HomeMy WebLinkAbout195 17TH ST - Building PermitsHAWAIIAN ISLE
GENERAL CONTRACTOR rveun nncerprises VALUE $ 5UV.UU
A.P. No. "I �"i-» LOT TRACT
FIRE ZONE DESCRIPTION OF WORK n001 Dign
I ECTIONS
DATE GROUP TYPE ZONECZ
ground Soil U.G. Water
eiginund Gas
SUBCONTRACTOR PERMITS ISSUED
TE NUMBER
Overhead Water and Gas
Rough Heating
Rough Plumbing
EDA
Miscellaneous
Prop. Swr. Line House Con. St. Swr.
8
Sprinkling System
Heating, Final
Plumbing Fixtures
Final Gas Test
Construction Pole
Underground Power
Rough Wiring>
Trenches Forms Steel
Floor System
Steel Reinforce Chimney Re -Rod
Bond Beam
Sheathing
and Flashing
Png, In Out
aster, brown coat
Plumbing Fixtures, Final
Electric Fixtures Final 1,
Building Final
OCCUPANCY
Form 210--5M-11-59 5-8 P 13072
V
R iiUbbLESTON.•bON,�:
DATE
JOB ADDRESS 191 East 17tH Street BUILDING PERMIT NO. 3093
GENERAL CONTRACTOR A' Ian A. Ritter VALUES 11,241.00
` -L, 82 BLOCK TRACT Newport Hgts Automotive Service Garage
GROUP E2
TYPE 111 ZONE C2 FIRE DISTRICT 3028
71
INSPECTIONS
1=-, -, _
DATE
SUBCONTRACTOR
PERMITS ISSUED
DATE
NUMBER
Footing Trench a ]IiUrG
/'S'
_
Foundation Forms and Grade to Garage
��tt�
�c- Ao-, G -J.2 *S
Rough Framing
Plumbing, Rough to a
- -;?2)6Z 4k
6-/9-�(=
Plumbing, Rough Complete
V
Temporary Pole
Wiring, Rough
Heating, Rough
Heating, Final
Sewer, House ewer, St?J44 (pr,
- /-,$��i
,Sl 3 % !
Seotic Tank or Cesspool
! 'Ing, In Out
Plastering
Plumbing, Final, Fixtures Complete
Plumbing, Final Gas Test
$�/•/SZ
- 'Q /
G
_ -
Wiring,Final
/
Occuoancv%. �/'i
-1iL <F.
FORM 210 9M 10.55 - 3093
M
COSTA MESA BUILDING DEPARTMENT
111 East 20th Street
Costa Mesa, California
N° 98
Date. ...� ._:__.
CITY OF COSTA MESA
CERTIFICATE OF OCCUPANCY
Building Permit No.30%3J-so
.....ecPermito upgeo..
Use of Building..L.s'r.......�........�"'.
....................
YY�����,
.....................� _--:.--.... _....,F- .............. ........
The.building located
I-
t...........5l..'"....................... Block...........................................
(See reverse side for Metes and Bounds)
has.been inspected and found to comply with outhe ..........
Y
ISSU,F;D TO: �% ��� / A. J. VOL2
rnGlA-/'."rn_J� er of Building)
City Building ,OtflClal/
..(......................................................................... ld/ U
yg (Owner of Building) By.........1.���. ...._.......... .. ................
W .d....
CC: Original—Owner ❑ 1st copy—Gas Co. ❑ 2nd copy--E/dison Co. rd copy—File
Por. 206 G -H IM I2-53
City of Costa Mesa
Building Safety Department CERTIFICATE OF OCCUPANCY 1
P.O. Box 1200
Costa Mesa, California
The Building located athas been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto
for a Group .-1• —Occupancy.
Use of Building _C'.-- - —
Legal Description "•n'_ 7/- - :.1
(See reverse side for Metes and Bounds)
Building Permit No. Electrical Permit No. Plumbing Permit No.
Number of apartments – - and/or guest rooms
ISSUED TO: Building Official
r
by
1 Date - •, �1 -
This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the
Building Official of the City of Costa Mesa under Sec. 306 lel U.B.C.
Form BU 34 Rev. 11/70
HEATING, VENT„ REFRIG. AND A.C., FIHAL
PLUMBING. FINAL AND GAS TEST
ELECTRIC, FINAL
BUILDING FINAL
9p
OWNER
JOB AC
GENER
Vo.
i.
EC
SOIL
SOIL
GAS
WATER
HUDDIMTON, Don
Mr
Al
UNDERGROUND n POWER
BOND BEAN
SHEATHING
DATE 6-26-68
BUILDING PERMIT NO.
21PTION of WORWon-Elec.Wall Si
ZONE VALUE $ 75.00
)UP TYPE V 2
SUBCONTRACTOR i _ PER
FRAME AND FLASHING
LATHING - IN OUT
PLl"TER, BROWN COAT
S_ 'URAL, FINAL ElectTic
HEAT (NG, VENT., REFRIG. AND A.0„ FINAL
PLUMBING, FINAL AND GAS TEST
ELECTRIC, FINAL
OWNER Emil 0 CO DATE 2-14-66
JOB ADDRESS 195E 17th Street BUILDING PERMIT NO. 25300
GENERAL 7
An No ll7
ki
OF WORK
DJ LOT TMACT FTRV aONTE V.IT TIL` C l n1 nn
PECTIONS Signature Date
GROUP j TYW—
T ZONE
boil
SUBCONTRACTOR I
PERMITS ISSUED
Date Number I Signature
Gas
Water
Plumbing
Rough Plumbing
Prop. Swr. Line 0 House Con. �0
Sprinkling System _
Miscellaneous
Rough Heating and Air Conditioning
Temporary Service or Pole
Underground 0 Power 0
Rough Wiring
Heating and Vent.
Trenches 0 Forms 0 Steel Reinf. 0
Floor System
Bond Beam 0 Steel Reinforce 0
Sheathing
Frame and Flashing
Lathing — In 0 Out 0
Plaster, Brown Coat _
F `.ural, Final
Electric
ii—ang, Vent., Refrig. and A.C., Final
—
Q
Plumbing, Final and Gas Test 0
Electric, Final
Building, Final .... _ . __..._ /Lff•6
.-----.--..
GENERAL CONTRACTOR Seeker and Jones DESCRIPTION OF WORK 2-U
A' '*o. 117.– 1-13 LOT TRACT FIRE ZONL•' VALUE $
1` ECTIONS
Signature
Date
GROUP J TYPE 1V ZONE C-2
Soil
I PERMITS ISSUED
SUBCONTRACTOR Date l Number I Signature
Gas
Water
_
Plumbing
Rough Plumbiag
Prop. Swr, Line 0 House Con, 0
Sprinkling System
IDfiscellaneauS
Rough Heating and Air Conditioning
Temporary Service or Pole
Underground ❑ Power p
Rough Wiring
Heating and Vent.
Trenches ❑ Forms q Steel Reinf. q
Floor System
Bond Beam q Steel Reinforce ❑
Sheathing
Frame and Flashing
Lathing — In p out q
P-=ter,Brown Coat
tura!, Final
Electric
Heating, Vent., Refrig, and A.C., Final
Plumbing, Final and Gas Test q
Electric, Final
Building, Final
OWNER SHELL OIL CO. DATE 10-28-75
JOB ADDRESS 195 East 17th Street BUILDING PERMIT NO. 40776
Soil-
GAS
OILGAS
WATER
ROUGH
PROP.
ONS
laq
MISCELLANEOUS
ROUGH HEATING AND AIR CONDITIONING
UNDERGROUND POWER
ROUGH WIRING
TRENCHES ❑ FORMS
FLOOR SYSTEM
BOND BEAM Fl STEEL REI
FRAME AND FLASHING
LATHING — IN n OUT
PL ?R, BROWN COAT
7, .'URAL, FINAL
HEATING,VENT., REFRIG.
PLUMBING. FINAL AND GAS
T
FIRE ZONE
SUBCONTRACTOR
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
SIGN
Job Address: 195E 17TH ST
Suite:
• Vicinity:
42542310 Zoning:
Parcel Nunmber,
Applicant:
ANITA CRUZ
Address:
935 ALMOND DR
BREA, CA
Owner:
HUDDLESTON, DONALD I TR
Address
2161 SAN JOAQUIN HILLS RD
NEWPORT BEACH, CA
Contractor:
OWNER -BUILDER
Address:
Arch / Eng :
Address:
INSTALL A 20.8
Plan
POMI
w.-.. $0!(
Total: $395
i.•? '4r �L
` I
Phone: 714-308-8730
Zip: 92821
Phone:
Zip: 92660
Phone:
Zip:
License:
Phone:
Zip:
Status: ISSUED
Applied: 11242003
Issued: 11242003
ISSUED BY:
ONO
Calc Valuation:
Claimed Valuation:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92.28. § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or 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
«wo iaw�
DECLARArIONS
WORKERS' COMPENSATION DECLARATION:EL
I hereby affirm under penally of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided lot by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued. .
❑ I nava and will maintain workers' componsahon insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this ponnit is issued.
My worxers' compensation Insurance carrier and policy number are:
Carrier: Policy Number:
17nis rac ion need not be completed it the permit IS valued at one hundred dollars ($100) or loss )
1 certify that in me 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 at Section 37DO of the Leb0r Code, I shall forthwith
comply won these provisions.
Applicant Signature: Date'.
WARNINGFAIL LIRE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 10 ONE HUNDRED
THOUSAND D(RIARE (S100,L00). IN ADDITION TO THE CAST OF COMPENSAI II DAMAGES AS PROVIDED FOR IN SECTION 3706 OF 111E LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
1
LICENSED CONTRACTORS DECLARATION: ! 1
I haropy affirm that I am liconsad under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bushes and Prnlessions C000, end my license is in lull
force and effect. LIC. • Classo i u i 1
Contractor's Signatute: Dale: .�'. ( 1 !
r
CONSTRUCTION LENDING AGENCY:
u,4 �. •. _ 6 t= 1
❑ I hereby affirm Inst snore Is a construction lending agency for the performance of the work for which this permit is Issued. (Sec: 3097; Civil CotlaJ.
Lendef s Name: Lender's Address: �' '{j, I,\
Signature: ..<=„ a"• rt DaIB:'
F l ,
OWNER -BUILDER DECLARATIONS:
I heresy affirm trial 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, domolisn, or repair any structure, priI its issuance, also requires the applicant for sucn permit
to file a signed statement that he or she is licensed pursuant to the prevISIOna'Of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or Inas he or she is exempt therefrom and Ire basis lot tole alleged exemption: Any violation at Section 7031.5 by any applicant tar a permit
liUD s me applicant to a civil penalty o1 not more than live hunarad dollars ($500).): I" f,
❑ I, as owner of the property, or my employees win wages a 'their sole compensation, WILL DO,THE WORK; end the structure la not intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors'Ucense Law does not apply 16 an ownts d properifiI builds or improves thereon, and who does such Work
himself or herself or through his or her own employees; provided that such Improvements are rot imended'ot abated fur sale. it, however. Ire building or improvement is
sold within one year of completion, the ownen0uilder will have the burden of proving that he or she did'nobbuild or improve tor'perpor" of sale.).
r
❑ I, as owner of Ins property, am EXCLUSIVELY CONTAACTNG WITH LICENSED CONTRACTORS to construct the project (Sec. 701 Business and Professions
Gape: The contractors License Law does not apply to on owner of properly who builds or improves Marson, and who contracts for auch;projecl with a conuactor(s)
license pursuant to ins Contractors License Laws, it } '' _ • ! y
❑ 1 am exempt under sec. Business and Prof
esaions Cdoe for [his reason:
Signature: / 4 1.. i } Date:
Owner ID verified by driver 9license, - 0 Vea � ONO ' Drivels licenie No. ' Expires:
Venhcation of Ownershiptry (type of document, i.e. • property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: lr l
❑ I hereby cavity Leel his aafavation live (S) Or moll ieet in depth into which a person isrequired to descend, will be matte 1n Connection with work authorized GYMS
permit, and that nil building structure. scaffolding; falsfiWOrk, or OemWition W dismanlh theroid, will be more than thirty-six (36) feet high, (Chap. 3.2, Orp 2, Art 2, Sec.
341, T rile B, California Administrative Code).
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such parson has a
parent 10 do sucp ILII from the division.
signature: - } • Dale:
(`
Division of Intluslriah$aferyPermit Number. -
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
I wit l the appticant or'present or,Aitura building occupant need to file and cenily a Business Plan for emergency response to release or threatened release of a hazardous
malarial'! ❑ Yea ❑ Nd
(Section 25505 01 the California Health,end Safely Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by ovary
business which has at any one erne dating a roponed year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 LUDIC feel o1 compressed gas al standard temperature and pressure).
.............................................,._..____............ ........_...................,......... .... ............ ....... ...... .......... .............. ... ................... .......-.............................,,..................................__............................ ........... ...,.....................................
Dues at will too aplAkam Or plesent`of future building occupam road to lite a segisuatlon lotm for acutely hazardous mmeriafs? ❑Ves ❑ No
(Secion 25S:i3 of ale California Health and Safely Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business wnicn at tiny
ane erre has un ran0,a.quonhly of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of
COmptesse0 gas al slanaard temperature and pressure).
bass 9 Does or will the applicant nt present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
'r us ❑Idu
I Section 25534 of the California Health and Safely Code provides that the Costa Mesa Fife Department may require the preparation, certification and filing with the Fire
I warmanL at an RMPP uy businesses which are required 10 register acutely hazardous materials with me Fire Depanmenl.
