HomeMy WebLinkAbout243 22ND ST - Building Permits Property Profile Page 1 of 1
Property Profile
C 2003 DataQuick Information Systems
This information is compiled from public documents and is not guaranteed. •
Primary Owner: AMMERMAN,MARK & SONJA -
Secondary Owner:
Mail Address: 243 E 22ND ST
COSTA MESA, CA 92627
Site Address: 243 E 22ND ST
COSTA MESA, CA 92627
V'4
Telephone
$7.7.77,:[. Ab' Number:
6,'$.'M? <4 x� r AI'N: 426-144-11
N2.;..t V.if., i 'AllReference APN:
rCALIFORNIA , ,,yfl'
Census Tract: 632.014
Housing Tract 516
Geo Level:o Number:
Lot Number: 283
Page Grid Old: 31-E2
Page Grid New: 889-B2
Legal Description: NEWPORT HEIGHTS LOT 283 N WLY 50 FT SELY 100
FT IN LOT-EX SWLY 150 FT-
Subdivision:
Property Characteristics
Bedrooms: 1 Y ar Built: 1946 Square -(eta )
Bathrooms: 1.0 G. Lot Size: 7,500 sq ft/0.17 acres
Total Rooms: 3 Fireplace: Number of Units: I
Zoning: Pool/View: Use Code: Vacant Residential
I-Ieating/Cooling:
Sale & Loan Information
Transfer Date: 04-17-1998 Seller: Document: 0000232353
Transfer Value: $205,000 Cost/Sq Feet: $284.72 Title Co.: First American Title
First Loan Ann:$164,000 Lender: Pff Bank& Trust Last Trans W/O$:
Loan Type: Interest Rate Type: V Last Trans W/O$ Doc:
Assessed& Tax Infornmtion
Assessed Value:$221,576 Percent Improvement: 7.70 Homeowner Exemption: Y
Land Value: $204,515 Tax Amount: $2,501 Tax Rate Area: 15044
Improvement Value:$17,061 Tax Status: current
•
[ Report Menu J
[Select New Target Property]
05Tp MFS CITY OF COSTA MESA
�L 9'
rte'•. P.O. BOX 1200 • 77 FAIR DRIVE • CALIFORNIA 92828-1200
1',4 N•74-ottico. 1.
,V Oi DEVELOPMENT SERVICES DEPARTMENT
✓a'
-q>axeRa\9('
•
•
Building Division(714)754-5273 • Code Enforcement(714)754-5623 • Planning Division(714)754-5245
FAX(714)754-4856 • TDD(714)754-5244 • www.ci.costa-mesa.ca.us
-
�c CITY OF COSTA MESA
4�� ►9 BUILDING DIVISION
arsi '` r 1 DEVELOPMENT SERVICES DEPARTMENT '' PE MIT NUMBER
F ( r f...::+ a 1
/ PERMITJ. " - B02-01093
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.c p51LDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 243 22ND ST U Status: ISSUED
Suite: Applied: 07/18/2002
Vicinity: Issued: 02/18/2003
Parcel Number: 42614411 Zoning:
Applicant: AMMERMAN, SONJA ISSUED BY:
Address: 243 E 22ND ST
Phone: 949-515-8032
COSTA MESA,CA Zip: 92627-1811
Owner: AMMERMAN; MARK
Address 243 E 22ND ST
Phone:
COSTA MESA,CA Zip: 92627-1811 - ,
Contractor:
Address:
Phone:
Zip: License:
Arch : DAVID COE WHEATLEY, AIA Eng:
Address: 881 SOUTH COUNTRY GLEN'WAY Address:
Phone: 714-281-2776 - Phone:
ANAHEIM HILLS,CA
Zip: 92808 License: C8150 License:
SCOPE OF PERMIT
CONSTRUCT NEW 2815 SF TWO-STORY SINGLE FAMILY RESIDENCE(1936 SF FIRST FLOOR AND 879SF SECOND FLOOR)WITH 631 SF
ATTACHED GARAGE AND 84 SF FRONT ENTRY PORCH.RESIDENCE WILL INCLUDE 3 BEDROOMS,2 BATHS AND A FIREPLACE.
EXISTING RESIDENCE TO BE DEMOLISHED UNDER SEPARATE PERMIT.
ZA-02-78
-
•
FEE SUMMARY
Plan Check: $1,217.42 Calc Valuation: $256,234.08
Permit: $1,872.95 Claim Valuation: $o.00
SMIP Res: $25.62
SMIP Corn: $0.00
Other: $0.00
Inspection: $0.00
Total: $3,115.99
PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front 20-0 Rear 26-0 Left 12-0 Right 4-7
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0
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 i .. •
WORKERS'COMPENSATION DECLARATION:
I hereby affirm underpenalty of pe#•gry one of the following declarations: !• y
❑ I have and will maintain a certificate of consent 10 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' pensation Insurance,as required by section 3700 of the Labor Code,for the performance of the wo for which thG permit is issued.
