HomeMy WebLinkAbout262 21ST ST - Building PermitsL_fY OF COSTA MES,_.,
CAUFORNIA 92626 P.O. BOX 1200
FROM THE OFFICE OF THE DIRECTOR OF BUILDING SAFETY
Project Address ::�'V 15-2 2�
Project Name z PCS
Owners Name /� r
Owners Address 6 2 "4�- ;4/ S %
Owners Telephone Z; 0
Permit # W3,f�
Type
City Use Only
I as Owner, Contractor, Agent (strike out all
except one) do hereby attest that employment of any person, or persons, is not
anticipated at the time of seeking the above -referenced permit. In the event that
any person, or persons, are employed under the provisions of this permit, I shall
immediately cause a valid Certificate of workmen Compensation to be filed with the
Costa Mesa Building Division.
I agree to defend at my own cost, and to indemnify and hold harmless, the City,
its officers, agents and/or employees, from and against, any and all liability,
damage, costs, losses, claims and expenses, howsoever caused, resulting directly
or indirectly from, or connected with the improvement under this permit.
I further state that I have read and fully understand the implication and re-
sponsibilities of the above statements, and will comply with all provisions of the
Contractors State License Law found under the Business and Professions Code,
Division 3, Chapter 9, of the State of California.
t� G��I IVT NeM
Signature
CMF 0777-46
X11 JO
Elate
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CITY OF COSTA MESA
t BUILDING DIVISION
> 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.costamesaca.0ov
°.� FOR INSPECTIONS CALL: (714) 7545626
PERMIT NUMBER: BC14-00923
PERMIT TYPE: B_COMBO STATUS: ISSUED
Sub Type: DEMO—ALL DATE ISSUED: 12/05/2014
ISSUED BY: CK
JOB ADDRESS: 262 21ST ST CM , s : ' Suite/Unit:
APN: 42615103 'i Zoning:
Vicinity: Primary Occ:
Const Type: V -B " SQ. FT: 0 Valuation: $300.00
SCOPE OF WORK: TAKINGCARE OF OVERGROWN DEAD GRASS IN PUBLIC VIEW, CAPPING OFF PLUMBING IN SECOND
UNIT. NOT COMPLYING TODEMO SECOND UNIT. -
OWNER: OWEN, WILLIAM L --' - Address: 262E 21ST ST
Unit: -q _ ...
Phone: City/State/Zip COSTA MESA, CA
APPLICANT: OWEN, WILLIAM L- Address: 262E 21ST ST
,k.-.
Unit
Phone: 9496426463 - City/State/zZip: COSTA MESA, CA
EONTRACTOR:- 1} License NO.
Phone:
Cell:
ARCHITECT:
ENGINEER: _ ?�, J
COMBINATION PERMIT FEE SUMMARY
Building Plan Check:
Building Fees:
Electrical Fees:
Mechanical Fees:
Plumbing Fees:
SMIP Residential:
SMIP Commercial:
Bldg: Std Admin Fund
TOTAL FEES:
^Refer to fee receipts for all fees paid for project
Address: Unit:
City/State:
License No. _
License No.
$0.00
$23.50
$0.00
$0.00
$33.30
$0.50
$0.00
$1.00
$58.30
ZipCode
PHONE:
PHONE:
Ir
HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279
Monday thio 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
{i1
r NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
„rggulations. (Ord. No. 92-28, § 1, 12-21-92)
'-EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
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INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
{:regtilied inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
_ICODE K. INSPECTION TYPE DATE INTRIALS CODE p INSPECTON TYPE DATE INTRIALS
Tl
.i 616 Fixed System Final Fire Prevention 206 Final Mechanical
1y1266 Pool Spa Final 208 Final Plumbing 'M, Iy'%/�''i'r-
FkO Final Re -Roof 210 Final Electrical /J /-tA•AF
`.201,. Final Block/Retaining Wall 212 Final Fire Prevention
X202. Final Factory Fire Place 220 Final Planning Approval
1203 -' Final Sign ,',,/'' 222 Final Site
A
=2�4 Final Demolition 250 Final Building/Occupancy
I
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -Insure for workers'
compensation, as provided for by section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
❑ 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 worker; compensation Insurance carrier and policy
number are:
Carrier:
(Thin def%CYI reef nat be empbted date Pm is rakedal ane fumaked dofers($100)xresaj
Policy Number.