................ ..._....... .._.......... .... ......... I..... .. .. ........ .......... ............... .. ......,... .._........
4 ban RMPP is presently required. has Section 25534 of the California Health and Safety Code been fully complied wiih7 ❑Ves ❑ No
S froeti or So tea applicant or p ly Ma or future building occupant toques lir the work ontch is she t or
- d This aep6Calion a�ermit tar such construction or mWihpaTon
from mu South Coast Air Uuatity Management District Or iwm any plh0t air pollution control district Or agency? L -I Vea NO
(Section 65950.2 d the California Government Code requires that the requested information be furnished on applications lot non-residential building permits).
........ ..... ........................ ........ ..... ,.......... ,... .... .... ........._......... ........................ .....................................___......................................................... ........-.,.,.-........... _.................. ., ......._.........................................................................._.
!i
Will any pert of the facility Io be constructed under this perms be Within 1000 Leet from me outer boundaries of a school'? ❑Yes ❑ No
it 'yes', the faulity must meet rte requirement o1 Sections 25534 and 42303 of the California Health and Safety Code).
..... ....._.._....._..............._._........_... _.............................'..___....._.........._............. .'.'...___...... _....................... .......__....._...._._.........._.....__.-...... .............................. ..__....................__.............._.._...__.................._.
........
7 II a permit troth Ire SOWN Coast Air Oualny Management District or other air pollution control district Or agency is required for the work which Is the sublecl of his
duplicators, have all of the disclosures prescribes by California Health and Safely Cone Section 42303 been made? [ 1 Yes CJ NO
.................................................................._......._....._......_.........._...._._.._.._...._............_._......._..............._.._......._....-...................................................__.._..........."___..__..__............... ..... ..._....._..._.
B 11I 'Yes', affect, cenificale o1 compliance from Ino appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I clarity that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city orainances
legarpmg Hazardous Maonals and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cenily under penalty of perjury that I have read this application and slate that Ire Information given is
Correct. I agree 10 comply with all state laws and city ordinances relating 10 building construction. and authorize fepresonlatiVOS of the City of Costa Mesa to enter upon the
above.descnbed property for inspection purposes. I agree not to occupy or allow• Occupancy at any building authorized by this permit until final inspection.
Signature Of Legal Ownegs) Data
AnatOr Authorized Applicant Date
CODE INSPECTIONTyPj PAR INTITIALa tobex INSPECTION TYPE pAU IT�ILAL
1616 Fixed Sy`siem'FTnal Fire Prevention \ 2061FInal MecrantcSI_7_;, ,
12fi6 Pod Spa Flnel ,t !' / ') t 20B ', iFinalPluindng`'
''
200. z1`41nal RaRochl ,� - 210 Final Electrical t•
204x' , Fleet Stackinelaining W ell 'I.1 1 212 Final �Fire Preyenflon
t.4 ry I 1
202Y' „t• Final Factory Fire Pjace`� w.� •'` v 220 ' IF Planning AppmJal
M1" ti 1! t
203 ��1F,I Slgny--- Lv, 7 � v 222 .Final $rte
204 Firul Oornditlom A s� '� �` , 1 ''�� 250 Final BuildmgtOccupancy i
(714) 754-5273 • Fax (714) 754-4856 • www.ei.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
ELECTRICAL PERMIT
Job Address: 195 E 17TH ST
Suite No
Vicinity:
Parcel Nunmber. 42542310
Applicant: ANITA CRUZ
Address: 935 ALMOND DR
ISSUED BY:
Status: ISSUED
Applied: 11/24/2003
Issued: 11/24/2003
Phone: 714-308-8730
BREA, CA Zip: 92821 -
Owner: HUDDLESTON, DONALD I TR ���"
Address -� 2161 SAN JOAQUIN HILLS RD ���qqq VrA
Phone: 'ty, L 101
NEWPORT BEACH, CA Zip: 92660 �f 7��
Contractor:. OWNER -BUILDER
Address:
Phone:
Zip:
License: 000000
SCOPE OF PERMIT
INSTALL A 20.8 S.F. BUILDING SIGN TO IDENTIFY THE FOOD MART. REF.: SB03-00118
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 authodzed under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
2x46-36(6/00)
FEE SUMMARY
Quantity
Quantity
ISSUE FEE
$23.50
Temp Dist System / Lighting
$0.00
0
Temp service test
$0.00
Busway /100 It
$0.00
0
Res. a/c package
$0.00
Standing Section
$0.00
0
New Res (1-2 units)
$0.00
0
Misc Electrical Equipment
$0.00
0
New Res (3+units)
$0.00
0
Transformers up to 1 kva/kw
$0.00
., 0
Pool / Spa
$0.00
0
_ : -'.. :::.::.........up to 10 kva/kw
$0.00
0
Lighting. Fixts
$0.00
0
- ,-. .............:...up to 50 kva/kw
$0.00
"- 0
Recept Outlets
-. $0.00
0
.................up to 100 kva/kw
$0.00
0 ,
Switches
$0.00
0
..................over 100 kSa/kw - -
$0.00
0
Non Res App, .
$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 dde)
$0.00
0
Motors to 1hp
$0.00
0
Circus (meth ride or lights)
$0.00-
0
Motors to 10hp
$0.00
0
Christmas Tree Stand
$0.00
.0
Motors to 50hp
$0.00.
0
Fireworks Stand
$0.00
0
Motors to 100hp
$0.00
0
Other Electrical Fee
$0.00 -
Motors over 100hp
$0.00
0
Communication drops
$0.00
0
Investigation Fee
$0.00
Sub panel to 200a
$0.00
0
,
Plan. Check Fee
$0.00
Pole Light Pkg
$0.00
0
Reinspection Fee
$0.00
Sign Circuits
$24.60
1
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work Is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authodzed under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
2x46-36(6/00)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I herebyaffirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of consent to self-Insure for workers' compensatlon, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is Issued.
❑ I have and will maintain workers' compensation Insurance, as required by section 3700 01 the Labor Code, for the performance of the work for which Ws pertdt is Issued.
My workers' compensallon Insurance carder and policy number are:
Cartier Policy Number:
(This section need not be completed It the permit valued at one hundred dollars ($f 00) or less.)
I certify that in the perform rice
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'
mpensati'm laws of G mIa. and agree t . t if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall forthwith
oomply with %hese provi to s.
Applicant Signature: Date: it 1
WARNING: FAILURE TO SECURE WORKERS' COMPEN AT10N O0VqtkN1E IS UNLAWFUL AND SHALL SUBIECT AN EMPLOYER TO CRIMINAL ENALTIE AND Cn< FINES UP TO ONE HUNDRED
THOUSAND DOLLARS (51011,0001, IN ADDITION TO THE COST OF CO7PE ATION, 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 o1 Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In fug
force and effect. Uc. a Class N
Contractor's Signature: Dote:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lenders Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby alfirn that under penalty of perjury that 1 am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or County which requires a permit to Construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (5500).):
❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors Ucense 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 seta. 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 conlraclor(s)
license pursu t to the Contract s License Laws.).
❑ 1 amexam u der sec Business an Professions Code for this reason:
Signature: / Date:
Owner ID ver fl y delvers license. ❑ s ❑ No Drivers License No. Ex res:
Verification of Ownership by (type of docume . -property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby cerffty that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made in connectlon with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (38) fast high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, Celifomla 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: Data:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 WIII the applicant or prosnl 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 Celifomla Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
.........................__.................—............_—__.____..__..__.._____...........__..................__............................................................._....._..__........._�..._
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 01 the Califomla Health and Safety Code, with some exceptions. requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials aqua to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of
compressed gas at slandord temperature and pressure).
3 Does Or will theappplicant or present or future building occupant need to prepare an RMPP (Risk Mntanagemeand Prevention Program for awlety hazardous materials)?
❑ Yes ❑ No
(Section 25534 of the Celifomla 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 Dy businesses which are required to register acutely hazardous materials with the Fire Department.
.....................................................................................................................................__...._..............................................................................._.........................I......................... ......................................... _.._...._............_.
4 Ii en RMPP Is presently required, has Section 25534 of the California..... Health and Safety Code been fully compiled
with? ❑Yes ❑ No
................_._...............___............—_._............................................_..__....._..........__........................._.............................................................. ................................................. ...__....................................
5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication aEEerrnit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Byes IJ No
(Section 65650.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residentlal building permits).
fi Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? [J Yes ❑ No
(If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
..............................................................._...................................._.........................._._......................._..........................._..............................................................................-.____._.........—...__.
7 Iia 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
B (I1 yes', edech 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: Data:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certity 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 Costs 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.
alure Of Legal Owner(s) D t
)VWQr oozed Applicant D e
CODE E. INSPECTION TYPE 2AR INTIMAL $ CODE] INSPECTION TYPE tin¢, INTRIA{�
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 206 Final Plumbing
200 Final Re-Root 210 Final Electrical
201 Final Block/Retaining Well 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
. CITY OF COSTA MESA
BUILDING DWISION
F DEVELOPMENT SERVICES DEPARTMENT
o PERMIT /—PE-4RMlMB—ER_
B98-01360
(714) 754-5273 • Fax (714) 754.4856 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address: 195 E 17TH ST Status: ISSUED
Suite: Applied: 07/30/1998
Vicinity: Issued: 09/25/1998
Parcel Nunmber: 42542310 Zoning:
Applicant: ANDREA FISCUS, G&M OIL COMPANY
Address: 16868 "A" STREET - -
�/ ; r Phone:= (714) 375-4700 X 327-
HUNTINGTON BEACH CA; - Zip: 92647 -
i
Owner: HUDDLESTON DONALD I TR / \\
I /
Address 2161'6AN'JOAOUIN HILLS RD
- - /
%- 'Phone -��-
/,ZNf/'E�T(��CH CA /i Zip 92660N
Contractor.
Adiiress:
�r Phone:
",7l Zips
�/ > Licensee
J
/Arch /Eng : � _ � • • • t , - �,
Address
h V.n
l _ Zip. \
License: '`�
SCOPE OF PERMIT L
REPLACE GASOLINE DISPENSIERS AND, UNDERGROUND PIPING. REMOVE EXISTING CONCRETE &/ 1
REPLACE WITH SAME.
' NOiINCREASE IN NUMBER OF DISPENSERS PROPOSED ;
-
X.
w _ FLEE SUMMARY
Plan Check $146.09 / Calc Valuation. $15,000.00
�\ Permit \ `,1$224.75
—, Claim Valuation: $15000.00
SMTP Res:�� �,A`$0.00
SMTPvCom: v $3515 -A
\Otlier:--' $0.00 '
Inspection: $0.00
Totah� $37399�\
PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front�0- 0 �� 'Rears ' 0-6 - 'Left 0-.0 Right 0 0
ACCESSORY Front 0- 0 -- Rear ; 0-0 "Left 0-0 _ � � ��Right 0-0
PARKING Existing: 0 Required: 0 'Proposed: -0
NOTES:
EXPIRED
DATE 2o O
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
s�
ri
�j
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of penury one of the following declarations:
❑ I have and will maintain a certificate of consent to sell -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is Issued.
❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My work compensat�ion 1I1n--su,rpnce carder and policy number are:
Carrier: rllJ�ll7 / Policy Number: -
(This section need not be completed if the permit is valued at one hundred dollars ($ f ) or less.)
❑ 1 certify that in the pe onnance of the work for whic this pend l is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of allfomi rid agree that If I s o Id become subject to the workers' compensation provlslons of Section 3700 of the Labor Code, I shall forthwith
comply with the pr s as.
Applicant Signature: Dale: 1 - X5 - IU
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVIERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of he ter 9 (commencing with Section 7 ) of Division 3 of the Business and Professions Code, and my license is in full
force and effect. tic. 11 Class P 8 r I ffF+2-
Contractofs Signature: Date: q - Z - q e
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this pennil 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 provislons of the Contractors License Law (Chapter 9 (commencing with Section 7000) 01 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 Ucense Laws.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires:
Verification of Ownership by (type of document, Le. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation live (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 WIII 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 forth for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
....................................................................................................................................................................................................................................................................................
3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ No
(Sectlon 25534 of the California Health and Safety Code pro -Ades 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 II an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑Yes ❑ No
......................will.......appl.............................. future
buil..........................quir..........................hich.................ject.. f thi..............tion.................................nstructi........... modification 5 Does or will the applicant u present or future building occupant require for the work which is the subject c this Nplicatlon apermit for such construction or motlification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes ❑ No
(Section 65850.2 of the California Government Code requires that the requested information be 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 apemnit 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? ❑Ves ❑ No
....................................................................................................................................................................................................................................................................................
e (If yes', attach certificate of compliance from the appropriate air pallufion 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 lawsand city.ordinancos relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for InI 9pect�oIT
purpSG u a a not to occupy or allow occupancy of any building authorized by this permit until final inspection.
lag
Of al rte s) Date
And/Or Au zed Applicant Date
C01111 11. INSPECTIONTYPE RATE ti muLS CODED INSPECTIONTYPE RATE I)IiITIA
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Rcot 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 - Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
2" 4e
Milillili
I
i
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesaalllDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 195E 17TH ST
Suite:
Vicinity:
Parcel Number: 42542310
Applicant: FISCUS, ANDREA
Address:
Zoning:
Phone: 714-375-4700
Zip:
Status:
ISSUED
Applied:
12/06/2001
Issued:
11/06/2002
ISSUED BY:
{�
'l
Owner:
HUDDLESTON, DONALD I TR
Plan Check:
1��
Address
2161 SAN JOAQUIN HILLS RD
SMIP Res:
4
�
SMIP Com:
$16.80
Other:
ti�
Inspection:
$0.00
Phone:
NEWPORT BEACH, CA
Zip: 92660
i< '
Contractor:
DIAMOND POINT CONSTRUCTION
Address:
. 1521 CAMINO LOS-ROBLES
" '
Phone: (714)738-1803
FULLERTON, CA
Zip:
92833; ,'
License: 657594
Arch : Eng: RFA INC.
