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HomeMy WebLinkAbout120 INDUSTRIAL WAY - Building Permits CITY OF COSTA MESA W.1 Fsp6 BUILDING DIVISION I 3/4 F I j TT DRIVE.COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us �,. FOR INSPECTIONS CALL:(714)754-5626 '`* "' PERMIT NUMBER: P11-00174 PERMIT TYPE PLUM STATUS: ISSUED APN: 42535108 DATE ISSUED: . 09/13/2011 ISSUED BY: KJB JOB ADDRESS: 120 INDUSTRIAL WY CM . Suite/Unit: Vicinity: SCOPE OF WORK: REPIPE EXISTING 1"WATER SERVICE LINE TO NEW LOCATION. REPIPE EXISTING PLUMBING FIXTURES FOR THE EXISTING BATHROOMS.CHANGE OUT 2 WATER CLOSETS AND 2 SINKS-SAME LOCATION. 1 NEW INSTA-HOT WATER HEATER. RELOCATE 1 EXISTING HOSE BIB. NO OTHER WORK AUTHORIZED BY THIS PERMIT. OWNER: KOCHNUK,ALEX J TR Address: 2431 CRESTVIEW DR PHONE: City/State/Zip: NEWPORT BEACH,CA APPLICANT: LA POINTE,DANIEL . Address: 1720 WHITTIER . PHONE: 949-646-1185 City/State/zZip: COSTA MESA,CA CONTRACTOR: EVANS PLUMBING INC License No. 498867 Address: 1720 WHITTIER PHONE: 949-646-1185 City/State: COSTA MESA,CA ZipCode: 92627 CELL: ARCHITECT: License No. PHONE: ENGINEER: License No. PHONE: PLUMBING PERMIT FEE SUMMARY PLAN CHECK FEE: $0.00 PERMIT FEE: $104.40 TOTAL FEES: $104.40 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord,No.92-28,§1. 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. POE S. INSPECnON rc DATE INTITIALS CODES INSPECTION TYPE DATE, IN1TAL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing X /0 , (p .1/ Offf 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 WORKERS'COMPENSATION DECLARATION: Owner ID verified by driver a license. ❑Yes ❑No I hereby 'trim under penalty of perjury one of the following declarations: Driver's License No. Expires: 0 I ave and will maint�n a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed): corn motion, as provided for by section 3700 of the Labor Code, for the p ormance of the work for which this permit is issued. I have and will maintain workers'compensation insurance,as required by s ion 3700 of the Labor Code,for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a number are: - person is required to descend,will be made in connection with work authorized �2n /Jn ' . _ — by this permit,and that no building swcture,scaffdtling,fa sewn k,a demolition Cartier. Q,w_ .ey Bred dollars ' ✓I or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp (Tho seam need ria be pletetl the permars valued at one hundred dollars($100)or less) 2.Art 2.Sec.341,Title B,California Administrative Code). Policy Number: /46/0 q . ) (..p ❑ As owner-builder, I will not employ anyone to do work which would 0 I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless issued.I shall not employ any person in any manner so as to become subject • such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if I should become subject to the workers'compensation provisions of Section 3700 of Applicant's Signature Date the Labor Code,I s •h comply with these provisio s. Division of Industrial Safety Permit Number: Applicant's Signature aye HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes ❑ No ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEY'S FEES. Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons.or 200 cubic feel of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure). with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file my license is in full force and effect. C Z°19/C ! a registration form for acutely hazardous materials? 