 Kapaa Drive �� -e;'�' e 7 3 Huntington Beach,CA 92646 1 �` ���'- LtT mitt ); (714) 337-4429 * Pager(714)431-5303 * Fax (714) 968-1671 REGISTERED INSPECTOR'S DAILY REPORT "• Pere^ 1. ED T1s TYPE OF 0 Reinforced Concrete 0 Structural Steel Assembly 0 Quality Control INSPECTION 0 Post Tensioned Concrete 0 Fire Proofing ti Other REQUIRED 0 Reinforced Masonry 0 Asphalt - rq-t ji j Job Address poi., e"�j City / A a. Job Name ,G`y{�)��,•yL} ! Permit No:> JE{i Issued By / ^n ' • Type of Structure C LA0 , '!/fit Architect' _ _ cd T� (_� MatyteJjriial/Deescriipption(type, grade, source) VII,k, /iWnY Engineer �E, 4r >,/ �u\ u tr'A "'j1�V r'P " c/"U ��''�� '(/�jl Contractor�'J1 VC,'V. F�"L1i� {bt /'��. Inspector(s) Name %-(2.14„,,06...14,e, Subcontractor 1 ,1 / t ((��(( TESTS PERFORMED TYPE OF SAMPLE SLUMP QUANTITY IN SET ADDITIONAL REMARKS ON SAMPLES INSPECTION SUMMARY-LOCATIONS OF WORK INSPECTED,TEST SAMPLES TAKEN,WORK REJECTED.JOB PROBLEMS.PROGRESS,REMARKS.ETC. INCLUDES INFORMATION ABOUT-AMOUNTS OF MATERIAL PLACED OR WORK PERFORMED,NUMBER,TYPE&!DENT.NO'S OF TEST SAMPLES TAKEN: STRUCT. CONNECTIONS(WELD MADE H.T. BOLTS TORQUED)CHECKED; ETC. (jbra✓�Y(�ttpZ1/4,4" O, fir 4/ friel fi/06 c' 'I/ AprS _• .'`txa, (15N\ (r `- rvT-i /r11+10f to Ai( . Y^r / Iwile>.) JFLLr--a'y Seri,y I a(v� s ILL�,,L ."p-evils MA- cru ���./y..c,F C,.e- o' /K..pr,y v 2 c — AlI \!d ILL ?fa— JQer-uc4Gt.T e . ( .f! C11TC'l,i/) f ">A I �-, . i p0 UNA;lm^ s / y 4 CERTIFICATION OF COMPLIANCE CONTINUED ON NEXT PAGE 0 PAGE OF I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE NOTED.I HAVE FOUND THIS TIME IN . TIME OUT REG. HOURS O.T. HOURS CYLINDERS WORK TO COMPLY WITH THE APPROVED PLANS.SPECIFICATIONS.AND APPLICABLE I SEC IIONS,OF�FTTHEEGOVERNING BUILDINGLAWS. 7;..1 � . "'a�s6-'i' ,i�`41A J All inspections based on a minimum of-4 hours and oven4 hours hour ; minimum. In addition„any'Ins'pection`extending past•noon hour 4ii11.beran B / gg SIGNATURE OF REGISTERED INSPECTOR ,y^� hour minimum. j / �1„ /�/7i/`)�j/ l B I/"\ • 0 A 7 .iv'7 4- K Y .1.,�✓o Approved By (/ �//(`A//�// (ii C SPECIALTY NO. AGENCY Project Superintendent t r WHITE -OFFICE COPY, CANARY-ACCOUNTING COPY. PINK- INSPECTOR'S COPY,GOLDENROD.JOB SITE COPY f CITY F COSTA MESA ,� 4 BUILDING DIVISION > •i• - DEVELOPMENT SERVICES DEPARTMENT PERM T NUMBER 111.411 PERMIT 4aw,0 ,fi" B05-00273 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 202 21ST ST Status: ISSUED Suite: Applied: 02/11/2005 Vicinity: Issued: 02/11/2005 Parcel Number: 42614101 Zoning: Applicant: MCCULLOUGH, DOMINIC ISSUED BY: Address: P.O.BOX 10714 l� Phone: (949)642-1029 COSTA MESA,CA Zip: 92627 Owner: BLACK, GARRY L Address 202 E 21ST ST Phone: COSTA MESA,CA Zip: 92627-2126 Contractor KIEGGO CONSTRUCTION INC Address: P.O.BOX 10714 Phone: (949)294-0902 COSTA MESA,CA Zip: 92627 License: 773135 Arch : Eng: • Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT DEMOLISH INTERIOR WALLF FOR FUTURE ADDITION B05-00146. FEE SUMMARY Plan Check: $0.00 Calc Valuation: $8,000.00 Permit: $153.25 Claim Valuation: $6,000.00 SMIP Res: $0.80 SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 Total: $154.05 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 end 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) WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ ave and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the w rk 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, orkers'compensatlo Insurance carrier and poll number are: 1 Sta. A P •Number: / 69 704 I-2_004 coon need not be completed 11 th r 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' co r.:. : • 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 fdrthwith comply with th:I ' �/ Applicant ..- .re: sem%. ate:" Z— 1 t — °S. WARNING:FAILURE TO SECURE '•'tnrwn in NSATION COVERAGE IS UN AND SHALL SUBJECT AN EMPLOYER •INAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOI I ARE($10,000),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 hereb :.' .. -:t4-am.Iicansed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business apd.2ro[essions Code,and my license Is in full fort: :.".:., 3 Class# �. –K Cotor's Signatur:��7/1�� "2 f f ) ( V 5 CONSTRUCTION LENDING AGENCY: f ❑ 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.-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,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 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 2 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 final inspection. er .� of(s) fil 0 ate ;ODE. INSPECTION TYPE 2TE PEMALE LODE I INSPECTION TYPE 21E IIIIMALS 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 �J�Jy.�S(� 203 Final Sign222 Final Site 1 204 Final Demolition 250 Final Building/Occupancy CITY OF COSTA MESA .. BUILDING DIVISION itac•r.,.r. 4 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER f PERMIT 4F 05-00788 (714)754-5273 • Fax(714)754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 202 21ST ST Status: ISSUED Suite No Applied: 07/27/2005 Vicinity: Issued: 07/27/2005 Parcel Nunmber: 42614101 ' Applicant: LISA ZOSCAK ISSUED BY: - - Address: 32244 PASEO ADELANTO#A Phone: (949)493-9548 SAN JUAN CAPISTRANO,CA Zip 92675 • Owner: BLACK, GARRY L Address 202E 21ST ST, " Phone: COSTA MESA,CA Zip: 92627-2126 Contractor: IES 5 W A N4'I Address: A 2.1151/.. 'gi gI O G tit R3 Phone: (94 49349548 ?I� 44tj 8Set- C/O i 4 6 w A Zip: �'92e75 9 26 . LA.4� F0 C s T License:744437 l .() '3 33 SCOPE OF PERMIT/ INGROUND POOL AND SPA REF 905-00728 " 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 .