Address: Address: 2050 S. SANTA CRUZ
- - Phone: - .. SUITE 2100 Phone: 714 938-6090
1 ANAHEIM, CA
Zip: License: 92805 License: C42980
SCOPE OF PERMIT
INTERIOR 1459SF TENANT IMPROVEMENT TO EXISTING BUILDING. CONVERT TO FOOD MART. SEE PA -01-30
Total: $1,425.49
PLANNING & ZONING
SETBACKS
MAIN STRUCTURE Front o-6 _>� -: Rear 0-0. - Left 0-0 Right 0-0
ACCESSORY Front 0.0 Rear — 0. 0 Lett 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 requirement/tntthe
Cal
'if 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 daysuspended 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 ccapplicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will piration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626
2"6.46 (600) /
FEE SUMMARY
Plan Check:
$554.94 _.Calc Valuation: $80,000.00
Permit:
$853.75 Claim Valuation: $80,000.00
SMIP Res:
$0.00
SMIP Com:
$16.80
Other:
$0.00
Inspection:
$0.00
Total: $1,425.49
PLANNING & ZONING
SETBACKS
MAIN STRUCTURE Front o-6 _>� -: Rear 0-0. - Left 0-0 Right 0-0
ACCESSORY Front 0.0 Rear — 0. 0 Lett 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 requirement/tntthe
Cal
'if 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 daysuspended 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 ccapplicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will piration of this permit.
FOR INSPECTIONS CALL: (714) 754-5626
2"6.46 (600) /
DECLARATIONS
WORKER& COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations: r
❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit Is issued.
I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit U issued.
/�_ My workers' camps satlo Insurance mer antl policy number are: /I TT
' :Cartier �-�hla-e Policy Number: (e::, Wo
(This'sectfon need not completed i/ the pew-rtn()11 r valued et one hundred ticllars ($100) or less.)
❑ 1 certify that in the patio soca 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'
comperwation laws of a fomia, antl more at If I should become subject to the workers' compensation provisions o1 Section 3700 of the Labor Code, I shall forthwith
complyfwith these pr vi I ns.
Applicant Signature:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVE GEIS UNLAWFUL AND SHALL IMINN SUBJECT AN EMPLOYER TO CRAL P In S AND CIVIL FINES UP TO ONE HUNDRED
I.L
THOUSAND DOARE ($1oe,ODe), IN ADDITION TO THE COST OF NSATION, DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
1 hereby a Ihlthlll am %ansed under provisions Chapter 9 (commencing with Section 7000) of Division Busin and Professions Code, an y license is in full
ferce�mri_CLBiaG,-UC' Glass j
Contracto ss Signature: ales
r
CONSTRU(' ON.LENDING AGENCY:
❑ `I firb,11, Ih�aLdM is Monstruction len' ing agency.foMhe pertortna ce of the Wdrk idr vihic6 this,pe Ilis Issued.'(Sec.3097; GIvil CotleLencer'ta+tm'+�`"t•�:Signa urs:iww - Date: ?1
OWNER -BUILDER DECLARATIONS:
"_T)
I hereby affirm that.untl77er,De_nalty of perjury that I em EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or oourity;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 lie orshe�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) oi.that heror 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 ofrnot'r6e than five hundred dollars ($500).):
1p f
❑ I, as owner o1 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,Cotla: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires:
Verification or Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 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 WIII 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).
_____......................__..............plican..........................._____...........ildi.................._....__............file..a regi......................._....................._....___.___............... .........._._...... o. ....
......._......... ___........ _.__
2 Does or will the applicant or present or future building occupant need to file a registration form far acatery hazartlous materials? ❑Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazartlous 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 me Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
.................................................................................................................................. .............................................................................................. __....................................................................._............E.....................__............................_
4 II en RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No
_.............__...._.................appli__............................._.._.._.._._.____....................._........................_.............s the su......._................._...__.......io.............._........_._._..._.._....._._tion or ....odifi.cati._....
5 Does or well the applicant u present or future building occupant require for the work which is the subject c ? a plication aggarmil for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? � Ves LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
........................_.-............................_..............................._.._................_..._..............................___..............................._......._..........._—..................._............................................__..............____................— .... _................
e Wiil any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
(11 yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
........................................................................................................._.......................................__.............................._.._........................_._.................................................................................__._....__......................_......_.—.
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ 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: Dere:
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.
51 ture O1 Legal Owner(s) D
at j j
A ut o Applicant Dates- "'
CODE INSPECTION TYPE QA3 ILLS CODE INSPECTION TYPE 21131 IKITTA
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
City of Costa Mesa
Building Safety Department CERTIFICATE OF O C C U P A N C Y N? 2373 C
P. O. Box 317
Costa Mesa, California`1
The Building located at 20 Eaft 3.7ft eumt
has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto
for a Group `�el Occupancy.
Use of Building Smim
Otatim mf
Legal Description J_1°
- (Sea reverse side for Metes and Bounds)
Building Permit No. � - Electrical Permit No. gsl+uPlumbing Permit No.
Floor Load Signs have been installed as Room Capacity Signs have been instaled as
required under Sec. 2308 U. B. C. required under Sec. 3301 (1) U. B. C.
17050. CERTIFICATE OF OCCUPANCY. (a) No apartment house, hotel, or lodging house shall be used or occupied
until the owner or operator has been issued a valid certificate of occupancy by the enforcement agency.
(b) A new certificate of occupancy shall be obtained whenever there is a change in:
1) Occupancy classification of a building or portion thereof
2) The number of apartments or guest rooms
3) Ownership
If Group H Occupancy, number of apartments and/or guest rooms as required under Sec. 17050.1 (d), California
Administrative Code, Title 8, Chapter 9, Article 8.
Number of apartments_ and/or guest rooms
ISSUED TO: Building Official
by
Date—MW2QiS0 t
This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed
except by the Building Official of the City of Costa Mesa under Sec. 306 (e) U.B.C. Form Bv34—IM-11-e3_s13 r
11 24914A
MESA, !CITY CF C v 3 .'.
COSTA MESA BUILDING -SAFETY DEPARTMENT
' p.0. BOX 1200 COSTA MESA, CALIFORNIA 926M•
- NOV 1'? '19"5Q�11��•5
1.7-1965
For Applicant to Fill In Compbhly
PLICATION FOP R
' TYPE AOR PRINT
_ _ UL
J
ADDRESS
_
R[C[IR NO. 1 M{2 Nl
COSTA • MESA. CALIFORNIA,
"IN: Y DA R[C IV[� �T[)saU[DS_
OWNS L' Ii..
y
MAILADDLDING
�-
J-7
ADDR
�j� _ TY A'cfu�,. N
CI)
FIR[
ZONE TYP GROUP
.Jkv3
j� 11JJ _ _
ARKRRK...,F. SE T8L 3-ui '
APPROVED DATH%� 6-b•s
Br'•
ENj7
C$ pS.li' 1L
ZONINGQ
DDRHIIII on
CD
ZONE NO. or �UW
BUILDING / FLAN/ �-UILDINGILDING U/ 3 4A11r'P a4
CONTRA
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r
D G U S � '
D�nclLilmo b'J• '. bo?
•
ADDP (�
E`1'V�F�n( ...
A. P. NO. I Z? -B
CRY
nATN `//�� --z3o`jZi -NL
NOTE: NO SAVE OVERHANG SHALL DBLEHS THAN
BO•TO 81DeBREAR .L
oiSl
/3 5-X/ SO
'.EAVES' -
HIZE NO.OPBLD49. I
ALLOWED (U. B. C. REQUIREMENT)
OF LOT NOW ON LOT
bB APPROVED
--APPROVED YAR
USEOP ...,���r�.. ,,,.� l'
EXI8TIN0 BLDO.�� ICC �l •�-1 1 """I
_
MAINBUILDINO ACCHS RY BU I LDINO
.,(FROM C/L fTRH[T>-- A
BHTDACK LINK FROM
CENTER OP STREET REAR YAR
FRM I
4'
� _
61D YAR LEFT RIGHTR.
I
ID 0' i J FT.
DESCRIPTION OF WORK
'REAR 0 FT. • /L PT. "/
JEW ALTERATION ADDITION
IF
DISTANCH BET. -' BET. M�A B
REPAIR MOVING DEMOLI
MAIN HLD02. ACCESS. BLDGS.
BUILDING , NO. OF
SIZE ROOMS RI
VAR. DATE
C. P. C Ga' bS APPROVE.D/
CEO ERI NOOR L I ROOF COVERING fL O
MFROVB�i`
my
DATE !!!
UK[ OF BYILOINS AND WORK TO BE PERFORMED
HOLD FOR SPEC
1 LQumE:'dLt;'T"5
D,
— (t i= S
w
— Z4 -)c s—o '-Z4-,ez
CA -•.(CD P `F's
IIQ. FT.
x
I HEREBY ACKNOWLEDGE THAT.1 HAVE READ THIS APPLICATION
AND STATE "AT MR ABOV9,I9 CORRECT AND AGR[[ TO COM•
TN9 AMOUNT /MOWN UNDER VALUATION 19 FOR TH1
►URPOBI OF ■RTABUBNING A PERMIT PER ONLY.
PLY WITH ALL CITY ORDINANCES AND STATE LABY R[YULATING
BYILDINO CONSTRUCTION.
VALUATION 00
7
SIGNATURE O, W � .:� _ ` C
PHRMI7 RE8
PBRM17T8
' QI OO fJ
S o o O
o
w
AUTHORIZED AGENT ✓
I Is y 5�
TOTAL BOB D V
HQLD FOR SPeeTAL REOUiRF `
dApr I �V (1 rr� MF C
�PECIAL-R QUIHN'MN:NTS:
I. -,Dedication.-6f the following land to the City of Costa Mesa for
I—st`reef_par 'oses:- (a) All land -40' -from the center line of -E-.
17th.Streeet; (b) Dedication_ of land necessary -for a spandrel
at the southwest corner of E. 17th Street.•sind :Orange Avenue under
the direction -of the City. Engineer; - - -
__2. The'owner,- at -his expense, immediately removes the existing
curb, replaces new curb -4'- back of existing curb line (32'.from
- - the . center- to - ew curb line) and -makes- the=necessar-y-stree C'-
improvements between the"new curb: and %he existing pavement.under
the direction of the -City, Engineer; 'on,E. 17th Street, t - ,•
3.- "Peimit toAe-lobtainefl-from' the -Fire -Department -to-remove-existing
_ - tanks;_permit.to-be,.obtained from the Fire Department to install -
new -tanks; -- .— ,- — — -
.4 -Installation "of -4-.$ "foot sidewalks -from -back of. curb .and' -concrete-
_ drivexay_appr_oaches•on.Orange Avenue and E. 17th Street, per. -
standard specifications of_the-City -cif Costa -Mesa, -ate
th-_ - ----
-- `exp ense--of-the__owner-aiid/or applicant. "_ _ _.- -__ __-_ _ -
5. 'Corner masonry :planter. -to 'be constructed similar to Planter -Detail
1 A. Detailed plans of material and type -of plants -to -.be -submitted
;to -the, Director of Planning •_
_'
•11`:6.,, -Add tional landscaping shall be.provided on Orange •Avenue to .:
coincide W_ItFi >r.. 17th Street-beautification=plan-, at -expense:
' of owner. or -applicant; --
I_- 7_, .Curbs, gutter,, base.and„paving to be constructed on E. 17th
street per standard specifications -of-ihe'City-of-•Costa-14esa; at
---- expense of-owner'and/oroapplicant;
.Tree wells to be.located and tree planting; to be compatible to the
j surrounding area iuider the direction-of'the Street Department. --
7
25338
"COSTA MESA BUILDINGSAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For Applicant to Fill In Completely I
TYPE OR PRINT
BUILDING /;�7-
COSTA MESA. CALIFORNIA
MAIL
SIZE
USE
BLDw.
SETBACK LINK FROM
DESCRIPTION OF WORK
IHUR68Y ACKHOWLBRE
DOE THAT 1 HAVE AD TRIG APPLICATION
AND "AM THAT THE ARRVIC 18 CORRECT AND AGREE TO COM.
PLY WITH ALL CITYDCp ANO STATE W8 REw LATINO
BUIL DING CONBTRY ON:
SIONATU REO ����� �/f /
PERMITTEP -� _
AUTHORIZED AGENT
CITY 'Of C 3SI A MESA
FEB 25 1966
APPLICATION FOR PI
RECEIPT NO.
V�I1z1VMJ<L9VfNJVP(L(/s
T
M7
OR REC2D
26/C{/
'-1/0�
r
s — U SR
PIRG
ZONE 8 GROUP.
APPROVED
BY DATE
ZONING
ZON4
•
ANO. OP
Puns O
USK or NKW
BUILDING
LEGAL
uncmmQX • .�C..
A. P. NO. O — 3
NOTE: NO SAVE OVERHANG SHALL BE LESS THAN
DO' TO SIDE a REAR P. L.