My workers'C mpley' Ion Insur riser and policy number are:
Carrier: y /wk' Policy Number: CA Ai-e-\
This section nee o b completed the permit is valued at one hundred dollars($100)or less.)
'certify that in the performance of the work for which this permit is Issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,and a that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these ns. - 1 J7�
Applicant Signature: A./Y�—� 2 Date: i
WARNING:FAILURE TO SECURE WORK 'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADD N 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 lull
force and effect.Lic.# Class N
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she Is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a 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 properly who builds or improves thereon,and who does such work
hims If 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
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 C.•rectors License Laws.).
❑ I am ex:.-- nder'sec Business and Professions Code for this reason: `7
Signature: taArs. `.I£ ►►s s ...
- D:t:: ai`11Lia
Owner ID van by S rs license,~ es ❑No Drivers License No. Expires: ,dilin.so
Verification of Owners •by(type..Gr ument,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 W III 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 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP Is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑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? 0 Yes LI No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑No
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 AN a •I THORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all s .te I ws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-describe ny for igspe,tion t rposes.I agree not to occupy or allow occupancy of any building authorized by this permit �11 final in pectio_ n.
11n e �-- Lid (v�Cr)
Ignature Of Legal Owner(s Date
nd/Or Authorized Applicant Date
CODE I INSPECTION TYPE QTR INTt11AL5 CODE! INSPECTION TYPE PATE MAL$
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 ,
`-r-0
204 Final Demolition ' ' C 250 Final Building/Occupancy `*'0-
NEWPORT-MESA UNIFIED SCHOOL DISTRICT N2 4225
CERTIFICATE OF COMPLIANCE OF DEVELOPMENT FEES
PURSUANT TO AB 1600 AND AB 181
To: ( City of Costa Mesa District Receipt Notal-Z-19')
( ) City of Newport Beach „�
( ) County of Orange Plan Check No.. V O'eq.:
Applicant: h/L( —
Address: 2 T n kick_
Telephone Number: C ^ SI 2'03
Tract/Parcel and Lot Number(s):
Location of Project: //7 vi N�
Number of Square Feet of: ���/}
Residential Space c J 1 `/ x $1.84 Total 3 8'5
(caetcfte,,z_Ajfit-, X06 .
Commercial and
Industrial Space x 3.30 Total
Commercial/Industrial Project is: (Check One)
Warehouse _ Motel _ Preschool
R & D _ Bank _ Auto Repair
Movie Theater _ Neighborhood Shops _ Hospital
Mini-storage Racquet/Health _ Large Office
Heavy Industrial _ Hotel _ Office Bldg.
Regional Shops _ Medical Office _ Restaurant
Light Industrial _ Office Park _ Fast Food
This project is exempt because
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. /)i�
i •road Re, - rdatNe
The above representation as to square footage is true. Applicant agrees that if R is later determined that such representations are not
true, then this certificate shall automatically terminate and the appropriate C County shall be notjte@d18 2883/11:83 NN/1 3854 8Q
qi,i01T - 1124218
Date: al /L.-V/1x
' ' ' " INSULATION CER FICATE ®z —o% 53 IC-1
Number and Street City
County Subdivision Lot Number
Description of Installationion „e`W �i er r
1. ROOF n
Material 64 1-÷- Brand Name 7 ft-
Thickness
L._Thickness(inches) /2" Thermal Resistance (R-Value) $O
2. CEILING y—
Batt or Blanket Type gt �- Brand Name :#5— it-11
Thickness (inches) 4'" Thermal Resistance(R-Value) /Z
Loose Fill Type Brand
Contractor's min installed weight/ft2 lb Minimum thickness inches
Manufacturer's installed weight per square foot to achieve Thermal Resistance(R-Value)
3. EXTERIOR WALL
Frame Type
A. Cavity Insulation
Material tiA 7 1 4' Brand Name 71.1"-
Thickness(inches) i rr Thermal Resistance(R-Value) /5 •
B . Exterior Foam Sheathing
Material Brand Name
Thickness(inches) Thermal Resistance(R-Value)
4. RAISED FLOOR
Material riFfe Brand Name �
Thickness (inches) ( a Thermal Resistance(R-Value) ref
5. SLAB FLOOR/PERIMETER •
Material Brand Name
Thickness (inches) Thermal Resistance(R-Value)
Perimeter Insulation Depth (inches)
6. FOUNDATION WALL
Material Brand Name
Thickness (inches) Thermal Resistance (R-Value)
Declaration
I hereby certify that the above insulation was installed in the building at the above location in conformance with the current
Energy Efficiency Standards for residential buildings(Title 24, Part 6, California Code of Regulations)as indicated on the
Certificate of Compliance, where ap licable.