- $49.50 1 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 . . oveu100 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. :1- $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 0Plan Check Fee. - " $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole S0.00 0 TOTAL CALCULATED FEES $73.00 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's 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 comp�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 r / 244846(WOO) , DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: 0 I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the ork for which this permit is issued. L/ •ave and will maintain workers'•• pensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 'rows' •m•e•::tion Insure e carrier and policy number are: �•7�y�-�7 • #4..-4( we - aa Po umber. `�b action need not be completed if t e permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the perform. a 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 a•••r ia,and agree that If hould become subject to the workers'compensation provisions of Section 3700 of the Labor Cade,I shall forthwith Com. wi • :se• at. n 1 I �^ Appli : 1 .nature: a` ,. et O- �(,/ D WARM :FAIL : •SECURE W • RS'CIMIPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT VM ER TO CRIMINAL PENALTIES AND CL FINES UP TO ONE HUNDRED THOUS • •• .-E(9100,000),IN MON 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 •. a', icons:d •:r provis'• s•f Chapter 9(commencing with Section 7000)of Division 3 of the Business a•- • •fessio -nd my license is in full force and- • 4' 6 _L-s- ;e / /N Co •signature: I% I I Date: rte n/.I`I'G. Ara CONSTRUCTION LENDING •IENCY: ❑ 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,end 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 end Professions Code for this reason: Signature: ... • Date: Owner ID verified by driver's 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 then 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: 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 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 en 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? ❑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? 1110 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? ❑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, re xi : al 49. ner(s) ' _ ,_ to�,U� A /T -A. IC 4 4 -..as � > ` And/Or Au r;• •ppi :• ate 7 v ;ODE I INSPECTION TYPE PATE INTR)ALS PDF I INSPECTION TYPE . MI BMW 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 1-3-0(o `,... 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 ME SA • @ BUILDING DIVISION :� tDEVELOPMENT SERVICES DEPARTMIENT PE IT NUMBER Ft ..m..1, I 4P% PERMIT 05-00251 se • . (714)754-5273 • Fax(714)-754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 202 21ST ST - Status: ISSUED Suite No Applied: 05/06/2005 Issued: 05/06/2005 Vicinity: /�`//��,},L Parcel Number: 42614101 " ' - - - ISSUED BY: 1 J Q' Applicant: LISA ZOSCAK 11 . Address: 24512 BRIDGER RD t -.� . . - . - - Phone :(949)859-8466 ' . ' ' • . LAKE• -FOREST,CA: Zip: 92630 , -Z' owner 'BLACK, GARRY-L; i Address: 202E 21ST ST-': Phone: COSTA MESA,CA Zip: 92627-2126 Contractor: SWAN POOLS-OF SOUTHERN CALIFORNIA . .Address: 24512 BRIDGER RD ' '' 'Phone: (949)859-8466 i.LAKE FOREST,CA-.• Zip: 92630 License:440333 SCOPE OF PERMIT INGROUND SUNITE POOL AND SPA REF-B05-00728 POOL HEATER. - , FEE SU ' MMARY , Quantity . - . ' Quantity ISSUE FEE $23.50 - -- - •:.-- - - Repair/,Alt Abtorbtion 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 $0.00 0 . Repair/Alt Cooling/Heat $0.00 0 . Evaporative Cooler , $0.00 0 Inst/Rep.Recess Wall Htr $0.00 0 Commercial.lncinerator $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 $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 , $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°l , 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 $0.00 0. Air Handlers> 10000cfm ' $0.00- ' 0 Over 50hp' ` % ,. $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee J Floor or Suspend Heater $0.00 0 -Investigation Fee - $0.00 Plan Check Fee $0.00 - - Reinspection Fee $0.00 TOTAL CALCULATED FEES $41.70 NOTICE: The-work authorized'by this.permit.shallcomply-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.workis 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:considereddegal,:such,work•must.comply.witli.all'applicable codes, and all required Inspectionsland final:approval•mustbe obtained.'Failureao.obtain.inspections andtinal.approval.will:resultin.tAe expiration of this permit. FOR!INSPECTIONS•CALL:4714).75445626 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. - t 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. fly wo ers'compensation Insu ance carrier and policy number are: -T CI Q_ C _Cartier. completed Policy Num r. 11 ] 1 `SU (This section need not be completed i 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 f California,and agree that If I should Come subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comp�ly INkt- p n (V //^^ - -0 -Applicaritl re l� Date: -J—I/o S G -WARNING:FAILURE TO SECURE WORKERS' ENSATION COVERAGE IS UNLAWFUL AND SHALL SU ECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5100,0)01,IN ADDITION T E COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 370e OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm t at lyerri II ersec,under•r•vis s of Chapter 9(commencing with Section 7000)of Division 3'of the'Busin s andProfessions Code,and my license Is in full force antl eHeG�LIc as lJ� Wass» S Contract s Ignature: I CC / Date: t— t—O5 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 end 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 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 ❑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? 