EAVES
ALLOWED (U. B. C. EQUIREMENT)
YARDS APPROVED
MAIN BUILDING
Y 3 APPR ED
• RY B .IJINO
1 FROM C/L STREET)
FRONT FT.
R.SIDE FT.
FT.
L.SIDIII rr, I
1
FT.
REAR
FT.
DISTANCE BET. l
MAIN BLD00,
BET. MAIN d
ACCESS. BLDOS.
VAR.*
C.U.P.
DATE
APPROVED
APPROV
By
DATE - S
SQ. PT. il
THE AMOUNT SHOWN UNDER VALUATION IS FOR THK
U
PRPOSE OF ESTABLISHING A PERMIT PER ONLY.
VALUATION
f goo
(lO
PERMIT PEE
PLAN CHECK 5
TOTAL FEE
31602
' COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For Applicant to Fill in Completely
ADDREBUILDISS "" 946
OWNER Si r�
MAIL /n^�
Z ADDRESS to C).
t>_ U CITY 6j' NOL. S 33-13'Y
Z
z< CONSTRUCTION
dLENDER
M
J BRANCH
J N
Q w ADDRESS
ARCHITECT TEL.
N OR ENGINEER N
L) Q
W ADDRESS
d W
J O CONTRACTOR
. m Z
J ADDRESS, 8J L ,r W • -"/'
W W
0 = TEL.
Z CITY
0 STATE o CITY ����}}
ina: U0. NO. I - �� LIC. NO. 496
SIZE.ir NO. OF BLDGS. Ap
OF LOT S SD r NOW ON LOT F
USE OF !�
EXISTINGBLDG. IK
SIZE OF NO. OF
z NEW BLDG. ROOMS STORIES
ta-i EXTERIOR WALL ROOF
_ COVERING COVERING
J USE OF BUILDING AND WORK TO BE PERFORMED
1
0 c b0 6
U)
Cn Q LIQ
z
0
VI hereby acknowledge that I have read this application and state
L) that the above information is correct and agree to comply with
cc all laws regulating building construction, and I shell not employ
F any person In violation of the workman's compensation laws of
H the State of California.
Z I hereby certify that I am properly licensed as a contractor under
the State of California Busine55 and Professions Code, Division 3,
Chapter 9, and that such licenses are in full force and effect, or I
am exempt from the provisions of the State of Cellforni usiness
and Professions Cotl . ision 3 Chapt�B
Signature of
Permittee
Authorized Agent
APR-6-7CCPH;A00 451 4"t"*10.00
APPLICATION
�FOR
(/BUILDING PERMIT p,
REc 17-' V DN �D / �D /in7 i7 757,
VALUE
APPROVED
LZONE
�/ PLA NS �l BUILDING EW4;fr /
YARDS APPROVED YARDS APPROVED
MAIN BUILDING I ACCESSORY BUILDING
REE
C.U:P. #
APPROVED
BET. MAIN &
ACCESS. BLD
DATE
SO. FT.
O
THE AMOUNT SHOWN UNDER VALUATIONIS FOR
THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
2
VALUATION
�`
m
PERMIT FEE $1e),
j
m
S A_Jt //
PLAN CHECK 5�—
E
t
LL
L
TOTAL FEE $ / f
4-)77h
COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
For Applicant to Fill in Completely — Use Ink Only
BUILDING
ADDRESS j 7 s
OWNER, �/�/-�.�L /J/
1C_ /\G1_ NOL
CITY
IPT PAID
a01157+`
I FOR STRUCTURAL PERMIT
J
n
m
i
m
IS FOR mO
ONLY:
a
m
��p U
��tJ
BRANCH
�+ /
OWNER tJ
ADDRESS
i
ARCHITECT TEL.
USE QaUES
R ENGINEER
FIRE
ADDRESS
ZONE oP. TYPE GROU
CONTRACTOR �'.Jf
L ��_
APPgOV ED
BY DATEL4
ADDRESS /�
NE/'//�
NO. OF
USE OF NEW
CITY�V NO. 3�S
r
PLANS
BUILDING
F
STATE CITY
YARDS APPROVED
YARDSAP
/
41 C. NO. 6�. 7 LIC. NO.
MAIN BUILDING
ACCESSOR
SIZE
NO. OF SLOGS.
(FROM C/L STREET)
A.
OF LOT
NOW ON LOT
FRONT FT.IBET.AIN
Q
USE OF
EXISTING BLDG.
R. SIDE
y
Separate permits are required for
L. SID T.
electric, plumbing and heating work.
G1
REAR
FT
W
USE OF BUILDING AND WORK TO BE PERFORMED
'CE BET.
AF
MAI
MAIN BLDCS.
ACCESS. BLDG
VAR. yy+
DATE
W L
C.U.P. 46
APPROVED
Q
7
/
APPROVEV7
'
r
�
a
w
0
1 hereby acknowlad Bo that I have read this application and state
[�
that the above information Is correct and agree to comply with
G,
all laws regulating building construction, and I shell not employ
Z
any Person in violation of the workman's compensation laws of
Sthe
State of California.
3
I hereby certify that I am properly licensed as a contractor under
SO. FT.
THE AMOUNT SHOWN UNDER VALUE
the State of California Business and Professions Coda, Division 3,
Chapter 9, and that such IIS�• sea ereIn ull force and effect, or I
THE PURPOSE OF ESTABLISHING A PERM
am exempt from the prov(sio sof the ate of Business
antl Professions Code, Ivi n 3, Ch er 9.
VALUATION
PERMIT FEE $
PLAN CHECK $
yu,
!/t
Signature of
Permittee
�^_�/s syr] .�
$y�CP (/
TAX $
Authorized Agent s
TOTAL PAID $
J
n
m
i
m
IS FOR mO
ONLY:
a
m
��p U
��tJ
1419 4/22/81 10.50
COSTA MESA BUILDING -SAFETY DEPARTMENT APPLICATION FOR STRUCTURAL PERMIT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
RECEIVED,BV PERMIT
For Applicant to FID in Complet ly —Use Ink Only!
�`sK//�•
BUILDING
A.P. NO, r�
ADDRESS =
OW
BUILDING /
TE lz
ADDRESS
UNIT OR
MAI LIN
SPACE NO.
ADORE
E .
CIT �O
TR.NO. LOT B BLK.
NEW ADD ALTER REPAIR MOVING DEMO ISH
-CONSTRUCTION
LENDER
BRANCH
NE L D•
ADDRESS
;UE
/QUO
ARCHITECT TEL.
US�V
OR ENGINEER N
ADDRESS
ZONE TYPE GROUP
APPROVED
C
BY DATE — Z'
A
CI
STATE CITV
APPROVED SETBACKS
LIC. N /✓ LIC. NO.
SIZE 1. NO. OF BL r�r
I
(FROM C/LSTREET)
OF LOT NOW ON LOT
FRONT
USE
EX gr
Separate permits are required for
L SIDE FT.
electric, plumbing and heating work:
REAR FT.
USE OF BUILDING AND WORK TO BE PERFORMED
PLANNING ACTION
DATE
APPROVED
APPROVERVD
y ti
I hereby acknowledge that I have read this application and state
that the above information is correct and agree to comply with
all laws regulating building construction, and 1 shell not employ
any person In violation of the workman's compensation laws of
the State of California.
I hereby certify that I am properly licensed as a contractor under
SQ. FT.
the State of California Business and Professions Code, Division 3,
THE AMOUNT SHOWN UNDER VALUATION IS FOR
Chapter 9, and that such licenses are In full force and effect, or 1
THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY:
am exempt from the provisions of the State of California Business
VALUATION PERMIT FEE $
and Professions Code, Division 3, Chapter 9.
PLAN CHECK $
Signature of
Permittee
$ / TAX E S (7
o
r
Authorized Agent Date
f/
TOTAL PAID E D.
. -COSTA MESA BUILDING -SAFETY DEPARTMENT
P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626
r
icant to Fill in Completely — Use Ink Only
Iq5
/
I Q SUA
U I NI f
W Y))2.NOL.
APPLICATION F6k7STRGeTQkA1L PERM IT335.76 TL
A.P. NO. `� t
BUILDING /
ADDRESS U
UNIT OR
SPACE NO.
iR. L
N ADD
OWNER
DATE
APPROVED
CLan
ADDRESS
Few
ECT ��_/ �L TEL.��
ARCHITECT
USE L
p(the
L
ORENGINEER CCK.
DEMOLISH
ADDRESS (
•
�7 ��t7
CONTRACTOR &,4 LY _
APPROV ILS r
BV
E GROUP
ADDRESS 1L(,1AJ4(S
I
.�j.. TEL.
33(o,7a
rr ( i-
i' 0
CITY J NO.
m
w
f.Fa
STATE CITV 2#34(,
APPROVED SETBM
s /
LIC. NO. ! l-77 % LIC. N0.0�7.J'1'b
SIZE r / NO.OF BLOCS
/50
(FROM C/L STREE
4
OF LOT )L ]� NOW ON LOT
RONT FT
a
USE OF
exempt
Lo
EXISTING BLDG.
R. SIDE F
y
S S
FSeparate
permits are required for
L. SIDE FT
electric, plumbing and heating work.
m
G
ature of.�le�. /N�PLAN
/��
REAR FT
[w.
USE OF BUILDING AND WORK TO BE PERFORMED
PLAG
a
TAX
8
f
o'ttae
oriaetl Agent Date
TOTAL PAID
.78
S�3
..7
a
w
DATE
APPROVED
CLan
J
BLK.
p(the
L
REPAIR MOVING
DEMOLISH
VALUE
4T J Q $
...
zperson
in violation of the workman's compensation laws of
f
Ur
E GROUP
6 d
ATE
:3
rr ( i-
i' 0
m
w
3reby
certify that I am properly licensed as a contractor under
SQ. FT.
s /
s
DATE
APPROVED
CLan
reby acknowledge that 1 have read this application and state
M
p(the
L
above information Is correct and agree to comply with
allws regulating building construction, and I shall not employ
/
/ Dp� cL�
...
zperson
in violation of the workman's compensation laws of
tate of California.
/ %
�`"
%�
r✓
m
w
3reby
certify that I am properly licensed as a contractor under
SQ. FT.
tate of California Business antl Professions Code, Division 3,
THE AMOUNTSHOWN UNDER VALUATION
IS FOR
mter
9, and that such licenses are in full force antl effect, or I
THE PU)iPOSE OF ESTABLISHING A PERMIT FEE ONLY:
exempt
from the provisions of the State of California Business
VALUATION
PERMIT FEE
S S
Code, Dlviston 3, Chapter 9.
,QpProfessions
m
ature of.�le�. /N�PLAN
/��
CHECKLL
TAX
8
f
o'ttae
oriaetl Agent Date
TOTAL PAID
.78
S�3
Applicant to fill In all spaces within heavy border lines and sign all appropriate declarations.
-CITY PF COSTA MESA
PER MM�I O
TRACT NO. LOT NO. BLDG. NO.
-
CONSTRUCTION PERMIT
��
T,�Y,/PE_OF CONSTRUCTION
�l1J--1 NEW ❑ ADD ❑ ALTERATIONS
REPAIR ❑ CONVERSION In' SH
33_-6
6/q 3/84 28.00
Project Address %
Owner `7 G Phon
Address
/�
Jam-'
❑ OTHER
ZONING REGULATIONS
Arch/Eng. License No.
Q//1/-t�r9�
DESCRIPTION OF WORK
6A.P.
PLNTGp.
Address
Contractor Phone
TYPE OF PERMIT
❑ GRADING ❑ FOUNDATION ❑ STRUCURAL
❑ TENANT ECTRICAL MBING MECHANICAV
UILD NG
CK C ST.Address
DLICENSED -
gRtEF�.piP
PROPEIRTLNLINE
CONTRACTOR DECLARATION
1 hereby affirm that 1 am licensed under provisions of Charter 9 (com-
E3OTHER
RIGHT
mencing with section 7000) of Division 3 of the Business and
Professions Code, and my license Is In full forte and effect.
REAR YARD (TO P/L)
PROJECT DES IPTI
License Class License No.
SO. FT. -
PKG. SPACE RED.
-
PROVIDED
-
Data Signature
OCCUPANCY_ CO NST R UCT ION TYPE
STREET WIDTH
ZONING APPROVED BY
PARK FEES
DATE
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -Insure ora
VALUATION ZONE
certificate of Workers' Compensation Insurance, or a certified copy
CONDITIONS:
thereof (Section 3800, Lab. C.).
GRADING CU. YDS. ACRES
.SPECIAL
Policy No. Company
Certified copy Is hereby furnished.
REMARKS:
Certified copy Is filed with the city Building Division.
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
-
(ThlS sects on need not be completed if the permit 15 for one hundred
-'
--
--
UDI or le55.
1
_
SEl
tart fy [hat n the performance of the work for which this permit Is
Issued, I shall not employ any person In any manner so as to become
PLUMBING PLAN CHECK
ELECTRICAL PLAN
CHECK
subject to the Workers Compensation Laws of. California.-
BATHTUBS SHOWERS
-
ate Signature
NOTICE: If after making this declaration. you should become subject
TOILETS URINALS
GENERATOR 0-1 KW_
1-10 KW
to the Workers' Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed
LAVATORIES DOUBLE LAVS
0
TRANSFORMER
APPLIANCE 10-50 KW_50
+ KW
revoked. _ ..