0 Yes 0 No Lic. `'�/9�� Class# (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 Contractor's SignMure to hazardous materials equal to or greater than a weight of 500 pounds. or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard CONSTRUCTION LENDING AGENCY: temperature and pressure). ❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? ❑Yes 0 No (Section 25534 of the Califomia Health and Safety Code provides that the Lender's Address: Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. Signature Dale 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes 0 No I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? ❑Yes ❑No issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Government Code requires that the requested that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits). License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes 0 No applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes", the facility must meet the requirement of Sections 25534 and 42303 five hundred dollars($500).): of the California Health and Safety Code). ❑ I. as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other compensation, WILL DO THE WORK. and the structure is not intended or air pollution control district or agency is required for the work which is the offered for sale(Sec.7044,Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by California License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes ❑No thereon,and who does such work himself or herself or through his or her own 8. (If"yes",attach certificate of compliance from the appropriate air pollution employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of control officer). completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions. LICENSED CONTRACTORS to construct the project(Sec.7044, Business and Professions Code:The contractors License Law does not apply to an owner of Signature Date property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that ❑ I am exempt under sec. ' the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described properly for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si nature of nr(z) ^ Wlq 92/ I / Signature Date I (> /O/a' 3057-46(]lel) Mellor Authorized Appiwm Ic OWNER FISHER, W. E. DATE 2-10-55 JOB ADDRESS 120 Industrial Way V BUILDING PERMIT NO, 901 GENERAL CONTRACTOR Owner-Builder VALUE $ 211 120.00 .E.z LOT AP# 117-050-19 BLOCK TRACT Industrial Building GROUP F2 PERMITS ISSUED TYPE III ZONE M1 FIRE DISTRICT 903 in INSPECTIONS DATE SUBCONTRACTOR I . C/ DATE NUMBER Footing Trench ern. 2 -.2V-Sr Foundation Forms and Grade to arage 22-35 14---as4 t� ,/1n 1 t •L' `' Rough Framing GG . S{ Plumbing,Rough to Slab-W- t�- 1.1.11:-/i Plumbing, Rough�Complete'l _f/- 1 - - _�•yct •Temporary Pole /) Eve-e---e 1 7 Lt__a t• J-//-SS rW00 Cc.ebei c..-1-al-ss Wiring, Rough �'-'-14i y`%t-ni OLir yr..e-,- EA cet - - - t 9041 Heating, Rough Heating, Final Sewer el/?, y/1//,f' , /„�.,Co A /o 41/2b/rt /7,74/ Septic Tank or Cesspool ,Lathing �Jp/�E��a!�/� / r� '___ /� .Lathing bu i Re- /4bI "/— tJQ f fa � J IA.�� 7 ; c Rob 4s A try -)1../r Plastering / 7 Plumbing,Final,Fixtures Completelor((,�C'' f+ L -.2 -J Plumbing, Final Gas Test G1$ n' 144 i--(3 Wiring, Final 7, ,r'c -,n �6:-.72e.-5-.1 _ Occupancy S b-1 .13" Form 210 G-H 1M 12-68 OWNER HARPER, JAMES T,. DAIt 10-13-67 JOB ADDRESS 120 Industrial Way BUILDING PERMIT NO. 27713 c GENERAL CONTRACTOR Owner-Builder DESCRIPTION of WORK Paint Spray Booth �AP No. 117-051-05 LOT 21 TRACT Npt.ggtsFIRE ZONE VALUE $!}00.00 INSPECTIONS Signature Date GROUP •E-4 TYPE III-N ZONE M-1 SOIL PERMITS ISSI, ED GAS SUBCONTRACTOR Date I Number I Signature WATER Plumbing ROUGH PLUMBING PROP. SWR. LINE❑ HOUSE CON. 9 SPRINKLING SYSTEM MISCELLANEOUS ROUGH HEATING AND AIR CONDITIONING TEMPORARY SERVICE OR POLE UNDERGROUND 9 POWER 9 ROUGH WIRING Heating and Vent. TRENCHES ❑ FORMS 9 STEEL REINF. FLOOR SYSTEM BOND BEAM n STEEL REINFORCE ❑ SHEATHING FRAME AND FLASHING LATHING - IN n OUT n PLASTER, BROWN COAT STRUCTURAL, FINAL Electric HEATING, VENT., REFRIG. AND-A.C., FINAL PLUMBING, FINAL AND GAS TEST n ELECTRIC, FINAL /Z/� • BUILDING. FINAL [J'0 Costa Mesa Building Department APPLICATION FOR PERMIT a 111 EAST 20th STREETB.0 I L D,I. N-.G.