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 agent? Yes 0 No (Section 85850.2 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 Quality Management District(37 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 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 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�ignaturref eget•w,r(s) ' S-� D6c Ai J U And/ebAuthorized Qgems Date COPE E INSPECTIONTYPE '- QAI ' INTfT1AL$ CODE It 'INSPECTION TYPE DAIS 1616 Fixed System Final Fire Prevention • . 206 ' Final Mechanical /-/R-06 r 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 • CITY OF COSTA MESA REFUND REQUEST FORM From: ❑ Finance Vendor#: ® Building Safety Permit#yt1/2)4 0167_ Tk04- (.1-/W ❑ Planning ❑ Amount: $ ", Public Services I� ❑ Community Services Date: t I�� v ❑ Other EUt•}. 0(071 I PU4- OCA4u0 - _oaf_ u • , Department Signature AccountFund Organization Program Project/Grant Amount _ 1.-1 01 l t SC_: 2i)4t0 L, a1 ►0 t ► 4-0 wi,. 1 QD i - i �lr 101 1 )0i) (LO 141t) k'�2. v•SCi Name and address of applicant: cScJ-N (:)-4 S12_ 1>I2i06i.iZ "kms �Gi' c r `12(23-c-1 Phone: Ct4C- I FS � -fc,10 • Applicant's Signature Date REASON FOR REFUND: • APPROVALS: Finance: City Manager: 2401.22 MW ONLINE 1 rpt^, - .. 3,�� l s �-.a`f NI -7-620C.. !* 1 c?-2 I2L / (tCY O C7_i(! s}f j Z,M1:,7!�-911q/ -frOd / S:/)/0 - O QI QQ - -7OJJ ung /2 7a--z ' �.'7d. ,;f� —Th/T �n ..ti7/l ��'p ? ?"J27 71/. /74J ,1-!7 jic/e2 f T _ • � �rS0; S-11-11! 9 4. CITY OF COSTA MESA 4 BUILDING DIVISION > al t____ DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER :f '4�%°r PERMIT 44* E04-01051 (714)754-5273 • Fax(714)754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT • Job Address: 202 21ST ST Status: ISSUED Suite No Applied: 09/29/2004 Vicinity: Issued: 09/29/2004 Parcel Nunmber: 42614101 /I Applicant: ZOSCAK, LISA ISSUED BY: ff Address: 1 Phone: 949-683-9862 Zip: \ , Owner: BLACK, GARRY L Address 202 E 21ST ST s Phone: ` `, COSTA MESA,CA, Zip: 92627-2126 \\�\1�1,�/U Contractor: SWAN POOLS OF SOUTHERN CALIFORNIA Address: 24512 BRIDGER RD Phone: (949)859-8466 LAKE FOREST, CA Zip: 92630 License: 440333 SCOPE OF PERMIT CONSTRUCT 230 SF IN-GROUND GUNITE POOL WITH A 40 SF DETACHED SPA AT THE LEFT SIDE OF AN EXISTING SFD.REF B04-01679. 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 , ,$99.00 2 • 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 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 J 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,ls suspended or abandoned for a period of 180 days. ii 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 i 1 2446-46/6'00) 1/111 DECLARATIONS t� r-~� 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. , � —[J' 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. __ ricracpmpensatipn Insurercarrier and policy number are: — �7 ) Ca Her t /nbf plat,Yl yrollay_ rsrler. L 1 ' section need n t 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 C fornix,and agree that If I sh Id become subject to the workers'compensation provisions of Section 3700 of the Lab r Code,I shall forthwith co••*t thesep vi /1 ^ A P A�Ts:': azure: ��` Date: (!If '� WARNING:FAILURE TO SECURE WOR RS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN AD TION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I her.• - - that 1 am How u dp(PzQvisions of Chapter 9(commencing with Section 7000)of Di ' e Busi9e,,ss_en Professions Code,and my license is in full to . air' .N �'! .TSD-3 Class# Li-'o / ontract•�.:•nature: 1� '•i q rag 6`T TRUCTION 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). 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). 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? 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? U Yes 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 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 property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. .Ir Si;,ature Of Le. Ow'. (s) -/ chit) i4 .� a � S " g 'nd/Or Autho zed App •'nt '"ate ' CODE t. INSPECTION TYPE 12D{ INTRIALS DOPE/ INSPECTION TYPE mg jNrrrIALS 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 • ' ' -Mr CITY OF COSTA MESA • ►� BUILDING DIVISION f41 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER J• PERMIT PO4-00660 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 - PLUMBING PERMIT Job Address: 202 21ST ST Status: ISSUED Suite No Applied: 09/29/2004 Issued: 09/29/2004 Vicinity: • ISSUED BY: ___64L____ Parcel Nunmber: 42614101 Applicant: ZOSCAK, LISA Address: Phone: 949-683-9862 Zip: • j\)S? Owner: BLACK, GARRY L Address 202 E 21ST ST Phone: COSTA MESA,CA Zip: 92627-2126 Contractor: SWAN POOLS OF SOUTHERN CALIFORNIA \ ,1 Address: 24512 BRIDGER RD �" Phone: (949)859-8466 LAKE FOREST,CA Zip: 92630 License: 440333 Arch / Eng: Address: Phone: Zip: License: SCOPE OF PERMIT CONSTRUCT 230 SF IN-GROUND GUNITE POOL WITH A 40 SF DETACHED SPA AT THE LEFT SIDE OF AN EXISTING SFD.REF 604-0679. 