' 8131 a`f
Item #s Signa4, Date Installing Subcontractor(Co.Name)OR
General Contractor(Co.Name)OR Owner
Item #s Signature, Date Installing Subcontractor(Co.Name)OR
General Contractor(Co.Name)OR Owner
Item #s Signature, Date Installing Subcontractor(Co.Name)OR
General Contractor(Co.Name)OR Owner
Revised March 1, 1996
E CITY OF COSTA MESA
4cAptibzo BUILDING ,DIVISION
• . DEVELOPMENT SERVICES DEPARTMENT PER NUMBER
�: PERMIT
0,111 Stbosano fi, 03-00266
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.c_a.us
BUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 243 22ND ST tS Status: ISSUED
Suite: Applied: 02/18/2003
Vicinity: Issued: 02/18/2003
Parcel Number: 42614411 Zoning:
Applicant: AMMERMAN, MARK ISSUED BY: 4--� —
Address: 243 E 22ND ST
Phone: 949-515-8032
COSTA MESA,CA Zip: 92627-1811
Owner: AMMERMAN, MARK
Address 243 E 22ND ST
Phone:
COSTA MESA,CA Zip: 92627-1811
Contractor:
Address:
Phone:
Zip: License:
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
DDEMOLISH 720 SQ. FT RESIDENCNO GARAGE.APPLICANT HAS CONTACTED THE AQMD AND HAS COMPLIED WITH THE
REQUIREMENTS FROM AQMD.
. FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $2,000.00
Permit: $69.25 Claim Valuation: $2,000.00
SMIP Res: $0.00
SMIP Corn: $0.00
Other: $0.00
Inspection: $0.00
Total: $69.25
PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0
PARKING Existing: 0 Required: 0 Proposed: 0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related
regulations.(Ord. No.92-28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
vial 11'1cTiIC•1;61111a
WORKERS'COMPENSATION DECLARATION: '
I hereby affirm under penalty of perjury one of the following declarations: 4 I • . '• •
❑ I have and will maintain a certificate of consent to self-Insure for workers'ccrPWWnsation,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 sectid- 700 of the Labor Code,for the performance of the work or whigh this permit is issued.
My workers'compe(nsan1 Insurance 'finer and policy number are:
'wrier: y omp ntilk Policy Number: �l;•VV/V)V
is section need nude camp shed if fhuyormit is valued at one hundred dollars($100)or 1814
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 ol California,and a e that if I should become subject to the workers'compensation provisions of Section 3700 f the La r Code,I shall forthwith
comply with the-: v' '.ns.
Applicant Signature: Xrr 0. �
. .� Date: ,a
WARNING:FAILURE TO SECURE W•- RS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIE AND CIVIL FINES�ONE HUNDRED
THOUSAND DOLLARE($100,000),IN A•• ION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am 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.Lie.# Class#
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a 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 Cont -"ors License Laws.).
❑ I am :g:- •t under sec. Business and Professions Code for this reason: J (C' pA _
Signature: t.._.� 1-i�.I a .as • - .ate_ o the: Ll l n l/V
Owner ID ve ed by drive. licens:-~es 0 No Driver's License No. ( Expires: n/---,
Verification of Ownership " (type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec,
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes ❑No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑No
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this 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? 01 Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑No
(If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes . El No
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-des ' property f�r insp tior,purposes.I agree not to occupy or allow occupancy of any building authorized by this permit u II final i peDtion.
Signature Of LegallOwner(s) �� Date U
And/Or Authorized Applicant
Date
CODE 0 IIISPECTION TYPE DATE IRrrALS CODE 0 INSPECTION TYPE PATE INTTML$
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 " L'/ 222 Final Site
204 Final Demolition )-- 3-0Y 6,44-
1�`�'Tr 250 Final Building/Occupancy . • - te----ree
•
WI 41
Environmental Monitoring Group
FINAL. REPORT
For
ASBESTOS CONTAINING-MATERIALS (ACM)
Prepared for
SONJA AMMERMAN
243 22"Street
Costa Mesa, CA 92627-1811
Located At
RESIDENTIAL. PROPERTY
243 22ne Street
Costa Mesa, CA
EMG Project Number: SA328518
Prepared by
ENVIRONMENTAL. MONITORING GROUP (EMG)
7500 SUZI LANE
WESTMINSTER, CA 92683
Reviewed by
CAI,- OSHA CERTIFIED SITE SURVEILLANCE TECHNICIAN
CSST #97-2186
TM A. Doan --
Approved by
John ' am, Op; ations Manager
J. ary 23, 2003
DBE AIHA AAR ELPAT
ENVIRONMENTAL CONSULTANT
7500 SUZI LANE., WESTMINSTER, CA 92683 • TEL: (714) 893-5166 FAX: (714) 893-5872
TABLE OF CONTENTS
Page
1.0 Scope Of Work 3
2.0 Building Description 3
3.0 Inspection Introduction And Investigative Methods 3
3.1 Procedures And Methodology 3
3.2 Laboratory Analytical Methods . 4
4.0 Results Of Investigation/Findings And Recommendations 4
5.0 Assessment 4
5.1 Recommendations 5
6.0 Inspection Limitations 5
7.0 Conclusion 6
C 2
Envuo rme nil Monnorina Group
1.0 SCOPE OF WORK
The purpose of an asbestos-containing materials (ACM) survey is to identify,
characterize and quantify the presence of ACM in the interior and exterior spaces of the
building on a property. The survey results will he used to assess and to properly manage
the abatement work in the building areas. Other reasons for the survey are to evaluate and
to ensure occupants/workers safety and compliance with regulatory requirements and to
manage the handling of asbestos containing-materials for demolition work at the site.