__- .1, '-- • COSTA MESA, CALIFORNIA "'-'- FOR OFFICE USE ONLY FOR APPLICANT TO FILL IN i eceipt No. Perniit'No. Address 4 L Witt' I : r ((/' G / 9 " I Building / � /7iuS f 1 , i rof Receivedib Date Re d. Date Issued I Costa Mesa, California _ i i n p,ti955 Nearest I i , FEB 1 cross stS� E2,o2 - /(iEL(JPo ryT Building d U e�p� AlL /f/� ' I Address 4y "' v sIe ki Owner et.). E. 1 S t+EC - : Costa Mesa, California ' Mail AddressC. t COA5 f Nearest j 1 Tel.1L,,� 2_4,143Crs St. : Cit /20434 DEL !`I$IL Nome— 2_4,143 Fos 3 Zone��,���A�f ; No.of Type Group Architect orr_ Lie. f I Plans r Engineer ,2. PIZ, ✓G-, No. App ved ? by , Date , Address L9OA119 $EF►e•EI I CORRECTIONS //� City Lic- Contractor ,i4Ai g,,� Iro J Address _ o r, ..- + .1_�.r _�. ' LegalLot I SL✓ �..�. ____ • Description I No. I Block ci / Tract fit/ rr J �z. �ii rIj�:�� (Attach Metes and Bounds)AP�/,-are, --,/� "than� '■■w. , No:of Bldgs. /]. '� :l ! II0 • O Size of Lot ?© x /LO Now on Lot WO ■d Use of No.of I No.of • j, A Existing Bldg. I Families Rooms ��•`' B • p 5 Setback Line from so Rear Yard 430140 ! _ ... • -�- /44"2' ,aC-0 2 Center of Street Side Yard " ' D DESCRIPTION OF WORT{ � r` r'11, f - r New I ✓ Alteration I Addition I ,,/ COSTA' MESA____. Repair I Moving I , Demolish -,• •- . l 4 Building �/ No.of Size 'y(J Q d Rooms • / Stories Exterior Wall I Roof APPROVALS Covering Covering Use of New ♦/ .''4' , , / • Building /jt//�(/$72..qL -65-r•� R 3 Foundation Location Inspector Date ///""��/J Forms,Materials, Under-Pinning Frame: Fire Stops, Bracing,Bolts Lath. int. I hereby acknowledge that I have read this Application ' and state that the above is correct and agr-• to comply Lath. Ext. withallCity Ordinances and . . • y regulating • building constr r,n. / Plaster, Int. Signature of Permittee 0 ...` Plaster,Ext. Authorized Agt. Masonry Reinforced Valuation Permit Fee $ y-44_• 0 0 n� ' a0 Plan Check $ /s--; •., 0 Bond Beam $ UC • Totalq 7 O ® 2.5- ,. _.. _.. .-- ._ .. Fee $ J� / . FINAL e --`) ^res\ kJ1 '. _ q.. es o a C , , l , a J a • a O. • ,. - - Ijt - • • • Street - ' - - tr 1 . PLOT PLAN Show location-and distances--from _ property line and between buildings. C , - t PATO 277 I� G OCT 13-67--,,,00 607 c % ***3I l COSTA MESA BUILDING-SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 9162E For Applicant to Fill In Completely APPLICATION FOR PERMIT TYPE OR PRINT BUILDING � For Office Use Only :DDR ES9 420 I ND(J>IF7AI JAI C,tilt 1 y�1'Q, R[C[IPTNO. =MIT NO. COSTA MESA. CALIFORNIA 77/ 9 // RE 1 DARRECEIVED•7jDATI IISUE_ E OWNER I(A {ll S N• P 2 A2PE • /' (/ -r7 / c- 7 - //�1 '/ BUILDING ADDRESSMAIL 1/420 /N,D, Lim/ / ADDRESS //74-7.5.79 NO. ,/�/ FIRE CITY Cos-%H 5f '77jj ZONEE. APPROVED ,megE GROUP /J OR ARCHITECT NO. BY V , T DATE /3 6/ ZING ADDRESS ZONE No.OF USE or NEW . / ./ --�J ./-� p- AA I PLANS E. I BUILDING SACS'1-AL CONTRACTOR OLIJNet — •O J 1/V E,v C p2�Y K00 DESCR J NEwn� ADDRESS DESCRIPTION ( (�^r Le 4 ZI K F i CITY A.P.NO. l'i / - OSI- S NOTE: NO[AVE OVERHANG SHALL BE LESS THAN STATE TEL BO'TO SIDE&REAR P.L LIC.NO. No, - OFOTHR/ , POI X h/S I r;.°101-"..WT I EAVES LALLOWED (U.B.C.REQUIREMENT) YARDS APPROVED YARDS APPROVED USESTINOF G BLDG. OCIDY she? - 61090C MAIN BUILDING ACCESSORY BUILDING EXISTING <PROM C/L STREET) SETBACK LINE PROM ,/tet / FRONT CENTER j E'OO�F STREET /.�P�T�l7V REAR YARD 0 ,�/ SImE YARD I LEFT #(y RIGHT Qo` R.SIDE FT. f /' "' FT. DESCRIPTION OF WORK L.SIDE Fr. VVV FT. NEW ALTERATION ADDITION REAR PT. FT. DISTANCE BET. BET.MAIN& REPAIR _MOVING DEMOLISH MAIN SLOGS, ACCESS.BLOCS. V .* DATE S Z IDINO /51X 51 ROOMS / ,Q�T/QRI�[e I CMU.P.# ���(J}� APPROVED / �1 EXTERIOR WALL7O-`/ 1 COVERING /i�Lt/f� PROy[Dn w.efl.'M4— DATE 1V�I3 "Ip / COVERING V(y, USE OF BUILDING AND WORK TO BE PERFORMED h -7C HOLD FOR SPECIAL REQUIREMENTS w Pa/d / Th MEET ALL. (cry- PeQc1/Rama/iii SQ.PT. X I HEREBY ACKNOWLEDGE I HAVE D THIS APPLICATION • THE AMOUNT SHOWN UNDER VALUATION IS FOR THE j AND STATE THAT THE ABO IS CORRE 'AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. 