KIT. SINKS DISHWASHERS
,MOTORS 0-1 HP
HP
CONSTRUCTION LENDING AGENCY
-1-10
I hereby affirm that there is a construction lending agency for the per.
SERVICE SINKS 'SUMPS
(INC. SOLAR) 10-50 HP
50 + HP
rmance of the work for which this permit Is issued (Section 3097
FLOOR SINKS FLOOR DRAINS
FIXTURES OUTLETS
SWITCHES
iv. C.).
Lender's Name
Lender's Address
DRINKING FOUNTAINS
GAS TUBE SIGNS
INTERCEPTORS CLARIFIERS - -
POLE LIGHTS
'
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from.the Contractor's License Law for
SWIMMING POOL - PTRAP
POLES METERED
SUB
the following reason (Section 7031.5 Business and Professions Code:
Any city or county which racul,os a permit to construct, alter,
WATER SERVICE ALTERATION
PANELS MAIN
SUB
Improve, demolish or repair any structure, prior to Its Issuance, also ro.
quires the applicant for such permit to file a signed statement that he
GAS SERVICE OUTLETS
SERVICE -
AMP
Is licensed pursuant to the provisions of the Contractor's License law
9 (commencing with Section 7000) of Division 3 Of the
WATER HEATERS BTU OUTPUT
(�
E(Chapter
usiness and Professions Coda) or that he Is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031.5 by
SEWERCONNECTIONS'
' any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).
SOLAR TANK- COLLECTORS
❑ 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
_
!I or offered for sale. (Section 7044, Business and Professions Code: The
SOLAR PIPING SVS.
ISSUE FEE
Contractor's License Law does not apply to an owner of a property
who bulltls or Improves thereon, and who does such work himself or
ISSUE FEE
APPLICATION APPROVED BY
DATE
his own employees, provided that such Improvements are not
ihrough
ntended or offered for sale. If, however, the building or Improvement
MECHANICAL PLAN CHECK
SUMMARY OF FEES
Is sold within one year of completion, the owner will have the burden
BUILDING
ot_P Gng he did not build or Improve for the purpose of sale).
HEATINGSYSTEM 0.100,000 BTU
PERMIT E
SMIP E
['J I, as owner of the property, am exclusively contracting with
AND DUCTING
licensed contractors to construct the project (Section 7044, Business
100,000 + BTU
PLAN CHECK $
PERMIT
and Professions Code: The Contractor's License Law does not apply to
ISSUANCE $
an owner of property who builds or improves thereon, and who ton-
REFRIGERATION 0-100,000 BTU
PLUMBING $
tracts from Such projects with a contrdttor(5)-Iicesnetl pursuant l0
SYSTEM
GRADING E
the Contractor'sLicense Law).
100,000 + BTU
PLAN CHECK S
❑ I am exempt unae Section B. & P. C. for this
-
BOILERS BTU
ELECTRICAL S
S
reason - ^ I
-�s-y
SYSTEM REPAIR, ALTERATION `I'
PLAN CHECK.. E
s•` -
MICROFILM E
TOTAL FEE E
it///Jy A' ��f/ �' r
Date n,,,�. r
� o
ECH
•MECHANICAL 9 -
I horebycertif that I have read this applitdtipn and state that th¢ above
EXHAUST SYSTEM MULTIPLE
LESS AD -
information is correct. I agree to Comply with all city and county
PLANCHECK E
VANCEPC E_
ordinances and state laws rete ng [o construction, and hereby au or' e
representatives Of hI5 to enter upon the above m ti d
property for
FINAL FEE $
Sig ur - ate-�
ISSUE FEE- - - - -
-
Drivers' License or SS 9F
CMF 0865-46 White -Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor
CONSTRUCTION AND PLANNING
APPROVALS Permit #
POOL & SPA '
Date Inspector APPROVALS Permit # Date Inspectoi -
1.
Temporary Electrical Service ei Peie
_1 _ e_ I" 43.
Pool & Equipment Location -
2.
Soil Pipe -Un rgrn
44.
Steel Reinforcement
3.
Electrical Conduit Utility-Undrgrn
45.
Forms
4.
Electrical Conduit-Undrgrn
46.
Electrical Bonding
5.
Steel ein orce
47.
Rough Plumbing & Pressure Test
6.
_ Electrical LIFER Grn
48.
APPROVAL TO COVER-GUNITE
7.
Footings
49.
Electrical Conduit-Undr rn
8.
Foundation
50.
Gas Pipe, ❑ Undr rn, Test
9.
Water Pip e-Undrgrn
51.
Backwash Lines P -Trap. EJndr rn
10.
Structural Floor System
52.
APPROVAL TO DECK
11.
Property Sewer Line & House Connection
53.
Backwash & Receptor -Final
12.
Street Sewer Connection
54.
Heater & Vent -Final
13.
Rough Plumbing
55,
Plumbina System - Final
14.
Rough Electric -Conduit
-56.
Electrical -Final
15.
Rough Electric-Wi ring
57.
Solar System -Final
16.
Rough Heating & Air Conditioning
WS.
Fencing & Access Approval
17.
Ducts in Structure
APPROVED FOR PLASTERING
18.
19.
20.
Ducts, Ventilating
Gas Pipe -Rough & Test
Roof Framing
60.
POOL/SPA SYSTEMS FINAL
21.
22.
Roof Sheathing
Frame and Flashing
NOTES:
23.
Insulation -
-
24.
Lathing & Siding
25.
Drywall Nailing
'
26.
Plaster Brown Coat
27.
Electrical Power Meter -Final
28.
Final Electric
29.
Final Heating & Air Conditioning
30.
Final Gas Pipe -Test .
31.
Final Plumbing
32.
Water Service -Final
- 33.
Gas Service -Final
34.
Solar Domestic -Final
35.
Landscape Sprinkling System
36.
Sound Attenuation
37.
Handicap Regulations
38.
FINAL STRUCTURE & BUILDING
39.
Special Requirements Complete -
40.
41.
Electric Release to Edison
Gas Release to Southern California GIs Co.
J.
42.
CERTIFICATE OF OCCUPANCY
No Date
Applicant to fill In all spaces within heavy border lines and sign all appropriate declarations.
CITY OF COSTA MESAP
T N
TRACT NO. LT NO. BLDG. NO.
1546
7/27/81
-.CONSTRUCTION PERMIT
/�
V1.0- ,O
TYPE OF CONSTRUCTION
1:1 NEW ❑ A
Project Address pqr or. 1,7 - $ j
Owner ! Phone yy'.
11, , ' ,- p
ADD ALTERATION
REPAIR CONVERSION ❑DEMOLISH
T_
Address / �.S- % 7 $
,E]
❑ OTHER
ZONING REGULATIONS
Arch/Eng. rtis v (^:�}� a j{e� License No. --
DESCRIPTION OF WORK qLL a
'�Lv'�61ti i� _
A.P.$ /+ "-- O j
ZONE PLNTTGo..
A�
Address /7 if �j r�-IYC+v�r._.+•-j ,•C_ A-4
Contractor At" L'b yi:2`R'w�JJ i•s C_•s.~K .Phone gyjj
TYPE OF PER
❑ GRADING ❑ FOUNDATION '❑ STRUCTURAL
❑ TENANT ❑ ELECTRICAL ❑PLUMBING ❑MECHANICA
SETBACK T.
SIOFVr - YARD
LS IED$ yq
ggRVCEsF�.. pp$
PROBRIP V LINE
I1 -e- _ ,���h ar
1
Address `+ ' L,&$ 1 0— ' L7
LICENSED CONTRACTOR DECLARATION -
firm licensed Charter 9
I hereby of that I am under provisions of (com-
7000) Division 3 Of the Business and
❑OTHER
RIGHT
mencing with section of
Professions Code, and my license Is In lull form
REAR YARD (TO P/L)
_
}an`d',�esfgfe�ct.
��� �_ 36
PROJECT DESCRIPTION �
-
Lltense Class Ll Cense No. 5,
SOFT. l•
OCCUPANCY -?-CONSTRUCTION TYPE (/
"40
PKG. SPACE REQ. PROVIDED -
STREET WIDTH PARK FEE $
ZONING APPROVED BY G•%/ DATE �/f
Date-7-AI-lii Signature � �t ``�L—•
WORKERS' COMPENSATION DECLARATION
I hereby that 1 have a certificate,of consent to seli4nsure or a
affirm
certificate Of Workers' Compensation Insurance, Or a certified copy
VALUATION ZONE
thereof (Section 3800, Lab. C.).\
GRADING CU. YDS. ACRES
SPECIAL CONDITIONS:
Policy NO. Company
_
r 1 Certified copy Is hereby furnished.
REMARKS:
-
.ertified copy Is filed with the city Building Division.
EMPTION FROM WORKERS' COMPENSATION DECLARATION
(This section need not be completed It the permlt.is for one hundred
_.
($3001 or Iessl.
L certify that n the performance of the work for which this permit Is
Issued, 1 shall not employ any person in any manner so as to become
PLUMBING PLAN CHECK
ELECTRICAL- PLAN
CHECK
subject to the Workers Compensatlo�0s Laws gf California. t
BATHTUBS SHOWERSSO,
ET_ SOFT
Date 7'87 -yr Signature '"^-= �� "`�-I��
NOTICE: If after making this declaration, you Should become subject
TOILETS URINALS
GENERATOR 0-1 KW_
1-10 KW
to the Workers' Compensation provisions of the Labor Code, you must
TRANSFORMER
forthwith comply with such provisions or this permit shall be deemed
LAVATORIES DOUBLE LAVS
APPLIANCE ' 10-50 KW_50
+ KW
revoked. - -
CONSTRUCTION LENDING AGENCY
KIT. SINKS DISHWASHERS
MOTORS 0-1 HP -1-10
HP
I hereby affirm that there is a construction lending agency for the per-
SE0.VICE SINKS SUMPS
(INC. SOLAR) 10-50 HQ_
50 + HP
formance Of the work for which this permit Is Issued (Section 3097
FLOOR SINKS FLOOR DRAINS
0
FIXTURES -OUTLETS
SWITCHES
Civ. C.). -
Lender's Name
Lender's Address
_
DRINKING FOUNTAINS -
GASTUBESIGNS
INTERCEPTORS CLARIFIERS
POLE LIGHTS
OWNER BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for
SWIMMING POOL P TRAP
POLES METERED
SUB
he following reason (Section 7031.5 Business and Professions Code:
Anycity or county which requires a permit to construct, alter,
WATER SERVICE ALTERATION -
PANELS MAIN
SUB
Improve, demolish or repair any structure, Prior to Its Issuance, also re.
quires the applicant for such permit to file a signed statement that he
GAS SERVICE OUTLETSSERVICE
AMP
Is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9 (commencing with Section 7000) Of Division 3 of the
WATER HEATERS BTV dUTP sT
50
usiness and Professions Code) or that he Is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031.5 byIV
SEWER CONNECTIONS J
any appilwnt for a permit subjects the applicant to a civil penalty
not more than five hundred dollars ($500).
SOLAR TANK COLLECTORS-
'
1, as owner of the property, or my employees with wages as their
.e compensation, will do the work, and thestructureis not Intended
or offered for sale. (Section 7044, Business and Professions Code: The
SOLAR PIPING SYS.
ISSUE FEE
Contractor's License Caw does not apply to an owner of a property
APPROVED
who builds or Improves thereon, and who does such work himself or
ISSUE FEE
APPLICATION BY
DATE'
Sill Z7
through his own employees, provided that such Improvements are not
Intended or offered for sale. If, however, the building or Improvement
MECHANICAL PLAN CHECK
SUMMARY
OF FEES
Is sold within one year of completion, the owner will have the burden
Of proving he did not build or Improve for the purpose of sale).
SYSTEM 0-100,000 BTV
"BUILDING/
/10
or
❑ I, as owner of the property, am exclusively contracting with
HEATING
AND DUCTING
PERMIT $ -Se
% /. d2
SMIP s
licensed contractors to construct the project (Section 7044, Business
100,000 +BTU
PLAN CHECK s
PERMIT
and Professions Code: The Contractor's License Law does not apply to
'PLUMBING !(f
ISSUANCE $
an owner of propertywho builds or Improves thereon, and who con.
REFRIGERATION 0-100,000 BTU
�.
$
tracts from such projects with a contractor(s) 11Cesned pursuant to
SYSTEM
GRADING .$
the Contractor's License Law).
100,000+BTU
PLAN CHECK s
❑ 1 am exempt under Section B. & P. C. for this
BOILERS BTU
ELECTRICAL $
$
reason
SYSTEM REPAIR, ALTERATION
EXHAUST SYSTEM MULTIPLE
PLAN CHECK $
MECHANICAL s
. MICROFILM $
TOTAL FEE $
.
LESS AD.
Date -Owner
1 hereby Certify that I have read this application and state that the above
Information is correct. I agree to comply with all city and county
-
PLAN CHECK $
VANCEPC $_
ordinances and state laws relating to construction, and hereby authorize
'
representatives of this city to enter upon the above mentioned
to in pec to Pose() ' -� y_
�J"O
202-37properly
FINAL FEE $
Signature 's^"^� /�"" Date
'
ISSUE FEE - -
- - -
Drivers' License or SS 9F
CMF 0865-46 White -Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor
CONSTRUCTION AND PLANNING
APPROVALS Permit #
POOL & SPA - - -
Date Inspector APPROVALS Permit # Date Inspector
1.
Temporary Electrical Service or Pole
43.
Pool & Equipment Location
2.