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 50.00 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 50.00 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 50.00 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 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements n r r 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)7545626 2446-46(600) • DECLARATIONS �l--., ---",, WORKERS'COMPENSATION DECLARATION: . I here y affirm under penalty of perjury one of the following declarations: ❑ 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 Ls issued. orke co ansa iyl Insurance carrier and policy number are: �1 �(. 7 LI Ca ' • $ ,1 �-t A Numb r. is section need not a completed if the permit Is valued at one hundred dollars($1 less ❑ I certify that in the pert rmance 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' compen ' 'on law of alifomia,and agree that if I should come subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith co hese ro " /z �� Appl'�: T: �/� QA ✓� WARNING:FAILURE TO SECURE WORKERS' MPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOUARE(S100,000),IN ADDmON THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I here',ro' .A am tic n u d r provisionsyf Chapter 9(commencing with Section 7000)of Division 3 of the skins Code,and my license Is In full t � i,.lure: �/,a�L� e:: Of v�"( �S..J"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.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 fore 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 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? 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? j�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 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 MD 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 O�L4gal• .l er(s)� l a And/Or Autho' :Pcan-I \ D CODE I 185PECTION TYPE RAE INm1AL$ ;ODEA INSPECTION mg RAE Mak 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 • CITY OF COSTA MESA • . to-a) BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT • 'PERMIT NUMBER v. i PERMIT Sotocannose B04-01679 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT • Job Address: 202 21ST ST Status: ISSUED Suite: Applied: 09/29/2004 Vicinity: Issued: 09/29/2004 Parcel Number: 42614101 Zoning: • Applicant: ZOSCAK, LISA ISSUED BY: /rrdl Address: Phone: 949-683-9862 Zip: Owner: BLACK, GARRY L Address 202E 21ST ST • Phone: COSTA MESA,CA Zip: 92627-2126 Contractor: SWAN POOLS OF SOUTHERN CALIFORNIA Address: 24512 BRIDGER RD Phone: (949)859-8466 LAKE FOREST,CA Zip: 92630 License: 440333 Arch : Eng: Address: - Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT CONSTRUCT 230 SF IN-GROUND GUNITE POOL WITH A 40 SF DETACHED SPA AT THE LEFT SIDE OF AN EXISTING SFD. FEE SUMMARY Plan Check: $261.20 Calc Valuation: $25,500.00 Permit: $401.85 Claim Valuation: 525,500.00 SMIP Res: $2.55 • SMIP Corn: $0.00 Other: $0.00 Inspection: $0.00 • Total: $665.60 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. ' '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 permit. FOR INSPECTIONS CALL: (714)754-5626 /r 2446-66(6/00) r 1 DECLARATIONS ('' 1 r " WORKERS'COMPENSATION DECLARATION: -• • I hereby affirm under penalty of perjury one of the following declarations: 0 I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. I h: - . -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. wo'., ',o pens: Insurance carrier and policy number are: [�. arrier: hvs At I. CP mbar: { 6 l-7 1, (Thi . 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' atlon laws of alifornia,and agree that if I should b epme subject to the workers'compensation provisions of Section] 37000, of the La or Code,I shall forthwith comply Ih?hes pr 'o q -,;e3.-64— • dq—T `/ •police :gnature: fl- A�✓`/1 ➢`_ Data, U •i-NING:FAILURE TO SECURE WORKERS PENSATION 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 affi etJ am IIcgnsTho signs of Chapter 9(commencing with Section 7000)of Division 3 of the sin 20d Professions Code,and my license is in full force a .H (-sL /I , (� /^�L', lass a (a'�7 �I1 Co acro ure: V����M- � \ 'M I 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). 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 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 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 Safely 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? IQ Yes D 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 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 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 ANO 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. S' natu a Of )Ow s Lege wdr:34Datr Auth nzed pplicant CODE I INSPECTION TYPE PAIF, INITIALS CODEI INSPECTION TYPE WI MALE 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 %L! CITY OF COSTA MESA . 4 • � •.> BUILDING DIVISION rf ..• DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER t � PERMIT sc M014 005+0 (714)754-5273 • Fax(714)754.4858 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 202 21ST ST Status: ISSUED Suite No Applied: 09/29/2004 Issued: 09/29/2004 Vicinity: Parcel Number: 42614101 ISSUED BY: Applicant: ZOSCAK, LISA Address: Phone: 949-683-9862 Zip: \1/4i\ON:filetP Owner: BLACK, GARRY L 1 V Address: 202 E 21ST ST \ IV Phone: \Y, - COSTA MESA,CA Zip: 92627-2126 V Contractor: SWAN POOLS OF SOUTHERN CALIFORNIA V Address: 24512 BRIDGER RD Phone: (949)859-8466 LAKE FOREST,CA Zip: 92630 License:440333 SCOPE OF PERMIT CONSTRUCT 230 SF IN-GROUND GUNITE POOL WITH A 40 SF DETACHED SPA AT THE LEFT SIDE OF AN EXISTING SFD. REF 804-01679 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 $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 $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 $38.30 . , i NOTICE: The work authorized bythispermit 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)7545626 2445-48(600) 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. ❑ ave and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. M w s'c ensauerr9nsurance Farrier and policy number are: Q Cervi }}��,�I'� p�leer: ah7t I is section need n f e cc plated 11 the permit is valued at one hundred dollars($100)or less.) - ❑ I certify that in the perfo mance of the work for which this permit is issued,I shall not employ any parson in any manner so as to become subject to the workers' •m•ensation law of//CII�Ilfornia,and agree that If I should become subject to the workers'compensati provisions of/✓Seeectionn 337�700�"�0 of the Labor Code,I shall forthwith "G:Signature: ALU Ef eTO SECUREt ply with these ro IWWO�' PE SATICOVERAGE LAWFUL AND SHALL SUBJECT Ni EMPLOYER TO CRIMINAL ENALTIES�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 CO . 'CIORS DECLARATION: I here�o•� . r.m licerteil(geerr provisions,p7j�Chapter 9(commencing with Section 7000)of Divisio ' e and Professions Code,and my license is in full tor•-'u,. . - 1 —b 1.12:x/ ssk X/_1.S� -1 .rs Si. ore: d••'- ii ��a to: CONSTRUCTION LENDING AGENCY: __0—Teby 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,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.). ❑ 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? ❑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 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 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). 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. ` i.•.fur Of egO ':r(s)� gere y , d/• • onze plicant Daje — CODE I INSPECTIQNTYPE - ME UI AU SODE I INSPECTION TYPE C— PAIL LIQrALS 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 - ' PIPIr i. PROJECT ADDRESS: ; 202 21ST ST UNIT: ' " 4 CITY OF COSTA MESA — BUILDING PERMIT rnrtf0 NU: c u74iiiy OWNER'S NAME: BLACK GARRY L ADDRESS., 02 21ST ST PERMIT NO: E 054714 PLAN CHECK NO: N Uuvi : N SUP?: N ifCOSTA MESA,CA 92627 CONSTRUCTION TYPE: 5—N PERMIT TYPE: ELE PURPOSE: OTH ARCH/ENGINEER: REG.ND.: JOB DESCRIPTION : ELECTRICAL SERVICE CHANGE OUT SQ FT; ADDRESS: UNIT: CLAIM VALUE: CALC—VALUE: GROUP OCC: R-3 / PERMITTEE: PDC ELECTRIC ( 714 ) 631 -6100 ADDRESS: 3003 FILLMORE 96 COMMENTS: NO 'BLDG ' PERMIT INVOLVED , COSTA MESA CA 92627 ***�L�E* *** *4(* EkE*�E , �E**�Eker x*�E�E***1(>E�E�E******>E****>E***>E*+t*** ESE****x*>F*>E****+e***** LICENSED CONTRACTOR DECLARATION: I hereby allirm that I am licensed under provisions of Chapter 9(commencing with Section ZONING REQUIREMENTS 70001 of Division 3 nt the Business and Professions Code.and my license is in full force and effect. SETBACKS CITY LIC.: 047477 STATE LIC.:547172 c ss: C , 0 _!a' `2..Y 9 Signature: pMAIN BUILDING ACCESSORY BUILDING Date: 7 - -jl FRNT; FT IN REAR; FT IN FRNT; FT IN REAR: FT IN WORKERS'COMPENSATION DECLARATION: I hereby affirm hat l have acenificale of consent to self-insure or a certificate of Workers' LEFT; FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN Compensation Insurance.or a certified copy thereof(Section 3800.Lab.C). POLICY NO.: EXP.DATE: PARKING REQ• PROV: PARCEL: 42614101 ZNE: REF NO: COMPANY: PLANNING NOTES> rl Certified copy is hereby turns a . 0 Cenified copy is filed with the city Building Division. > _ale; _ 4>"" G / Applican. DEVELOPMENT _•'S. E R V ICES REQUIREMENTS EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need not be completed it the permit is for one hundred($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 ZONING APPROVED BY DATE subject to the Workers'Compensation Laws of California. Date: id'2- y—"9/ signature: 4- BUILDING APPROVED BY ; DATE: NOTICE:If.atter making this declaration,you should beco a subject to the Workers'Compensation provisions of the Labor Code.you must forthwith comply with such provisions on this permit shall be deemed revoked. r CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED B Y: �� _ . ��► . _ _ DATE• __O 1 which this permit is issued(Section 3097.Civ.C). *'****'**********************.— f ********** - ** LENDER: *******************************4************ .** Bi * * ***************** ***** ***** ADDRESS: LEGALIZATION:N F E E SUMMARY 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: Any city of county which requires a permit to construct,alter,improve,demolish,or PERMIT 1850 • repair any structure.prior to its issuance,also requires the applicant for such permit to file a signed statement that he/she is licensed 5 0 3 SM I P/NON—RES pursuant to the provisions oI the Contractors'State License Law(Chapter 9(commencing with Section 701711)of Division 3 of the Business PLAN and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). ISSUE FEE • 15, 00 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE I, as owner of the property or my employees with wages as their sole compensation, wit do the work, and the TOTALS----> 18 , 50 15 . 00 0 .00 33 , 50 33 , 50 , 00 ❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'State License Law 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 or offered for sale.If.however the building or REVENUE DIVISION TOTALS--> COLLECTED: 33 . 50 OVER/SHORT; . 00 improvement is sold within one year of completion,the owner wit have the burden of proving he/she did not build or improve BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK for the purpose of sale). 