❑ I certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as 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 oompty with these provisions.
Applicant's Signature
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and
my license is in full force and effect.
Class #
ContractWa Signature Date
CONSTRUCTION LENDING AGENCY:
❑ 1 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 Data
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).):
,W,[ 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 appy to an owner of
property who builds or improves thereon, and who contracts for such project with
a contractors) license pursuant to the Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code for this reason:
��, tom' r a -S I
sg6w. Date
305746 (3107)
Owner ID verified by driver's license. Gj�fes ❑ No
Drivers License No. Expires: r�^
Verification of Ownership by (type of ocument, 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, Tide 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.
Applicant's signature Data
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant need to file and
certify a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some
exceptions, that a Business Plan be filed with the Costa Mesa Fire Department
by every business which has at any one time during a reported year a quantity
of hazardous materials equal to or greater than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
temperature and pressure).
2. Does or will the applicant or present or future building occupant need to file
a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some
exceptions, requires registration with the Costa Mesa Fire Department by each
business which at any one time has on hand a quantity of acutely hazardous
materials equal to or greater than a weight of 500 pounds, or a volume of 55
gallons, or 200 cubic feet of compressed gas at standard temperature and
pressure).
3. Does or will the applicant or present or future building occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the
Costa Mesa Fire Department may require the preparation, certification and
filing with the Fire Department of an RMPP by businesses which are required
to register acutely hazardous materials with the Fire Department.
4. If an RMPP is presently required, has Section 25534 of the California
Health and Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or will the applicant or present or future building occupant require for
the work which is the subject of this application a permit for such construction
or modification from the South Coast Air Quality Management District or from
any other air pollution control district or agency? ❑ Yes ❑ 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? ❑ 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. 1 agree to comply with all state laws and
city ordinances regarding Hazardous Materials and Emissions.
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 jjs Quit until` naajnspection. /'—, .r'&
Signature of Legal O"er(s) Date
Ai Ior Authorized Applicant Data
C,
Costa Mesa
VIOLATION NOTICE
CODE ENFORCEMENT DIVISION
P.O. BOX 1200,77 FAIR DRIVE (2ND FLOOR)
CALIFORNIA 92628-1200
To: Wi I 11`0 M a &A Date: q&141/4
i
C,
ala 4 i - GM '1 j 7,W76ase#: CA%� ^b�
Location: �� �I 14 • lilil 02i02,7
As part of our continuing program to preserve and improve our residential and business community, I observed the
following violation(s) of the Costa Mesa Municipal Code (CMMC):
In
■
H■
Conducting business not consistent with terms of Planning approval
or C.U.P. (CMMC 20-12(ii))
Conducting business without a city license and Zoning approval
(CMMC 20-12(hh))
Illegal storage in public view (CMMC 20-12(e))
Storage of inoperative vehicle or parts thereof
(CMMC 20-8(a))
Living in garages or commercial/industrial unit
(CMMC 20-12(n))
Outdoor work, storage or display without a permit (CMMC 13-44)
Outdoor work/industrial (CMMC 13-53)
Violation of home occupation standards (CMMC 13-168)
Use of residential yard areas for parking/storage of vehicles
(CMMC 20-8(c)(6))
Portable signs on private or public property (CMMC 13-112(g))
Flags, banners and pennants not in compliance with code
(CMMC 13-112(d))
Living in trailer or RV (CMMC 20-12(m))
Deteriorated or peeling paint (CMMC 20-6(d))
to: 111
Failure to corrYfft the
❑ Use of tarps or temporary canopies in public view
(CMMC 20-6(c))
❑ Deteriorated building exterior or roof (CMMC 20-6(b))
❑ Broken windows and glass doors (CMMC 20-6(g))
❑ Deteriorated walls, fences, trash enclosures (CMMC 20-60))
�❑/ Deteriorated parking areas and sidewalks (CMMC 20-6(k))
p� Dead or dying landscape, weeds, overgrown vegetation in R1 zone
1/\ (CMMC 20-6(n))
❑ Dead or dying landscape, weeds, overgrown vegetation in parkway
(CMMC 20-6(o))
❑ Dead or dying landscape, weeds, overgrown vegetation (all zones
except R1) (CMMC 13-108[a])
❑ Street numerals displayed in prominent location
(CMMC 20-6(t))
CBC 105.1 Building permits required
Pushcart/sidewalk vendors (CMMC 9-191(a))
❑ Garage sale permit (CMMC 13-30(9))
❑ Other: CMMC §
I
in the next progressive step in enforcement, in which1
you may be issued an Administrative Citation. If you have any questions regarding this notice, please feel free to contact 1
me at (714) 754-�226r (a:DCOSTAMESACA.GOV. The City appreciates your cooperation
and staff looks forward to working with you to resolve this matter.