On January 17. 2003, Environmental Monitoring Group (EMG) conducted surveys for
suspect ACM at a residential property located on 243 22i° St., in the city of Costa Mesa.
California.
2.0 BUILDING DESCRIPTION
The subject site is a single-story home with an extended room. For the purpose of this
inspection and sampling, the building materials in each locations/areas were considered
to he homogeneous.
The house is constructed of wood frame on a concrete slab foundation. Its interior
consists of hardwood floor. some marble floor tile, sonic carpet. plaster walls and ceiling,
and drywall wall and ceiling as well. The exterior walls consist wood siding. 'The
roofing material is composition shingle roofing on the main house and cap sheet rooting
w/ rock on the extended portion.
3.0 INSPECTION INTRODUCTION AND INVESTIGATIVE METHODS
The visual inspection, sampling and assessment were completed on January l i, 2003, at
the above mentioned property site.
Cal-OSHA Certified Site Surveillance Technician Mr. Tim Doan performed the hulk
sample collection for ACM.
All Bulk samples for ACM were submitted for analysis by polarized light microscopy
(PLM) to In-house EMG Laboratory. an All-IA accredited laboratory. Certifications are
available upon request.
3.1 PROCEDURES AND METHODOLOGY
The inspection included visual examination and sampling of suspected ACM in the
building. Observations were made regarding the condition. friability and accessibility of
the materials. The strategy used for ACM bulk sample collection was consistent with the
guideline in Chapter 2 of EPA. "Purple Book", EPA 560/5-85-024. Guidance for
Controlling .Asbestos-Containing Materials in Buildings. 1985. and OSHA 29 CFR
WIC 3
E.m,mmemal Noniiuur(rnir
. W. MC
Environmental Monitoring Group •
CERTIFICATE OF POLARIZED LIG IT MICROSCOPY
ANALYTICAL REPORT
CLIENT NAME: SONJA AMMERMAN EMG Project #SA328518
243 22nd Street
Costa Mesa, CA 92627
PROJECT SITE: Residential Property
243 22nd Street Date Reported:01/23/03
Costa Mesa, CA
The following samples of materials suspected of containing asbestos were collected from the locations listed below and
analyzed for asbestos content. Percentage and type of asbestos were determined by using the principles of Polarized light
Microscopy and dispersion staining, using NIOSH approved Method7403. The method is further defined in the E.P.A.
600/M4-82-020, "Interim Method for the Determination of Asbestos in Rulk insulation Samples". The results, dates and
locations of the samples are listed in the report below.
Type Of I Asbestos I Total Fibrous Total Nonfibrous
•
Sample no. Lab no. Sample Date I Sample Location Material I Mineral Type f Non•Asbestos Non-Asbestos
Mineral Types Mineral Type
01 28812 01/17/03 Living Room Plaster None Detected 5-10% 85-90 %
Wall
02 28813 01/17/03 Bedroom Drywall & Joint None Detected 15-20% 75-80%
Wall Compound
II
03 28814 01/17/03 Bathroom Drywall & Joint None Detected 15-20 % 75-80 %
Wall Compound
Page: 1
DBE AIHA AAR ELPAT
ENVIRONMENTAL CONSULTANT
7500 SUZI LANE., WESTMINSTER, CA 92683 • TEL: (714) 893-5166 FAX: (714) 893-5872
.