33 , 50 I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business ❑ and Professions Code: The Contractors'State License Law does not apply to an owner of properly who builds or improves thereon *,*,*,*,*,*******,*,*,*,*****,*,*,*,*k*********************************************.*********.* and who contracts for such projects with a contractor(s)license pursuant to the Contractors'State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL F E E BREAKDOWN O I am exempt under Section: B.8 P.C. for this reason: TYPE QTY DESCRIPTIO N UNIT COST TOTAL COST Date: Owner: ELE 1 SERVICES BELOW 600 V & BELOW 201 AMP 18 , 50 18 . 50 I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505,25533.and END OF FEES 25534 and that I or any tutere building occupant Will/will not(circle one)need to comply with said state codes and the requirements for a permit for construction or modification from the Air Quality Management District.Residential construction applications are exempt from these provisions. Date: Applicant'. I hereby certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and slate laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned Date: y//Iprinspection purposes.(� V •Jni: ,-._, rt .�� Date.—[_v_� / N Signature: C, . x 'i. . Driver's License or Social Security a: / - 1641.46 White—Budding:Green—Code Enforcement;Canary—Applicant:Pink—Revenue:Goldenrod—Assessor li CONSTRUCTION AND PLANNING POOL °A Date Inspector Date Inspector APPROVALS Permit# APPROVALS Permit # I -. • 1. Ten porary Electrical Servite or Pole t;j 52. Pool & Equipment Location in ,t 2. s-,i Pipe-Undrgrnd. A': c453. Steel Reinforcement r ---a - L ^ i ,, 3. Electrical Conduit Utility-Undrgrnd. 1,'I 54. Forms 4. Electrical Conduit-Undrgrnd/ T �.. 55. Electrical Bonding '''.-- 5.'Steel i5.'Steel Reinforcement .1\ 56. Rough Plumbing & Pressure Test 6: Electrical UF ER Grnd. ' 57. APPROVAL TO COVER-GUNtTE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation , Gas Pipe, 0 Undrgrnd.,Test • l 1. '. 9. Water Pipe-Undrgrnd. 4 ./,, 60. Backwash Lines, P-Trap, 0 Undrgrnd. t. / 10. Structural Floor System 4. . 61. APPROVAL TO DECK ./. 11. Property Sewer Line & Houi'eft-Ponnection 62. Backwash & Receptor-Final 12. Sewer Cap it 63. Heater & Vent-Final - 13. Roof Drains .�- 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical-Final 15. Rough Electrical-Conduit 66. Solar System-Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT 20. Rough Factory Fireplace APPROVALS Permit # 21. Ducts,in Structure • 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil 1 23: Gas Pipe-Rough & Test - - 72. Underground Flush 24. Roof Framing 73. Undergrnd.Storage 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& Siding A - • 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall NailingHEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat i ,..t t x 79. FINAL INSPECTION 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED 777 /4I iel,e t 33. Final Electric i- Notes: - - 34. Final Heating & Air Conditioning Ai .i 1 35. Final Gas Pipe-Test - 7 /1 _ " • 36. Hood or Canopy .-' ' 37. Final Factory Fireplace N. • /� A _ 38. Final Plumbing . " ✓1/�• 39. Water Service-Final I ..t 40. Gas Service-Final ) 41. Solar Domestic-Final I 42. Backflow Preventer 1 I 43. Backflow Irrigation 44. Landscape Irrigation System • 45. Sound Attenuation • 46. Handicap Regulations -. 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 2, 49. Electric Release to Edison l; 50. Gas Release to Southern California Gas Co ,117/ 1\ 51. CERTIFICATE OF OCCUPANCY \ No. Date THIS PERMIT IS ISSUED - fr /COUNTY OF ORANGE SUBJECT TO ANY FEDERAL Q BUILDING DEPT.'. R�.gT g� 3 �Q �1 • 63.6 No. Broadway Appliciai °TforSBuilding Permit -Permit No Santa Ana, California Phone: KI 2-6211 AND FOR A Certificate of Use and Occupancy / 9 Dace �/r...v-sem % F/J�j�/ 1. OWNER'S NAME... .. __ _---- -- . ...-- --- PHON( ! 6)pZ MAILING ADDRESS.__./--)`' 6 V 46CL CITY 77 0 Name Name diet'......(Architect or Engineer) y /C, (� ots�attor ((// Address Address/e✓ , E. Zed �/r�s Jar City _ City - r15 ' " 64e- State StateQ/ ,�jC 41 CE Lie. No. Phone Lic. No.ll! ( V Phone"r"`�- PROPOSED USE: /+t 9_ �.-,cam �i� , 2. JOB LOCATION 2 .Q Z E y i — "' a `L� �-!/L� ›~ (House No.) S ©, ,,,,,,a,„,„, ,,„4„..47. �� '(Town or School District) 3. LEGAL DESCRIPTION: Lot x_ d921.612.01/ ract ' (Metes and Bounds Djes�` ptionLUs reserse side of 4. CORNER LOT ( V ) INTERIOR LOT ( ) �/ - NO. OF STORIES THROUGH LOT ( ) SLOPE OF LOT ( ) f4 -� q L 5. SIZE OF BLDG.: .Z'TJ-_ 3-a AREA- - 3 Sp 'v_.__SIZE OF LOT:.,1J__K,.L_C2O-AREA: _.7 O 0 0 6. HEIGHT OF BLDG.: _____7 1 CEILING HEIGHT:.___.__y - 7. NO. FAMILIES . Size of Smallest Bedroom: _/!--.�--// Size of Kitchen: _7 ^ / 0 L B. EXTERIOR WALL CONSTRUCTION INTERIOR WALL COVERING y �•.e�_ ._ria—. (Frame, Stucco, Etc.) (Plaster-Drywall, Etc. 9. SETBACKS: Front Yard from Center Line of Street 'CO t //G/V/ Nearest Side Yard__I NI __Rear Yard �� Distance in Feet Between Bldgs. on Same Lot 10. A COMPLETE PLOT PLAN IS REQUIRED, SHOWING ALL STRUCTURES AND USE OF EACH. v.-Z.' 4 ✓ 11. For (a) Footing: Width....///� Depth in Ground ,n-• Width of Wall Accessory h art (' /r�Siand (b) Size of Studs: ZX Spacing "CC Material of Floor Similar Structures: (c) Size of Floor Joists: Spacing "CC (d) Size of Rafters: Spacing "CC 12. VALUATION OF PROPOSED WORK: IngAi arbor, plumbing, electrical wiring, heating, fire sprinklers, paint- ing and sewage disposal $.