Soil Pipe -Un rgrn
-7T.
Steel Reinforcement --
3.
Electrical Conduit tility-Undrgrn
45.
Forms "
4.
Electrical Conduit_-Undrgrn
46:
Electrical Bonding
-5.
Steelein orce
47.
Rough Plumbing & Pressure Test `
6.
Electrical UFER Grn
48.
APPROVAL TO COVER-GUNITE
7.
Footings
49.
Electrical Conduit-Undr rn
8.
Foundation _
50.
Gas Pipe ❑ Undr rn, Test
9.
Water Pipe-Undrgrn
51.-
Backwash Lines P -Tr ❑ Undrqrn
10.
Structural Floor System
52.
:APPROVAL TO DECK
11.
Property Sewer Line & House Connection
53.
Backwash & Receptor -Final
12.
Street Sewer Connection
54.
Heater & Vent -Final
13.
Rough Plumbing
--
_ Final
14.
Rough Electric -Conduit
-56.
Electrical -Final
15.
Rough Electric -Wiring
57.
Solar System -Final
16.
Rough Heating & Air Conditioning
b8.
Fencing & Access Approval
17.
Ducts, in Structure
59.
APPROVED FOR PLASTERING
18.
19.
20.
Ducts, Ventilating
Gas Pipe -Rough &Test
Roof Framing
60.
POOL/SPA SYSTEMS FINAL
21.
22.
Roof Sheathing
Frame and Flashing
a NOTES:
23.
Insulation
'
24.
Lathing & Siding
25r
Drywall Nailing
26.
Plaster Brown Coat
27.
Electrical Power Meter -Final
28.
Final Electric
29.
Final Heating & Air Conditioning
-
30.
Final Gas Pipe -Test
31.
Final Plumbing
-
32.
Water Service -Final
33.
. Gas Service -Final
34.
Solar Domestic -Final
35.'--
Landscape Sprinkling S Stem'
36.
Sound Attenuation
37.
Handicap Regulations • -
'
38.
FINAL STRUCTURE & BUILDING
39.
Special Requirements Completed
40.
Electric Release to Edison
I-
41.
Gas Release to Southern California Gas Co.
42.
• '-'
CERTIFICATE OF OCCUPANCY
No Date
kh-
Applicant to fill in all spaces within
CITY OF COSTA MESA. PERMIT NO.
:CONSTRUCTION PEf MIT P '?�
Address
Address ' 1660'Wilshire, L.A.
Contractor M - Yr��rY Q{lone 634-116
Address 1510
I lnois, Paramount,
LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I am licensed under provisions of Charter 9 (com.
man Ong with section 7000) Of Ion 3 gOf the Business and
Professions Code, antl my,3l ke In f I farcy, lanlL7gffect.
License Class Bl l• bb ansa No.J //
Dates -G -sl Signature
WORKERS' COMPENSATION CLAR&CON --
I hereby affirm that I have a certificate/of consent to self -Insure or a
certificate of Workers' Compensation Insurance, or a certified copy
thereof (Section 3800, Lab. C.).
Policy No. 014774 Company RPAIrPY
�-Certified copy is hereby furnished. '
ertifietl copy is filed with the city Building Division.
`MPTION FROM WORKERS' COMPENSATION DECLARATION
(This section. need not be completed if the permit is.for one hundred
($100) or less).
I C¢ I. y 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.
Data Signature
NOTICE: If after making this declaration, you should become subject
to the Workers' Compensation provisions Ot the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed
revoked. -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for the per-
formance of the work for which this permit is Issued (Section 3097
Civ. C.). - I
Lender's Name _
Lender's Address _
OWNER BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for
the following reason (Section 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 re.
quires the applicant for such permit to file a signed statement that he
Is,yicensed pursuant to the provisions of the Contractor's License Law
(chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031.5 by
-ny applicant for a permit subjects the applicant to a civil penalty
not more than five hundred dollars ($500).
I, as owner of the property, or my employees with wages as their
-,le compensation, will do the work, and the structure.is not intended
or offered for sale. (Section 7044, Business and Professions Code: The
Contractor's License Law does not apply to an owner of a property
who builds or improves thereon, and who does such work himself Or
through his 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 will have the burden
of proving he did not build or Improve for the purpose of sale).
❑ I, as owner of the property,am exclusivelycontracting with
licensed contractors to construct the project (Section 7044, Business
and Professions Code: The Contractor's License Law does not apply to
an owner of property who builds or improves thereon, and who con.
tracts'from such projects with a contractors) Ilcesned pursuant t0
the Contractor's License Law).
❑ I am exempt under Section B. & P. C. for this
reason
I have lead this applicalion and stale that the above
pct. I agree to
comyffywith all City and county
Idws rClati to co ruction, antl hereby authoriZe
this city o e upon the above :me nt"oned
to �
border lines and sign all appropriate declarations
TRACT NO. LOT NO. I BLaP. NO.
URINALS
DOUBLE LAVS
HEATINGSYSTEM
OF CONSTRUCTION
- BOGO
7/02/61
ITG�7YPE
L.,1 NEW ❑ ADD ❑ ALTERATION
DISHWASHERS
SUMPS
SYSTEM
❑ REPAIR ❑ CONVERSION ❑DEMOLISH
0-1 HP -1.10
10-50 HP -50
HP
+ HP
_
❑ OTHER t -
ZONING REGULATIONS
DESCRIPTION OF WORK
A.P. 9P
OUTLETS
SWITCHES
ZONE
PLNTrGp.
TYPE OF PERMIT
SLIMING
.
ggR �LE11FLL. pp9P
PROPEIRTY LINE
❑ GRADING ❑ FOUNDATION ' ❑ STRUCTURAL
SETBACK ST.
I YARD
CLARIFIERS
❑ TENANT ❑ ELECTRICAL ❑MECHANICA
POLE LIGHTS
MICROFILM
L•1PLUMBING
RIIGHT
PTRAP
❑ OTHER
POLES
METERED
SUB
REAR YARD (TO P/L)
ALTERATION
PROJECT DESCRIPTION
-
_
-•�
PKG. SPACE REO.
PROVIDED
SO. FT.'
SERVICE
-
AMP
'STREET WIDTH
PARK FEE $
OCCUPANCY— CONSTRUCTION TYPE
-
VALUATIONZONE I.- ,
ZONING APPROVED BY
DATE
GRADING CU. YOS. ACRES
SPECIAL CONDITIONS:
26.00 TG
' PLUMBING ✓ � .PLANCHECK 1 1 1 ELECTRICAL PLAN CHECK 1 1 1
TOILETS. -
LAVATORIES
URINALS
DOUBLE LAVS
HEATINGSYSTEM
GENERATOR
TRANSFORMER
APPLIANCE
0.1 KW_
10-50 KW_50+KW
1-30 KW -
KIT. SINKS
SERVICE SINKS
DISHWASHERS
SUMPS
SYSTEM
MOTORS
(INC. SOLAR)
0-1 HP -1.10
10-50 HP -50
HP
+ HP
FLOOR SINKS
FLOOR DRAINS,FIXTURES
MULTIPLE
PLUMBING
OUTLETS
SWITCHES
DRINKING FOUNTAINS
GRADING
$
GAS TUBE SIGNS
$�
INTERCEPTORS
CLARIFIERS
$
POLE LIGHTS
MICROFILM
- -'
SWIMMING POOL
PTRAP
POLES
METERED
SUB
WATER SERVICE
ALTERATION
PANELS
MAIN
SUB
GAS SERVICE
OUTLETS
SERVICE
-
AMP
WATER HEATERS
BTU OUTPUT
^y,
-
SEWER CONNECTIONS
SOLAR TANK
COLLECTORS
-
-
SOLAR PIPING SYS.
ISSUE FEE
ISSUE FEE
APPLICATION APPROVED BY
DA
MECHANICAL
PLAN CHECK
HEATINGSYSTEM
0-100,000BTU_
AND DUCTING
100,000 + BTU
REFRIGERATION
0.100,000 BTU_
SYSTEM
100,000 + BTU
BOILERS
BTU
SYSTEM REPAIR, ALTERAT ION
EXHAUST SYSTEM
MULTIPLE
ISSUE FEE
I Drivers' Licenser
CMF 0865-46 White -Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor
FINAL FEE $�
SUMMARY OF FEES
BUILDING
PERMIT
$ SMIP
$
PLAN CHECK
$ PERMIT
ISSUANCE
$
PLUMBING
$
GRADING
$
PLAN CHECK
$�
ELECTRICAL
S_c{_)61��
$
MICROFILM
$
PLAN CHECK
$
MECHANICAL
$ - TOTAL FEE
$
S AD-
PLANCHECK
$ 'VANCEPC
$_
FINAL FEE $�
CONSTRUCTION AND PLANNING
APPROVALS Permit#
Date Inspector
POOL & SPA "'W -` -
APPROVALS Permit # Date Inspector
1.
Temporary Electrical Service or Pole
43.
Pool & Equipment Location
2.
Soil Pipe-Undrgrn
44.
Steel Reinforcement
3,
Electrical Conduit Utility-Undrgrn
45.
Forms
4.
Electrical Conduit-Undrgrn
46.
Electrical Bonding '
5.
Steel ein orce
47.
Rough Plumbing & Pressure Test
6.
Electrical UFER Grn
48.
APPROVAL TO COVER-GUNITE
7.
Footings
49.
Electrical Conduit-Undr rn
B.
Foundation
50.
Gas Pipe, ❑ Undr rn, Test
9.
Water Pipe-Undrgrn
51.
Backwash Lines P-Trap, n rn
10.
Structural Floor System
52.
APPROVAL TO DECK -
11.
Property Sewer Line & House Connection
53.
Backwash & Receptor-Final '
12.
Street Sewer Connection
54.
Heater & Vent-Final
13.
Rough Plumbing
o7
55,
Plumbing System - Final
14.
Rough Electric-Conduit
56.
Electrical-Final
15.
Rough Electric-Wiring -
_
57.
Solar System-Final
16.
Rough Heating & Air Conditioning
W.
- Fencing & Access Approval
17.
Ducts in Structure
'-
APPROVED FOR PLASTERING
18.
Ducts, Ventilating
"
60.
POOL/SPA SYSTEMS FINAL '
19. Gas Pipe-Rough & Test
20. Roof Framing
21.
Roof Sheathin
NOTE
22.. Frame and Flashing
23.
Insulation
at C r iii- a t/
24.
Lathing & Siding
-
( 2
25.
Drywall Nailing
_
26.
Plaster Brown Coat
-�
27.
Electrical Power Meter-Final
28.
Final Electric
29.
Final Heating & Air Conditioning
-
30.
Final Gas Pipe-Test
31:
Final PlumbingIRS�L7
32.
Water Service-Final
'
33.
Gas Service-Final
34.
Solar Domestic-Final
35.
Landscal2e Sprinkling System
36.
Sound Attenuation
37.
Handicap Regulations
38.
FINAL STRUCTURE & BUILDING
39.
Special Requirements Completed
40.
Electric Release to Edison
41.
Gas Release to Southern California Gas Co.
42.
CERTIFICATE OF OCCUPANCY
No Date
Applicant to fill in all spaces within heavy border lines and sign all appropriate declarations.
CITY OF COSTA MESA
PERM T NO. -
TRACT NO. LOT NO. BLDG. NO.
-
-.CONSTRUCTION PERMIT
TYPE OF CONSTRUCTION
0 -NEW ❑ ADD ❑ ALTERATION
❑ REPAIR ❑ CONVERSION ❑DEMOLISH
1:1 OTHER
31 24 B/10/61 16.00
ZONING REGULATIONS
Project Address r -r y b ANG
Owner d (Y' L O Phone
Address
Arch/Eng. - License No.
DESCRIPTION OF WORK p �•
? -rr� M
OF PERMIT
❑GRADING ❑ FOUNDATION yyON ❑ STRUCTURAL
❑ TENANT ❑ ELECTRICAL WPLUMBING ❑MECHANICA
A.P. #
ZONE PLNG. REF. $
B TO BUILDING
SETBACK T. GFO PE R'fY LINE
I YARD
5l E YMM
Address -
Contractor C �J) Phone yTVPE
Address C
/ 0 N �L' C� /O o
LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Charter 9 (com-
mon ting with section 7000)of Division 3 of the Business and
11 OTHER
RIGHT
Professions Code and m Ilcense Is In full force d effect.
REAR YARD (TO P /L)
�� GPKG.
PROJECT DESCRIPTION
License Class - is nse M
SPACE REG.
PROVIDED
Date k' 7- / Signature
Sq. FT.
♦
WORKERS' COMPENSATION 0 CLARATION
OCCUPANCY_ CONSTRUCTION TYPE
STREET WIDTH
PARK FEE E
1 hereby affirm that I have a certificate of Consent to self -Insure or a
VALUATION ZONE
ZONING APPROVED BY
DATE
Certificate Of Workers' Compensation Insurance, or a certified COPY
SPECIAL CONDITIONS:
thereof (Section 3800, Lab. C.).
GRADING CU. YDS. ACRES
Policy No. Company
REMARKS:
_
Certified Copy is hereby furnished.
,ertified Copy is filed with the city Building Division.
_
.EMPTION FROM WORKERS' COMPENSATION DECLARATION
(This section.need not be completed.if the ,permit Is for one hundred
or leu ) .