CERTIFICATE OF POLARIZED LIGHT MICROSCOPY
ANALYTICAL REPORT
PROJECT SITE: Residential Property EMU Project #SA328518
243 22nd Street Date Reported:01/23/03
Costa Mesa, CA
ITotal Fibrous Total Nonflorous
Sample no. Lab no. Sample Data Sample Location Tyne Of Asbestos Non-Asbestos Non-Asbestos
Material Mineral Type Mineral Type Mineral Type
04 28815 01/17/03 I Kitchen Plaster None Detected 5-10 % 85-90%
Wall
05 128816 01/17/03 Extended Room Drywall& Joint None Detected 15-20 % 75-80 %
Wall Compound
06 28817 01/17/03 Composition Shingle Roofing Core Roof None Detected 40-45 % 50-55%
Front Composite
07 28818 01/17/03 Composition Shingle Roofing Core Roof 1 None Detected 40-45 % I 50-55%
Center Composite II
I l
08 28819 01/17/03 Composition Shingle Roofing Core Roof Nene Detected 40.45 % 50-55%
Rear Composite
09 28820 01/17/03 Cap Sheet Roofing w/ Rock Core Roof None Detected 40-45% 50-55%
Over Extended Room Composite
Page:2
Fmnmmenul Menirurmt Croup
i
•
CERTIFICATE OF POLARIZED LIGHT MICROSCOPY
ANALYTICAL REPORT
PROJECT SITE: Residential Property EMC Project a SA328518
243 22nd Street Date Reported:01/23/03
Costa Mesa, CA
•
Type Of ITotal Fibrous Total Nontlbrous
Sample no. Lab no. Sample Date Sample Location
Material Mineral eNon-Asbestos Non-Asbestos
Type Mineral Type Mineral Type
10 28821 01/17/03 I Cap Sheet Roofing w!Rock Core Roof None Detected 40.45 % 5C-55%
Over Laundry Room Composite
11 28922 01/17/03 Cap Sheet Roofing w/Rock Roof Mastic Chrysotile 5-10% 30-35% 55-60%
Roof Penetration I
12 28823 01/17/03 Cap Sheet Roofing w/Rock Transite Flue Chrysotile 35-40 % 10-15 % 40-45%
Roof Heat Exhaust
›ertOALM‘sav•
Sean Tran
Laboratory Analyst
Note: Our pulley is:o dispose or samples unless written notification is received in our office oithin 30 dais of this report
Page. 3
112
WC
Emnwnenul Nmdang Group
1926.1101 concerning building inspection and hazard assessment for asbestos. Bulk
samples of homogeneous materials that were suspected ACM were collected. A
homogeneous material is defined as a surfacing material, thermal system insulation, or
miscellaneous material that is uniform in color, texture, use, construction/application
date, and general appearance.
Typically, at least three bulk samples were collected from each homogeneous area, if the
material was greater than 100 square feet. As these materials were identified. bulk
samples were collected and properly placed into individual sampling containers and
assigned with sample numbers and submitted under chain-of-custody procedures to the in
house laboratory.
3.2 LABORATORY ANALYTICAL METHODS
All samples submitted for analysis were analyzed by Polarized Light Microscopy (PLM)
with dispersion staining as described by the "Interim Method for the Determination of
Asbestos in Bulk Insulation Samples", NIOSH Method 7403 (Federal Register/Volume
47, No. 103/May 27, 1982) and 40 CFR 763, Subpart F. Appendix A CAMERA). This is a
standard method of analysis in optical mineralogy and a definitive method the
determination of asbestos in Bulk Sample. A suspected material is immersed in a solution
of known refrative index and subject to illumination by Polarized Light Microscopy. The
characteristic color display enables mineral identification.
4.0 RESULTS OF INVESTIGATION AND FINDINGS
A total of 12 samples were submitted to the Laboratory, and 02 samples were found to
contain asbestos. Material containing more than 1% asbestos by weight is considered
Asbestos Containing Material at the Federal Level and those materials identified to
contain "trace" amounts or more than one tenth of one percent asbestos are considered a
regulated materials at the State Level. When "None Detected" (ND) appears in this
report, it should be interpreted as meaning that no asbestos was observed in the sample
material.
Table of ACM
Affected Areas
Roof Mastic ) Penetration &Patching 10 stun. �,
Transite Flue Roof Heat Exhaust 1-flue
5.0 ASSESSMENT
Most of the areas that were inspected see Table of ACM above, are found to be in good
condition and do not requires an immediate repair and/or removal.
MSC 4
EnvirmxmY~wing Group
I
None of the material discovered is considered"friable". Friable is defined as "a material
that can be crushed by hand pressure".'Accessible friable materials may have a greater
potential for asbestos fiber release if disturbed compare to "non-friable" material such as
flooring materials.
5.1 RECOMMENDATIONS:
CMG's recommended the following actions:
A. Notify Contractors and Subcontractors working in the building. The State of
California requires this notification. The notification can be in the form of a letter,
example: "The roof mastic material throughout this site contain asbestos. It is
your duty not to disturb these materials in any way. If the materials becomes
damaged, you must notify the Safety Section immediately."
Notification to contract workman must be made and a statement that they have
read and understood the presence of asbestos in the identified areas in the building
and they are not to disturb these materials.
B. Use a certified and license asbestos abatement contractor to perform any removal
of ACM prior to any demolition activity that will disturb the materials. Also, an
industrial hygienist must be present to perform engineering control and regulatory
asbestos air monitoring during any abatement project. The South Coast Air
Quality Management District (SCAQMD) has strict rules regarding how ACM is
removed and mandates a 10-days notification and the use of a certified abatement
contractor for removal of > 100 square feet of ACM (Rule 1403). Notify the
SCAQMD 10 working days prior to the ACM removal. In an emergency, the
District may grant a 24 hours notice.
6.0 INSPECTION LIMITATIONS
The survey was performed using the degree of care and skill ordinarily exercised under
similar circumstances by reputable environmental consultants practicing in this or other
localities, The information in this report is deemed reliable, but there cannot be guarantee
that all hazardous materials and conditions have been located or identified.