___- ->�-__.77a- 13. I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE INFORMATION IN THIS APPLICATION IS CORRECT AND THAT THE CONSTRUCTION WORK WILL CONFORM TO ALL LAWS OF THE COUNTY OF ORANGE AND THE STAATEE(�OFF��CALIFORNIA APPLICABLE THERETO. Signed: �^ / �/ / Owner) Plans Filed• / - By:. (Authorized Agent) FOR DEPARTMENTAL USE ONLY FEES: CHHEE(CKKING BY Bldg. Permit - $.--Zit/e? GROUP _. ------ APPLICATION HEALTH Plan Check - $_.,., >..? -' rTYPE j FIRE Total - - - ___ 742.4::.42.4::. DIST. ZONING MARSHAL _ $ / MAP Cie/ PLANS AND Receipt No. - - J� SPEC'S STATE Paid to SHEET NO CORRECTIONS ENGINEER ---------------- Date ._... /- _b VERIFIED CAL it e-- PERMIT ISSUE BY,!:. COUNTY BUIUJII' G t DATE /- )* \sr-7 '.-..�1 G Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. PERMIT NO. TACT NS, LOT NO. UNIT NO. CITY OFCOSTA dress1MM�E��SAq SV- t- UJ(/TIONPERMIT 133lie1ck \ I w +1L' A.P.#. Zone (�I Project Address ng 410/ eS� a `a Sr'O. hr 10581_ - [ S Main Building: �aead+44.44 I) Accessory Building: Applicant's Mailing Address QAl sr S-T, TYPE OF CONSTRUCTION N W ADD U ALTERATION ❑ REPAIR E Z e� ❑ CONVERSION ❑ DEMOLISH ❑ OTHER ' T Front • 0 Owner's Name alt • < Phone /. DESCRIPTION OF WORK/USE OF BLDG. B Rear ap, 4o I• , N Address • _. _5-i- i r. v p ( 1 Arch/Eng. License No. TYPE OF PERMIT ❑ GRADING ❑ FOUNDATION El STRUCTURAL K Right V N Address ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL i $' Left R Contractor's Name Phone ❑ OTHER ',Ping. Ref.# Parking Req./Provided E 0 Address(mailing) PROJECT DESCRIPTION SQ. F7. OCCUPANCY vv Planning Notes: 6I x60 r LLB - .,it M CONSTRUCTION TYPE -. - VALUATION$ �Zhu T City License No. ZONE GRADING CU.YDS. ACRES S. LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: / _ O (^��s• �1 �'� �l� f with section 7000) of Division 3 of the Business and Professions Code, and CP -\ Ar+Ea. a my license is In full force and effect. - e (� ELECTRICAL FEES License Class License No. \J -k Date Signature PLUMBING FEES Automatic Washer Transformer ❑ 15-50 KW WORKERS'COMPENSATION DECLARATION Bar Sink Showers Construction Pole Sub. ❑ 50+KW I hereby affirm that I have a certificate of consent to self-insure or a certificate ' Workers' Compensation Insurance, or a certified copy thereof (SectionBackflow Preventer Service Sink Cooking Unit Meter ❑up to 100 amps 00, Lab. C.) .-olicy No. Company Backflow Irrigation Sewer Cap Dishwasher Meter Dover 100 amps 8 Certified copy is hereby furnished. Dryers ❑Gas ❑Electric Sub Panel Certified copy is filed with the city Building Division. Bathtubs Sewer Connection Date Applicant Fan Motors 00-1 HP 01''A-6 EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Clarifiers Solar Collectors essis section need not be completed if the permit is for one hundred ($100)orlDishwasher Solar Piping F.A.U. Inc.Solar 09-15 HP ❑16-15+ I certify that in the performance of the work for which this permit is issued I Fixtures shall not employ any person in any manner so as to become subject to the Drinking Fountains Solar Tank Microwave Workers' Compensation Laws of California. Device Boxes Date Signature Floor Drains Swimming Pool w/SpaPole Light NOTICE:If,after making this declaration, you should become subject to the e Outlets Ran Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks Urinal 9 comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet Switches Sign I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097 Civ. C.) Interceptors Water Heater Garbage Disposal Standing Sections . Lender's Name Generator 00-5 KW 05.15 KW Trash Compactor Lender's Address Kitchen Sink Water Service OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto-Wash following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct,alter,improve,demolish or repair P-Trap Laundry Trays any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/She is licensed pursuant to the provisions of Roof Drains the Contractor's License Law(Chapter 9(commencing with Section 7000) of •Division 3 of the Business and Professions Code) or that he/she is exempt Reinspection Fee $15 Issue Fee $ 3 erefrom and the basis for the alleged exemption. Any violation of Section 31.5 by any applicant for a permit subjects the applicant to a civil ity of not more than five hundred dollars($500). DEVELOPMENT SERVICES REQUIREMENTS:/J, as owner of the property or my employees with wages as their sole Reinspection Fee I $15 Issue Fee $ 3 Zoning Approved By Date �9 compensation, will do the work,and the structure is not intended or offered _ for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES Building Approved BYDate 8 License Law does not apply to an owner of a property who builds or improves e-z2 —e thereon, and who does such work himself/herself or through his or her own —� Application Issued By D k., Date employees, provided that such improvements are not intended or offered for Boiler Hood or Type I ❑ sale. If, however, the building or improvement is sold within one year of com- Canopy, Type II ❑ SUMMARY.DF FEES pletion, the owner will have the burden of proving he/she did not build or Int- Duct-Under Ground v". pjove for the purpose of sale). . BUILDING PERMIT $ 7 Cl SMTP• - $ 0 L I I, as owner of the property, am exclusively contracting with licensed con- Duct-Structural Refrigeration System PLAN CHECK $ ��gT PERMIT tractorsto construct the project (Section 7044,Business and Professions Code: - a. The Contractor's License Law does not apply to an owner of property who Duct-Ventilating 00-100,000 BTU ❑100,000 BTU PLUMBING $ ISSUANCE' $ builds or improves thereon.and who contracts for such oroiects with a con- $ ENERGY P.C. $ tractor(s) license pursuant to sne Contractor's License Law). I am aware that Exhaust System ❑ Multiple ❑ System Repair/Alteration I PLAN CHECK 25% proof of their Worker's Compensation insurance should be provided to me. ELECTRICAL $ GRADING $ ii 0 I am exempt under Section B.