S$1DD1
Cert((fy that n the performance of the work for whl ch this permit Is
Issued, I shall not employ any person in any manner so as to become
PLUMBING - 'PLAN CHECK""
ELECTRICAL PLAN
CHECK
subject to the Workers Compensation Laws of California. -
BATHTUBS - SHOWERS
"
Date Signature
NOTICE: If after making this declaration. you should become subject
TOILETS URINALS
GENERATOR 0-1 KW_
1-10 KW
to the Workers' Compensation provisions ofthe Labor Code, you must
TRANSFORMER
forthwith comply with Such provisions or this permit shall be deemed
LAVATORIES DOUBLE LAYS
APPLIANCE 10-50,KW_50
+ KW
revoked.
CONSTRUCTION LENDING AGENCY
KIT. SINKS- DISHWASHERS'
MOTORS 0-1 HP_
1-10'HP
1 hereby affirm that there Is a Construction lending agency for the per-
SERVICE SINKS SUMPS- -
(INC. SOLAR) 10-50 HP
50 + HP -
formance of the work for which this permit is Issued (Section 3097
FLOOR SINKS - FLOOR DRAINS
FIXTURES - OUTLETS
SWITCHES
Civ. C.).
Lender's Name
_
Lander's Address.
DRINKING, FOUNTAINS
'GAS TUBE SIGNS
-
OWNER.BUILDEII OECLARATION'
- -
,INTERCEPTORS CLARIFIERS
-
POLE LIGHTS
-
I hereby affirm that I am exempt from the Contractor's License Law -for
-SWIMMING POOL - PTRAP -I'U
POLES -METERED
SUB
the following reason (Section 7031.5 Business and Professions Code:
Any city or county which requires a Permit to construct, alter,
WATER SERVICE ALTERATION
PANEL'S MAIN
SUB
Improve, demolish or repair any structure,' prior to its issuance, also re-
quires the applicant for such permit t0 file a signed statement that he
GAS SERVICE - OUTLETS -- -
SERVICE' -
AMP
Is licensed POrsuant to the provisions of the Contractor's License Law
/Chapter 9 (commencing with Section 7000) of Division 3 of the
- WATER HEATERS BTU OUTPUT
- -
-
Business and Professions Code) at that he is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031.5 by
SEWER CONNECTIONS
any applicant for a permit subjects the applicant to a civil -penalty-
not more than five hundred dollars ($500),
SOLAR TANK OL C O -
- �-
I, as owner of the property, or my employees with wages as their'
Ae compensation, will do the work, and the Structure is not Intended
Cr offered for Sale. (Section 7044, Business and Professions Code: The
_ —
SOLAR PIPING SYS.
ISSUE FEE -
- -
Contractor's. License Law does not apply to an owner of a property
_•-
APPLICATION APPROVED
who builds or improves thereon, and who dots such work himself or
ISSUE FEE ' •�
BY
DATE
through his own employees, provided that such improvements are not
intended or offered for sale. It. however, the building or Improvement
MECHANICAL PLAN CHECK
SUMMARY
OF FEES
is sold within one year of completion, the owner will have the burden
BUILDING - -
of proving he did not build or Improve for the purpose of sale).
HEATING SYSTEM 0-100,000 BTU
PERMIT E
SM_IP $
❑ 1.n as owner of the property, exclusively contracting with
- AND DUCTING
-
construct the project (Section Business
licensed contractors p
100,000 +BTU
PLAN CHECK E
PERMIT
not apply ro
: es not
and 'Professions Cotle: The Contractor's License Law does
ISSUANCE $
a
owner of property who builds or improves thereon, and who ton-
REFRIGERATION 0-100,000 BTU
PLUMBING E
tracts from such projects with a contractors) Ilceined Pursuant to
tracts
SYSTEM
-
GRADING' $
the Contractor's License Law).
100,000 + BTU
PLAN CHECK E
- -
❑ 1 am exempt under Section B:& P. C. for this
BOILERS BTU
ELECTRICAL $
E
reason-
SYSTEM REPAIR, ALTERATION
EXHAUST SYSTEM MULTIPLE
PLAN CHECK E
MECHANICAL $
MICROFILM $
TOTAL FEE $
LESS AD -
Date Owner
I hereby cerlifythat I have read this application and state that the above
Information is correct. 1 agree to comply with all city and county
PLAN CHECK S
VANCE PC E _
ordinances and state laws relating to construction, and hereby authorize
representative Of t.!hi city ler upon the above mentioned
oroQarty fqr inspen r
/
FINAL FEE E
Signe ura Date
ISSUE FEE -
Drivers' L c nse or SS
CMF 0865-46 White -Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor
TL
CONSTRUCTION AND PLANNING
APPROVALS Permit # Date Inspector
POOL & SPA ..'_ •�
APPROVALS Permit # Date Inspector
1.
Temporary Electrical Service or Pole
43.
Pool & Equipment Location
2.
Soil Pipe -Un rgrn
44.
Steel Reinforcement -
3.
Electrical Conduit Utility- ndrgrn
45.
Forms
4.
Electrical Conduit•Undrgrn
46.
Electrical Bonding
5.
Steel em orce
47.
Rough Plumbing & Pressure Test
6.
Electrical UFER Grn
48.
APPROVAL TO COVER-GUNITE
7.
Footings
49.
Electrical Conduit-Undr rn '
. 8..
Foundation _
50.
Gas Pipe, Q Undr rn, Test -
9.
Water Pipe-Undrgrn
51.
Backwash Lines P-Trao.Q ndr rn
10.
Structural Floor System
52.
APPROVALTO DECK
11.
Property Sewer Line & House Connection -
53.
Backwash & Receptor -Final
12.
Street Sewer Connection _ -'
54.
Heater & Vent -Final
13.
Rough Plumbing _System-
-
14.
Rough Electric -Conduit - -
- 56.
Electrical -Final
15.
Rough Electric -Wring
57.
Solar System -Final
16.
Rough Heating & Air Conditioning.
b8.
Fencing & Access Approval
17.
Ducts in Structure59.
APPROVED FOR PLASTERING
18.
Ducts', Ventilating -� -
60.
POOL/SPA SYSTEMS FINAL
19. Gas Pipe -Rough & Test -";t
20. Roof Framing - -
21.
Roof Sheathing
NOTES:
22. Frame and Flashing
23.
Insulation
i r p
24.
Lathing & Siding -
i
25.
Drywall Nailing
1�1
26.
Plaster Brown Coat
27.
Electrical Power Meter -Final
28.
Final Electric - -
29.
Final Heating & Air Conditioning -
30.
Final Gas Pipe -Test yes Sf
31.
Final Plumbing
32.
Water Service -Final
33.
Gas Service -Final
34.
Solar Domestic -Final
35.
Landscape Sprinkling System
36.
Sound Attenuation
37.
Handicap Regulations
38.
FINAL STRUCTURE & BUILDING
39.
Special Requirements Completed
40.
Electric Release to Edison
41.
Gas Release to Southern California Gas Co.
42.,
CERTIFICATE OF OCCUPANCY
'No Date
L'
17,
Applicant to fill in all spaces within
WY QF COSTA MESA PERMIT NO.
CONSTRUCTION PERMIT /y=/oS
Addrea
Arch/Eng. License No.
VCS /MC
1 hereby affirm that I am licensed under provisions of Charter 9 (com-
mencing with Section 7000) of Division 3 of the Business and
Profession Codes and my license Is In full force and effgCt.
`
Liconso Class I nze Not'!¢/ ?c?
Dathl?. 26'-'H 519 nature _
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I haw a certificate of consent to self -Insure or a
Certificate of Workers' Compensation Insurance, or a Certified copy
thereof (Section 3800, Lab. C.).
Policy No. Company
': ertlfied copy Is hereby furnished. -
a;,,x
W Rerlif ietl copy Is /sled with the city Building Division. _ _
YNMPTION FROM WORKERS' COMPENSATION DECLARATION
(This section need not be completed If the permit Is for one hundred
1EI001 or law
cert((fy that 1n the performance of the work for which this permit is
Issued, I shall not employ any person in any manner so as to becomeot
subject the Workers Compensation Laws of California: -
Date Signature
NOTICE: If after making this declaration. you should become subject
to the Workers' Compensation provisions ofthe labor Code, you must
forthwith Comply with such provisions Or this permit Shall be deemed
revoked. -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for the Per.
formance of the work for which this permit is Issued (Section 3097
Civ. C.).
Lender's Name
Lender's Address
OWNER BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's.License Law for
the following reason (Section 7031.5 Business and Professions Code:
Any city or county which requires a permit to construct, alter,
,more ve, demolish or repair any structure, prior to its issuance, also re-
quires the applicant for such Permit to file a signed statement that he
Is licensed pursuant to the provisions of the Contractor's License Law
(Chapter .9 (commencing with Section 7000). of Division 3 of the
9 usiness and Professions Code) or that he is exempt therefrom and the
basis for the alleged exemption. Any violation of. Section 7031.5 by
-� applicant for a permit subjects the applicant to a civil penalty
tot more than, five hundred dollars ($500).
i, as owner of the property, or my employees with wages as their
cele compensation, will do the work, and the structure Is not Intended
or offered for sale. (Section 7044, Business and Professions Code: The
Contractor's License Law does not apply to an Owner Of a property
who bullds or Improves thereon, and who does such work himself or
through his 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 will have the burden
of proving he did not build or improve for the purpose of Sale).
❑ 1, as owner of the property, am ex CluSlw y Contracting with
licensed contractors to construct the project, (Section 7044, Business
and Professions Code: The Contractor's License Law does not apply to
an owner of property who bulltls or Improves thereon, and who con.
tracts from such projects with a contractor(s) Iicesned pursuant to
the Contractor's License Law). _
❑ 1 am exempt under Section B. & P. C. for this
reason
Date- - Owner '
1 hereby Certify that I have read this application and state that the above
Information is Correct. I agree to COMDly with all city and county
border lines and sign all appropriate declarations.
TRACT NO. I LOT NO. •BLDG. NO.
KNEWOF CONSTRUCTION I/
oL NEW ❑ADD ❑ALTERATION
❑ REPAIR ❑ CONVERSION ❑DEMOLISH
❑ OTHER
DESCRIPTION OF WORK
4I? I l ' 8/26/a f �.2°�� TI
ZONING REGULATION
A.P. $
ZONE PLNG. REF. iF
TYPE OF PERMIT
SETBACK
4NOPek fLI NE
13 GRADING ❑
FOUNDATION ❑ STRUCTURAL
1 YARD
❑ TENANT 11ELECTRICAL ❑PLUMBING �85AECHANIC
SIpE Y
RIGHT
❑ OTHER
REAR YARD (TO P/L)
PROJECT DESCRIPTION
PKG. SPACE REQ.
PROVIDED
SQ. FT.
STREET WIDTH
- PARK FEE $
OCCUPANCY_
CONST R UCTI ON TYPE
ZONING APPROVED BY
DATE
VALUATION
ZONE
GRADING CU. YDS.
ACRES
SPECIAL CONDITIONS:
1 •
REMARKS:
Ff
` n '
PLUMBING
PLAN CHECK
,ELECTRICAL PLAN CHECK
BATHTUBS
SHOWERS
TOILETS
URINALS
GENERATOR 0-1 KW_
1-10 KW
TRANSFORMER.
LAVATORIES
DOVBLELAVS
APPLIANCE 10-50 KW_50+KW
KIT. SINKS
DISHWASHERS
'MOTORS 0-1 HP -140
HP
SERVICE SINKS
SUMPS
(INC. SOLAR) 10-50 HP_50+HP
FLOOR SINKS
FLOOR DRAINS
FIXTURES OUTLETS
SWITCHES
DRINKING FOUNTAINS
GAS TUBE SIGNS
INTERCEPTORS
CLARIFIERS
POLE LIGHTS
t
SWIMMING POOL
PTRAP
POLES METERED
SUB
WATER SERVICE
ALTERATION
PANELS MAIN
SUB
GAS SERVICE
OUTLETS -
SERVICE
AMP
WATER HEATERS
BTU OUTPUT {
SEWER CONNECTIONS
SOLAR TANK
COLLECTORS
SOLAR PIPING SVS.
ISSUE FEE
ISSUE FEE
APPLICATION APPROVED BY
DATE QS
MECHANICAL
PLAN CHECK
SUMMARY OF FEES
BUILDING
HEATING SYSTEM.
0-100.00OBTV
'PERMIT $
SMIP S '
AND DUCTING
100,000 4 BTU O d4O
PLAN CHECK E
PERMIT - -
REFRIGERATION
0-100,000 BTU 44,9 00 0
PLUMBING E
ISSUANCE $
SYSTEM
GRADING $
100,000 i BTU
PLAN CHECK E
BOILERS
BTU
ELECTRICAL $
E
PLAN CHECK E
MICROFILM -'
SYSTEM REPAIR, ALTERATION
/ -2.
$ q
TOTAL FEE E
MECHANICAL $ -
EXHAUST SYSTEM
MULTIPLE
-
LESS AD.
PLAN CHECK E
VANCEP PC E
FINAL FEE $ /I - --
ISSUE FEE
CMF 0865-46 White-Builtling; Cana ry-ApPI icant;Pink-Accounting; Goldenrod,AsSessor
CONSTRUCTION AND PLANNING
APPROVALS Permit # Date Inspector
POOL & SPA .'
APPROVALS Permit # Date Inspector
1.
Temporary Electrical Service or Pole
43.
Pool & Equipment Location
2.
Soil Pipe -Un rgrn
4 .
Steel Reinforcement
3.
Electrical ConduitUtility-Undrgrn
45.
Forms
4.