1 2�I ?no)"020cft- 6^4JI,14 *12 x
Code Enforcemeni Officer I.D. # Violator's Signature
Print First and Last Name
Building Division (714) 754-5273 • Code Enforcement (714) 754-5623 • Planning Division (714) 754-5245
FAX (714) 754-4856 • TDD (714) 754-5244 • w .costamesaca.gov
City of Costa .Mesa Bui(,ding Division"
77 Fair Drive, Costa Mesa, CA 92626
Costa Mesa 714-754-5273 / Fax 714-754-4856
OWNER BUILDER VERIFICATION
Permit # eG lel-00 uj
Disclosures & Forms for Owner- Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been su mitted in your me listin yourself as the builder of the
property improvements specified at (02 2rr Sc�
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you
aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of
each provision, signed, and returned this form to us at our official address indicated. An agent of the
owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting
authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
b/l(l. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Builder' building permit that erroneously implies that the property owner is providing his or her own labor and
material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any
injuries sustained by an unlicensed person and his or her employees while working on my property. My
homeowner's insurance may not provide coverage for those injuries- I am willfully acting as an Owner -Builder
and am aware of the limits of my insurance coverage for injuries to workers on my property.
1�42. 1 understand building permits are not required to be signed by property owners unless they are
responsible for the construction and are not hiring a licensed Contractor to assume this responsibility.
&vd3. I understand as an "Owner -Builder' I am the responsible party of record on the permit. I understand that
Fm -ay protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his
or her name instead of my own.
W4. I understand Contractors are required by law to be licensed and bonded in California and to list their
license numbers on permits and contracts.
Ni 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors,
and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may
be {,considered an "employer" under state and federal law.
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state
and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and
contribute to unemployment compensation for each "employee." I also understand my failure to abide by these
laws may subject me to serious financial risk.
WO 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed
by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of
the work is performed under contract with a licensed general building Contractor.
3148-30 CALBO Jan 1, 2009 OB Packet template 1 of 2
&8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable
for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent
construction defects in the workmanship or materials.
�6. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit
Payments, and the California Division of Industrial Accidents. I also understand I may contact the California
Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information
about licensed contractors.
Ao /10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand
that I am the party legally and financially responsible for proposed construction activity at the following address:
WO 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will
abide by all applicable laws and requirements that govern Owner -Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the
public. If you contract with someone who does not have a license, the Contractors' State License Board may be
unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against
unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed
Contractor or employee of that individual or firm is injured while working on your property, you may be held
liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible
for verifying whether or not those Contractors are properly licensed and the status of their workers'
compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner
and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's
driver's license, form notarization, or other verification acceptable to .the agency is required to be
presented when the permit is issued to verify the property owner's signature.
Signature of property owner
(/Uv� /Ci
Date: 12-
Note:
L
Note: The following Authorization Form is required to be completed by the property owner only when
designating an agent of the property owner to apply for a construction permit for the Owner -Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility
hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents
necessary to obtain an Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled
out the above information and certify its accuracy. Note: A copy of the owner's driver's license, form
notarization, or other verification acceptable to the agency is required to be presented when the permit is issued
to verify the property owner's signature.
Property Owners Signature:
Date:
3148-30 CALBO Jan 1, 2009 OB Packet template 2 of 2