The findings and areas of investigation are based on visual observations and limitation of
the access to the areas/locations during the inspection. Materials and conditions, which
are concealed or are inaccessible, may not have been discovered. No other samples were
taken for other Materials except as noted in this report. Sampling was performed on a
random basis and all material sampled was assumed to he homogeneous. The possibility
exists that material composition may differ from the sampling location.
e 5
E watt.'watt.Gap
7.0 CONCLUSIONS
The asbestos containing-materials that were discovered arc found to be in good condition
and do not pose an exposure hazard at this time. However, if future damage occur, action
must he taken as mentioned above.
The asbestos containing-materials listed in the Table of ACM shall be removed and
disposed of prior to any demolition work in the building. All removal, disposal and
handling of these asbestos containing materials shall he in accordance with Federal. State
and Local agency ordinances, laws and regulations.
ill
F.nvnmmepul MOMwm((nmip
• -vs CITY OF COSTA MESA• F
u, 9 BUILDING DIVISION
:4- „„ .1. DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER
t ) PERMIT 11. -IT -wfrver
03-00154
J
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 243 22ND ST Status: ISSUED
Suite No Applied: 03/05/2003
Vicinity: Issued: 03/05/2003
Parcel Nunmber: 42614411
Applicant: AMMERMAN, SONJA ISSUED BY: -
Address: 243 E 22ND ST
Phone: 949-515-8032
COSTA MESA,CA Zip: 92627-1811
Owner: AMMERMAN, MARK
Address 243 E 22ND ST
Phone:
COSTA MESA,CA Zip: 92627-1811
Contractor: OWNER-BUILDER
Address:
Phone:
Zip:
License: 000000
SCOPE OF PERMIT
CONSTRUCT NEW 2815 SF TWO-STORY SINGLE FAMILY RESIDENCE(1936 SF FIRST FLOOR AND
879SF SECOND FLOOR)WITH 631 SF ATTACHED GARAGE AND 84 SF FRONT ENTRY PORCH.
RESIDENCE WILL INCLUDE 3 BEDROOMS,2 BATHS AND A FIREPLACE.
ELECTRICAL TO INCLUDE: NEW DWELLING, 1 LIGHT FIXTURE, 1 SWITCH AND 1 OUTLET FOR
GARAGE. REF.: B02-01093.
AMENDED 3/10/03.ADD TEMP POWER POLE.
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) $157.64 2815 Misc Electrical Equipment $0.00 0
New Res(3-1-units) $0.00 0 Transformers up to 1 kva/kw $0.00 0
Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0
Lighting Fixts $1.10 1 up to 50 kva/kw $0.00 0
Recept Outlets $1.10 1 up to 100 kva/kw $0.00 0
Switches $1.10 1 over 100 kva/kw $0.00 0
Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0
Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0
Service to 200a $0.00 0 Misc.Conduit $0.00 0
Service to 1000a $0.00 0 Misc.Conductor $0.00 0
Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0
Motors to 1 hp $0.00 0 Circus(mech ride or lights) $0.00 0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord. No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2448-48(WOO)
DgCLARATIONS
WORKERS'COMPENSATION DECLARATION: A
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:
Carder: Policy Number:
(This section need not be completed it the permit is valued of one hundred dollars($100)or less.)
❑ I certify that In the performance of the work for which this permit Is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provisions.
Applicant Signature: Date:
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($1oo,o0o),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.Lic.# Class#
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5.Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business end Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not Intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of properly who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,talsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,Califomia Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If en RMPP is presently required,has Section 25534 of the Cafifomia 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 eEermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
8 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.
Signature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
SODS• INSPECTION TYPE DAT% INTITIALS OODE• INSPECTION TYPE • gtug INTRIAL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical 7
1266 Pool Spa Final 208 Final Plumbing /Y�Y G /2
200 Final Re-Roof 210 Final Electrical W-(BBl R.4.0
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 • Final Building/Occupancy
6S CITY OF COSTA MESA • • )
4 9 BUILDING DIVISION
e y .`I DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
PERMIT E03-00154
sr,
4rosarso et
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 243 22ND ST Status: ISSUED
Suite No Applied: 03/05/2003
Vicinity: Issued: 03/05/2003
Parcel Nunmber: 42614411
Applicant: AMMERMAN, SONJA ISSUED BY:
Address: 243 E 22ND ST
Phone: 949-515-8032
COSTA MESA,CA Zip: 92627-1811
Owner AMMERMAN, MARK
Address 243 E 22ND ST
Phone:
COSTA MESA,CA Zip: 92627-1811
Contractor: OWNER-BUILDER
Address:
Phone:
Zip:
License: 000000
SCOPE OF PERMIT
CONSTRUCT NEW 2815 SF TWO-STORY SINGLE FAMILY RESIDENCE(1936 SF FIRST FLOOR AND
879SF SECOND FLOOR)WITH 631 SF ATTACHED GARAGE AND 84 SF FRONT ENTRY PORCH.
RESIDENCE WILL INCLUDE 3 BEDROOMS,2 BATHS AND A FIREPLACE.