& P.C.for this reason Firepl/Fact.BIt. ICBO# Fire Dampers MICROFILM $ PLAN CHECK 50% $ �t Date - Owner Heating System& Ducting Registers s .3� MECHANICAL $ � -- I hereby certify that I have red t is application state that the above 00-100,000 BTU 0100.000 BTL - TOTAL FEE' $ ulPLAN CHECK 25% Information is correct. I agree to comply with all ci and county ordinances $ - and state laws relating to building construction,and hereby authorize repre- sentatives of this 'ty to en er up the above-men 'onetl property for Inspection pure Reinspection Fee $15 Issue Fee $ 3 Drivers' Licen e or SS# 01 00012569-00012571 TOT 48.35 0865-46,rev.5/88 White - Building: Canary - Applicant; Pink -Accounting; Goldenrod - Assessor DATE: 08/22/88 TIME: 1106 • CONSTRUCTION AND PLANNING POOI ''PA APPROVALS Permit Date Inspector APPROVALS Permit# _ Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pip✓:-Undrgrnd. 53. Steel Reinforcement t•( 3:;Electricql Conduit Utility-Undrgrnd. 54. Forms ll - 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5 Steel Reinforcement 56. Rough Plumbing & Pressure Test 62 Electrical UFER,Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8.'Foundation I • 59. Gas Pipe, 0 Undrgrnd.,Test i 9. Water Pipe-Undrgrnd. 60. Backwash Lines,P-Trap, O Undrgrnd. l 10.•Structufal Floor System 61. APPROVAL TO DECK 11.4 Property Sewer Line & House Connection 62. Backwash & Receptor-Final ; • 12.;Sewer Cap 63. Heater & Vent-Final I • 13. Roof Drelns 64. Plumbing System - Final 14. Rough Plumhing 65. Electrical-Final , 15. Rough Electrical-Conduit 66. Solar System-Final . 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling • 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT 20. Rough Factory Fireplace • APPROVALS Permit# 21. Ducts, in Structure 70. Underground Hydro 22.. Ducts, Ventilating 71. Product Piping 0 Gas ❑Oil 23. Gas Pipe-Rough& Test 72. Underground Flusht .24` Roof Framing 73. Undergrnd.Storage 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 & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing • HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat .' 79. FINAL INSPECTION 32. Electrical Power Mete)--Final ' 80. FOOD CERTIFICATE ISSUED 33. Final Electric • i Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe-Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing • 39.,Water Service-Final 40.'Gas Service-Final 41. Solar Domestic-Final 42. Backflow Preventer• c • 43. Backflow Irrigation ' I 44. Landscape Irrigation System to 45. Sound Attenuation: .� 46. Handicap Regulations /CTb ,/App Oj 47. FINAL STRUCTURE & BUILDING �� ( Dom _ �6 $ i `p g% o U c0& 48. Soec;al Requirements Completed 49. Electric Release to Edison 50• Gas Release to Southern California Gas Co " I 51. CERTIFICATE OF OCCUPANCY • I •' No. Date _ STREET e _ 1 a ^to APPROVED jwj bf , CITY OF COSTA MESA PLANNING DEPT. .)/ 1.........__._....„... BLDG. c t� 2 DATE..__aANNING , ^ e 0 ^ 0 ^ !a n n ti ^ •a ni es ^ City c, tint-4 Dc. • CPC.._... - arn.- tte �!! T;N,55 -)r `-- — — — — — —' � tTH[gID.C� , Q•l.l� 7r.`iCF L I. NO CH?, •(y, (tea • a THEA_:t'. ,n•> _�.a�n'� SPLANS r.. ,'"901 y Or ,.r.. !C. .i13N 0 n.":1 o �. PERMI' .:>. • • OC•• 'SUtA!NL 10 G ^ THE pn�•'IS!'J' '+I�<OU-.` :.:;SIC") CAT T! ^ AUTH:ie!. - •• ,a. �' inc WORK OR II: COOL r.T • - A. \\.......—.,._ r� - ...,...T . U;O PiA.$S AN;• THE "'• PE ;rtD:N:i OcyKIAt '0/A 1 tTtr.... ...0 11. :1':..3q. ERRORS IN ' D .h!•: .. -• .•.A-.10:: . LnOM PREVENTING ID 1,10 v'. - _ ,Tr2EUNDER WHEN ,. 'li%IN•:;iF�.. 'I.On � ",_;.r. ` ;:E11 ORDNANCE OF • C R _. STREET CIrT. • TYPICAL 6it CONCRETE BLOCK FENCE ® - CementCopingOptional :=7j . - ' , 1 GENERAL- NOTES i Channel Block With 1-3/80 t Horizontal Top of all - Fences . �� 1 MORTAR: One Part Plastic Cement, and Three Parts Sand For Fences 5'or Less °Q GROUT: One Part Cement Three and Vert.Bars 3/8"0 at 4'-0"O.C. rEl o ___-_ • I One Half Parts Stand COPING: One Part Cement Three For Fences Higher Than 5' °N i t I -, ' Parts Sand ° Vert. Bars 3!8"¢ at 32" O.C. > w CONCRETE: Well Mixed 1:2-I/2:3-1/2 Fill Cells Solid With Grout fi _ > ZWater Per Sack of Cement Where Steel Occurs > - JOH Max. of 7 I/2 Gallons of Reinforcing Steel Shall ' f °O • GROUT MAYBE POURED FROM THE TOP I • OF THE FENCE IN CELLS WHERE STEEL Conform to Sec.A-15-39 m 0 _ - -- OCCURS. A.S.T.M. IIi w ~ �ICELLS AND AREAS OFHORIZONTAL REIN- ll Steel to be Lapped is. __ FORCEMENT SHALL BE CLEAR,CLEAN& A An Or to Code I . FREE OF ALL MORTAR DEBRIS,ETC. 6 mi . i 1 ,,, NATURAL GRADE Sr J O 4 0 ' - TWO 3/B"OBARS 'TS07 Dn e _ .� • s •.. . CONTINUOUS TOP r &BOTTOM ` . I--**—WIDTH - TO 16 O.C. MAX. SEE CHART S -- ' 3fORMSTEEL MUST BE TIED IN BELOWa DEPTH OF EARTHTCOTH PLACE AT TIME OF TRENCH . _ . _ •el• •. * e. 1/3 THE HEIGTH OF FENCE INSPECTION. L + .t - - OW 'BOTTOM OF FOOTING. 1., • �-°^l o° 2.. +11* SCALE: 1/2" = I' • FOOTING REQUIREMENTS CHART WALL HEIGHT - 6 ' 5 4' 1 3' 1 . WIDTH 14" 14" i 12 . . 12 THICKNESS lo" . 10" 8 " 8 " DEPTH OF EARTHTOOTH . . . 24" : . . . . . . . . .20" 16" . . . . . . . . - 12" SPACING OF EARTHTOOTH. . 12' . 14' 16' - 16' City of Costa Mesa California OWNERS NAME /12L/ i- S ILSi- — -- — _ JOB ADDRESS. 3Q,2 /L-1' Si- _ 1 PERMIT NUMBER: Building Department SIGNATURE: • -_;•�_, 2evlseo Nov.az