1R PLY WITH ALL CITY ORDINANCES AND STATE WS REGULATING VALUATION OWBUILDING CONS ON. / SIGNIg ° Z& a PERMIT FEE $� p PERM -rgITTBF A(,Q "Stele o PLAN CHECK $ ---.1 � IS "' AUTHORIZ AGENT . .. a . .. ....a'•, -";: .. - - TOTAL FEE $ ' _ Jr CITY OF COSTA MESA i r ‘ BUILDING DIVISION PERMIT NUMBER I.t' DEVELOPMENT SERVICES DEPARTMENT 4" PERMIT B99-01128 (714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92628 ' BUILDING PERMIT Job Address: 120 INDUSTRIAL WY Status: ISSUED Suite: Applied: 07/19/1999 Vicinity: WHOLE BUILDING-120 INDUSTRIAL WY Issued: 07/19/1999 Parcel Nunmber: 42535108 Zoning: ISSUED BY: •r" 1 Applicant: ROBERTS, WALT - -- _ Address: 1653 SUPERIOR AV j7. • _ ��-- - - Phone: (949)642-7222 - COSTA MESA CA, Zip: 92627 Owner ,KOCHNUK, ALEX J TR Address X7,2431 CRESTVIEW DR - - - - - - //0:77// '-�, - Phone: vv / t///NEWPORT BEACH CA'' Zip: 92663 Contractor: L`EE-ROOFING OF COSTA MESA V"' ,._A'ddress: 1653 SUPERIOR AV 4. ,';-�- Phone: (949)642-7222 COSTA MESA CA Zip: 92627 ' : : 'License: 349686 ' , . . '- . - Eng: . 1 'Address: , - / , ' - Address: - Phone: Phone: '' a . N , vZip - ., License: Zip: License: • - > / - : , ' SCOPE OF-PERMIT REROOF EXISTING COMMERCIAL BUILDING(52 SQ).TEAR OFF EXISTING ROOF&INSTALL NEW BUILT-UP ROOFING SYSTEM(1-LAYER OF 5#ROSIN, 1-LAYER OF 25#BASE,2-LAYERS OF 11#PLY,& 1-LAYER OF 72#CAPSHEET, Z WITH HOT ASPHALT BETWEEN EACH LAYER.NEW PERIMETER&PIPE FLASHINGS. -. FEE SUMMARY , . >Plan Check: - $0.00 Calc Valuation: , ' $7,350:00 Permit: $137.25 - _ Claim Valuation: $7,350.00 SMIP RS: ' $0.00 - ',SMIP.Comy-. 'x`:$1.54 , 1/, Other:- :$0.00 • - Inspection: $0.00 , vTotal: $138.79 ' PLANNING 8:ZONING •A SETBACKS `y-.Y- ' - ' : ' MAIN STRUCTURE Front- 0-0 Rear 0-0 • Left 0-0 Right 0-0 ACCESSORY Front 0=0 - Rear 0-0 Left 0-0' Right 0-0 PARKING Existing: 0 Required: 0 Proposed:. 0 ' NOTES: • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 `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. EL,..--(rave and wi0 maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work /for �whiicchh this permit is issued. My workers'compensationcopeInsurance carrier an cy number are: ��fOD—!'--�-T/ Carrier: . of,c 1 ! - .Policy Number: (This section need not be completed if tile permit Is a uad at one hundred dollars($100)or less) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. 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($100,000),IN ADDMON 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 pr C apter 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# C' Contractor's Signature: f4(Lf - 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 Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires: • Verification of Ownership by(type of document,i.e.•property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made In connection with work authorized by this permit,and that no building structure,scaffolding,fatsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: • HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health end Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑Yes i5 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control'district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If'yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPUANCE 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-describC ' 1r ;'5) or inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. -7 -/1-qc. An, Or Aut orized Applicant Date CODE I INSPECTION TYPE Dilff jMIIDE& CODE! 1NSPFCTION TYPE PIM '2T1/19I9 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final �yf/i 208 Final Plumbing • 200 Final Re-Roof 7-03-99 210 Final Electrical 201 Final Block/Retalning Wall , _ 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site • 204 Final Demolition 250 Final Building/Occupancy 2446-46