ELECTRICAL TO INCLUDE:NEW DWELLING, 1 LIGHT FIXTURE, 1 SWITCH AND 1 OUTLET FOR
GARAGE. REF.:B02-01093
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) $157.64 2815 Misc Electrical Equipment $0.00 0
New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0
Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0
Lighting Fixts $1.10 1 up to 50 kva/kw $0.00 0
Recept Outlets $1.10 1 up to 100 kva/kw $0.00 0
Switches $1.10 1 over 100 kva/kw $0.00 0
Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0
Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0
Service to 200a $0.00 0 Misc. Conduit $0.00 0
Service to 1000a $0.00 0 Misc.Conductor $0.00 0
Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0
Motors to 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
•
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 M-this:armit.
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 Cale,for the performance of the work for which this permit is Issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed it the permit is valued at one hundred dollars($100)or less.)
I certify that in the performance of the ork for which this permit is issued,I shall not employ any person In any manner so as to become subject to the workers'
compensation kat California,and ae that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shell forthwith
comSig with th:L1517717' ., a �L{�(,('��(,y ?I'510 3
Applicant Signature: I y Ltir`_ Date:
WARNING:FAILURE TO SECURE i• ERS'COMPENSATION COVERAGE IS UNLAWFUL MID SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE(5100,0001,IN••DITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Lic.N Class#
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she Is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than live hundred dollars($500).):
❑ I.as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contras ors License Laws.).
I a- - 'i� .t under sea T. (�/� Vin Business and Professions Code for this reason: I 1
eture�O f ,.._. , �f I L 0/1/n/t �}•T. �$� /
Expires: I (-1 /�
Verification of Owners••y(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
i (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 andWaVention Program for acutely hazardous materials)?
❑Yes 0 No
(Section 25534 of the Calif omia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this Application a_aermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes E No
(Section 65850.2 of the California Govemment Code roquires that the requested information be furnished on applications for non-residential building permits).
6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If yes",the facility must meet the requirement of Sections 25534 and 42303 of the 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
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 and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-desc' pr erty for inspectio pu oses.I agree not to occupy or allow occupancy of any building authorized b t 's pe it until final inspection.
fature Of Legal Owner(s) Date
And/Or Authorized Applicant Date
CODE fr, INSPECTION TYPE PATE INTmALS CODE# INSPECTION TYPE, PATE ICL$
• 1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing 4,( !V,-fs` ��_/�-B3 LG,
200 Final Re-Roof 210 Final Electrical "R' '
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
ett)
DIVISION
°rd,�.^i
PERMIT NUMBER
i :m : DEVELOPMENT SERVICES DEPARTMENT
J PERMIT
4tt.,,w o`4" P03-00154
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 243 22ND ST Status: ISSUED
Suite No Applied: 03/05/2003
Issued: 03/05/2003
Vicinity:
ISSUED BY:
Parcel Nunmber: 42614411
Applicant: AMMERMAN, SONJA
Address: 243 E 22ND ST
Phone: 949-515-8032
COSTA MESA,CA Zip: 92627-1811
Owner: AMMERMAN, MARK
Address 243 E 22ND ST
Phone:
COSTA MESA,CA Zip: 92627-1811
Contractor: OWNER-BUILDER
Address:
Phone:
Zip:
License: 000000
Arch/ Eng:
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
CONSTRUCT NEW 2815 SF TWO-STORY SINGLE FAMILY RESIDENCE(1936 SF FIRST FLOOR AND
879SF SECOND FLOOR)WITH 631 SF ATTACHED GARAGE AND 84 SF FRONT ENTRY PORCH.
RESIDENCE WILL INCLUDE 3 BEDROOMS,2 BATHS AND A FIREPLACE.
PLUMBING TO INCLUDE: 1 BACKFLOW IRRIGATION,2 BATHTUB, 1 DISHWASHER, 1 GAS(OVER 4
OUTLETS), 1 LAUNDRY TUB/WASHER, 1 LANDSCAPE IRRIGATION,7 P-TRAP, 1 SEWER
CONNECTION,3 SHOWERS, 1 KITCHEN SINK, 1 SERVICE SINK, 1 WASH BASIN,2 WASH BASIN
SET, 1 WASTE&VENT SYSTEM,3 WATER CLOSETS, 1 WATER HEATER AND 1 WATER PIPING.
REF.:B02-01093
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 $9.80 0 Landscape Irrigation $14.80 1 Swimming Pool $0.00 0
Backflow Preventer $0.00 1 P-Trap $68.60 7 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
•
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 ,v//
2446-46(600)
DECLARATIONS •
i
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
El I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit Is issued. .
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
I (Thi section need not be completed If the permit is valued at one hundred dollars($100)or less.)
I certify that in the performance of t :work for which this permit Is issued,I shall not employ any person in any manner so as to become subject to the workers'
r GGGJ"` compensation laws of California,a ••�•gree that if I should become subject to the workers'compensation provisions of Sect'on 3700 of the Labor Code,I shall forthwith
comply with e: r 's' A I n I n - Date: ��� D '3
'AARNI G Signature: [OV Yw`—
WARNING:FAILURE TE t S R).W ERS'CO THE
COST O PENS IT UNDAMA G S A SHALL SUBJECT I AN E EMPLOYER TO THE AL OR CODE. AND CML RDFS UP TO ONE HUNDRED.
THOUSAND DDLLARE(5100,000),IN DITION TO TME COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION OF3106THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full
force and effect.LIc.# .vv Class#
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: LendersAddress:
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 L ense Law does not apply to an owner of property who builds or improves thereon,and who contracts for uch project with a contractor(s)
license pursuant to the tractors License Laws.). ,7 �� �O
I a u•t un;:r 5: , �1 Business and Professions Code for this reason: V/t
"B mai ' / �nWgf�������
Expires:.T( _
Verification of Own: . ip by(type of docu e i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code). .
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the Califomia Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds. or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application 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 Govemment Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes ❑No
8 (If'yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE 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 corn. .'h all state laws a•• ty ordinances relating to building construction,and authorize representatives of t e City of Costa Mesa to enter upon the
above-describe• . ••arty for i .pection purpo-_- -gree not to occupy or allow occupancy of any building authorized by this permit ntil T a'Inspection.
-0 'j7 a
eig d.re OI Leg�ner s) - - `Da e— .
An. • Authorized Applicant Date
RODE E INSPECTION TYPE PAM INTSIELS CODE I INSPECTION TYPE RALE INTRIALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical //�� /
1266 Pool Spa Final 208 Final Plumbing I Q•I10•03 .RN
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
' rt. CITY OF COSTA MESA
6 BUILDING DIVISION
• ,' -4 g DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER
14. :' PERMIT
iltb4PoRrco 1144
M03-00102
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
MECHANICAL PERMIT
Job Address: 243 22ND ST Status: ISSUED
Suite No Applied: 03/05/2003
Issued: 03/05/2003
Vicinity:
Parcel Number: 42614411 ISSUED BY:
Applicant: AMMERMAN, SONJA
Address: 243 E 22ND ST
Phone: 949-515-8032
COSTA MESA,CA Zip: 92627-1811
Owner: AMMERMAN, MARK
Address: 243 E 22ND ST
Phone:
COSTA MESA,CA Zip: 92627-1811
Contractor: OWNER-BUILDER
Address:
Phone:
Zip:
License:000000
SCOPE OF PERMIT
CONSTRUCT NEW 2815 SF TWO-STORY SINGLE FAMILY.RESIDENCE(1936 SF FIRST FLOOR
AND 879SF SECOND FLOOR)WITH 631 SF ATTACHED GARAGE AND 84 SF FRONT ENTRY
PORCH.RESIDENCE WILL INCLUDE 3 BEDROOMS,2 BATHS AND A FIREPLACE.
MECHANICAL TO INCLUDE: 1 INST FAU<100 K BTU, 1 GAS PIPING, 1 FACTORY
FIREPLACE, 1 HOOD W/MECH EXHAUST,AND 2 VENT FANS. REF.: B02-01093
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 $6.15 1 Up to 3 hp/100 k BTU $0.00 0
Factory Fireplace $10.65 1 3 To 15 hp/500 k BTU $0.00 0
Hood w/Mech Exhaust $10.65 1 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 $14.50 2 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
•
•
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.tliis permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION: '
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
• lls section need not be completed it the permit Is valued at one hundred dollars($100)or less.)
ffh
7J I certify that in the performance of the •rk for which this permit is issued,I shall not employ any person In any manner so as to become subject to the workers'
compensation I; . of California,an. :e that if I should become subject to the workers'compensation provisions of Sction$700 of the Labor Code,I shall forthwith
comply with t :se.rovisions. ' + � �{ 11g`/ IV
Applicant Signature: ..tAaj A
A LA . L a — Date: " 1 V 3
WARNING:FAILURE TO SECURE W 0�ERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARS(5100,000),IN ITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that 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.Lis.N Class k
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
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 ' ense 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 th= •ntractors License Laws.).
Y7 I a• ..r n-e7 s: Business and Professions Code for this reason: l /
Signatur.SiA . V'11h(��r##..
Expires: 2 Alp
Verification of Owner ip 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 end certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the 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 ap,ermit for such construction or modification
from the South Coast Air Duality Management District or from any other air pollution control district or agency? U Yes 8 No
(Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If yes',the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND 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 t m with all state I. :nd city ordinances relating to building construction,and authorize representatives f the City of Costa Mesa to enter upon the
above-describe prope r inspe'ction . .es I agree not to occupy or allow occupancy of any building authorized by this r it u al inspection.
I j�S 1 e
Si tura Of Legal Owner(s) bate
And/or Authorized Applicant Date
C005 II INSPFCTION TYPE OATS INTmAL$ COOFt INSPECTIONTYPE BATF INTITIAL$
1616 Fixed System Final Fire Prevention 206 Final Mechanical ) -J G.• c-') SN
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