Electrical Conduit-Undrgrn
46.
Electrical Bonding
5.
Steel ein orce
47.
Rough Plumbing & Pressure Test
6.
Electrical UFER Grn
48.
APPROVAL TO COVER-GUNITE
7.
Footings
49.
Electrical Conduit-Undr rn
8.
Foundation -
50.
Gas Pipe, ❑ Undr rn, Test '
9.
Water Pipe-Undrgrn
51.
Backwash Lines P-Tra �-❑ Undrarn
10.
Structural Floor System
52.
APPROVAL TO DECK
11.
Property Sewer Line & House Connection
53.
Backwash & Receptor -Final - -
- 12.
Street Sewer Connection-
54.
Heater & Vent -Final
13.
Rough Plumbing
55,
Plumbino S stem Final- - - -
14.
Rough Electric -Conduit
:56.
Electrical -Final _ -
- -15.
Rough-Electric-Wirin --- _
57..
Solar System -Final
_ 16.
Rough Heating & Air Conditioning _
_�B.
Fencing & Access Approval -
17.
Ducts in Structure
APPROVED FOR PLASTERING -
18.
Ducts, Ventilating
60.
POOL/SPA SYSTEMS FINAL
19. Gas Pipe -Rough & Test..
20. Roof Framing -
21.
Roof Sheathing
NOTES:.
22. Frame and Flashing
23.
Insulation
24.
Lathing & Siding
25.
Drywall Nailing
26.
Plaster Brown Coat -
- --
27.
Electrical Power Meter -Final
28.
Final'Electric•
_
29.
Final Heating & Air Conditioning
30.
Final'Gas Pipe -Test
31.
Final;Plumbing
'
32:
Water Service -Final
33.
Gas Service -Final -
34.
Solar Domestic -Final
35.
Landscape Sprinkling System
36.
Sound Attenuation -
-
37.
Handicap Regulations
-
38.
FINAL STRUCTURE & BUILDING _ 1
-
39.
Special Requirements Completed
40.
Electric Release to Edison
--
41.
Gas Release to Southern California Gas Co.' -
-
42.
CERTIFICATE OF OCCUPANCY
No Date
-
COSTA MESA BUILDING—SAFETY DEPARTMENT
P.O. BOX 1200
Costa Mesa, California
8532 7/10/81 3 .E_ TL
ELECTRICIAN `
TRACT NO.
LOT NO
REC•0 BY
PERMIT NO.
E
ISSUED
ADDRESS
7aisaajDATE
BUILDING USE
iITY TEI. NO Q
STATE LICENSE NOX i'CLASH
T�
BUILDING — r.
ADDRESS
CITY LICENSE NO.
NO.
ITEM
IACN
FEES
COSTA MESA, CALIFORNIA
Dwelling, Sq. Ff.
f
\V
�
CRONEARESSSSTT. Y
Garage, Sq. Ft.
OWNER —\\
First 20 Outlets, each
_ r v
"it ADDRESS
ADDRESS
Outlets, Additional
CITY ��QJ fj�%J%�3�f TEL. NO.
O
First 20 Fixtures, each
�Q
1 HEREBY ACKNOWIEDGF THAT 1 HAVE READ THIS APPLI.
a
CATION AND •STATE THAT THE ABOVE IS CORRECT AND AGREE
TOtCOMPLY'WITH ALL CITY ORDINANCES AND STATE LAWS REG -
TING((ULAELECTRICAL WIRING.
�\ v'I CERTIFY THAT I POSSESS THE ABOVE VALID STATE OF
CALIFORNIA CLASSIFICATION OR 1 AM THE LEGAL OWNER OF
THE SINGLE FAMILY RESIDENTIAL PROPERTY DESCRIBED ABOVE.
Signature of /
PERMITTEE
14
Fixtures, Additional
Dryer
��pp
.lai
25
Fan
,�' s jL
Heater
n 'i
Oven, Domestic {
v
NO.
ITEM
RACN
FINS
Pale, C ... uvction'_�
Sign 6 I Trans.
2.00
Range, Domestic
Transformen
KV/
y
Generators
KW
Motors ISee Schedule)
HP
HP
-
Sub -Total Fees /YIETmM Rr1_ As,0c) y'` 5 -95
HP
APPROVALS
Meters, e0.1101EQOe
— DATE
TEMP. POLE
Permit Fee
3
00
UNDERGROUND CONDUIT
ROUGH
Sub -Total Fees
/ ix
O
FIXTURES JLA —
Total Fees
POWER
UTILITY CO. NOTIFIED
FINAL
CMF 0313-46, rev. T Ts For items not listed refer to Fee Schedule BLDG. PERMIT NO. _
Applicant to fill in all spaces within heavy border lines and sign all appropriate declarations.
CITY OF COSTA MESA
PERMS NO.
TRACT NO. "LOT NO. BLDG. NO.
-CONSTRUCTION PERMIT
E (/T�/
TYPE OF CONSTRUCTION
C3 NEW ❑ADD Ig�yyw.LTERATION
REPAIR ❑ CONVERSION ❑DEMOLISH
❑ OTHER
-
2pQla 0/03/FI IC.Ie
ZONING REGULATIONS
Project Address S
Owner Phone
Address�15 144,4
Arch/Eng. 1s"6oI,,7V License No.
DESCRIPTION OF WORK JJC-4W
%s///�/ L /
TYPE OF PERMIT
❑ GRADING ❑ FOUNDATION ❑ STRUCTURAL
❑TENANT ELECTRICAL ❑PLUMBING ❑MECHANICA
A.P.
ZONE
SETBACK
10 YARD
PLNG. REF. ge
Tp g1/1LD ING
PROPS IiTY LINE
Address �AJ
_
Contractor �� Phone=-,VJ
Address el ,70 /I/. /✓ i
LICENSED CONTRACTOR DECLARATION Q�j>S
1 hereby that 1 licensed d� 9
affirm am under provisions Girona (com-
mencing with section 7000) Of Division 3 of the Business and
❑ OTHER
I T
RIGHY
Professions Code, and my license is in full force ants le 1q�I.
REAR YARD (TO
P/L)
y�
PROJECT DESCRIPTION
Licensee is sic 5eN
PKG. SPACE REO.
PROVIDED
Date �� �/ Signature A.. �
SO. FT.
OCCUPANCY_ CONST R UCTI ON TYPE
STREET WIDTH
PARK FEES
WORKERS'CePENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -Insure or a
'VALUATION ZONE
ZONING APPROVED BY DATE
ce r0ficate of Workers' Compensation Insurance, or a certified copy
thereof (Sec o = 0 12D C.). f/!D�/'�%
GRADING CU. VCS. ACRES
SPECIAL CONDITIONS:
Policy No. Company S-27.077
_-r ^ertlfietl Copy Is hereby furnished.
REMARKS: -
rtified copy is filed with the city Building Division.
APTION FROM WORKERS' COMPENSATION DECLARATION
(i itssSction need not be completed if the permit Is for one hundred
dT�tC '
S§10if
certify rile erformanca of the work for w is permit is
Issued, I shall not em arson in any so as to become
PLUMBING PLAN CHECK -
ELECTRICAL
PLAN CHECK
subject to the Work erz' Camper Ilforn]a.
_
BATHTUBS SHOWERS
SQ- FT
Date Signal
NOTICE: If after ma s declzratlon, you shout ubject
TOILETS URINALS
GENERATOR
0-1 KW— 1-10 KW
to the Workers' nsation provlslons of the Labor Code, you utt
TRANSFORMER
forthwith y wiin such provlslons or this permit shall be deemed
LAVATORIES DOUBLE LAVS
APPLIANCE
10-50 KW -50 + KW
rave -
C NSTRUCTION LENDING AGENCY
KIT. SINKS DISHWASHERS
MOTORS
0-1 1-10 HP
hereby affirm that [hare Is a construction lentling agency for the per-
SERVICE SINKS SUMPS
(INC. SOLAR)
H
10-50 HP 50 + HP
mance of the work for which this permit is issued (Section 3097
FLOOR SINKS FLOOR DRAINS
FIXTURES
OUTLETS WITCHES
CI C.).
LBO r't Name
YE
Lantler Address
DRINKING FOUNTAINS
GAS TUBE SIGNS
OWNER UILDER"DECLARATION
I herebyy a m that I am exempt from the Contractor's Lit se Law for
INTERCEPTORS CLARIFIERS
POLE LIGHTS
SWIMMING POOL P TRAP
the followin reason (Section 7031.5 Business and Prof sions Code:
Any city or ounty which requires a permit to t struct, alter,
POLES
METERED SUB
WATER SERVICE ALTERATION
PANELS
MAIN SUB
Improve, demo) or repair any structure, prior to Its nuance, also re-
quires the appli t for such permit to file a signed lament that he
GAS SERVICE OUTLETS
SERVICE
-AMP -
is licensed pursuan to the provisions of the Contr or's License Law
(Chapter 9 (comm ting with Section 7000) Division 3 of the
WATER HEATERS BTU OUTPUT
Business and Professi s Code) or that he is exe of therefrom and the
basis for the alleged a motion. Any vloiatio of Section 7031.5 by
SEWER CONNECTIONSit
any applicant for a pe it subjects the ap ice nt to a civil penalty
more than five h area dollars ($5 ).
SOLAR TANK COLLECTORS
-
as owner of file pro rty, or my ployees with wages as their
I ompensation. will tlo t work, a the structure is not Intended
SOLAR PIPING SVS.
ISSUE FEE
-
0
or offered for sale. (Section 7 4, B ness and Professions Code: The
Contractor's License Law does poly to an owner of a property
-
ISSUE FEE
APPLICATION APPROVED BY GATE -
who builds or Improves thereon d who does such work himself or
his own employees, or to that such improvements are not
MECHANICAL PLAN CHECK
SUMMARY OF FEES
ihrough
ntended or offered for sale.,howe r, the bullding or improvement
is sola within one year of mletion, a owner will have the burden
of proving he did not ui to or impro for the purpose of sale).
HEATING SYSTEM 0-100,000 BTV
BUILDING
PERMIT $
-
SMIP $
❑ as owner of a property, o usi contracting with
• AND DUCTING
a ti
n Section
I lcensetl contractors o construct the p
100,000 *BTU
PLAN CHECK E
PERMIT
s Lice w does not apply to
antl Professions of C e: The Contractor's es not apply
- ISSUANCE E
proves
owner of or arty who bullas or Improves t eon, and who ton-
o
REFRIGERATION 0-100,000 BTU
PLUMBING E
tracts h protects with a contractor(s) II nod pursuant to
Ir
SYSTEM
GRADING E
lila Contra r•s Licence Law).
Ira
100,000+BTU
PLAN CHECK §�
❑ I am empt under Section 9. 6 C. for this
BOILERS BTV
ELECTRICAL E
n' $
r9a5
SYSTEM REPAIR, ALTERATION
EXHAUST SYSTEM MULTIPLE
PLAN CHECK E
MECHANICAL E
MICROFILM E
TOTAL FEE $
LESS
e Owner
this acomply and state that the above
I hereby certify that I have readagree
is correct. I agree to comply with all city and county
PLAN CHECK E
E P
VANCE PC $-
ores antl stale laws
ordina ces
ordinances ng to construction, and hereby authorizecned
sty
ntatl vas Of this City to enter upon the above mentioned
property I an urpptes.
proper
�/� /�
FINAL
Signature pate
ISSUE FEE
-
FEE §-/ Lids
Drivers' License or SS #
CMF 0865-46 White -Building; Canary -Applicant; Pink -Accounting; GoIdenrod-Assessor
TL
CONSTRUCTION AND PLANNING
APPROVALS Permit #
Date
Inspector
POOL & SPA _ ..
APPROVALS Permit # " Date Inspector
1.
Temporary Electrical Service or Pole
43.'
Pool & Equipment Location - -
2.
SoiPipe-Undrgrn
44.
Steel Reinforcement
3.
Electrical Conduit Utility Undrgrn
"
"-145.
Forms -
4.
Electrical Conduit-Undrgrn
',��
-.(7✓, L° , "'
146..,
Electrical Bondin i ' ' • -` - �`'v
5.
Steel ein orce
47.
Rough Plumbing & Pressure Test
6.
Electrical UFER Grn
48.
APPROVAL TO COVER=GUNITE
7.
Footings
49.
Electrical Conduit-Undr rn '
B.
Foundation
50.
Gas Pipe, 0 Undr rn, Test. .
9.
Water Pipe-Undrgrn
51.
Backwash Lines P -Trap." ❑ Undrarn
10.
Structural Floor System
52.
APPROVAL TO DECK -
11.
Property Sewer Line & House Connection
53.
Backwash & Receptor -Final
12.
Street Sewer Connection
54.
Heater & Vent -Final
13.
Rough Plumbing
55,
Plumbona System - Final • ` -•
14.
Rough Electric -Conduit
g- ,$1
t`„
_56.
Electrical -Final
15.
Rough Electric -Wiring -
�-
r_' .
57.
-Solar System -Final
16.
Rough Heating & Air ConditioningFencing
& Access Approval
17.
Ducts in Structure
APPROVED FOR PLASTERING
18.
Ducts, Ventilating
60.
_
POOL/SPA SYSTEMS FINAL
19. .Gas Pipe -Rough & Test
20. Roof Framing
21.
Roof Sheathing x� '
NOTES:
22.. Frame and Flashing
23.
Insulation
24.
Lathing & Siding
25.
Drywall Nailing
'
26.
Plaster Brown Coat
27.
Electrical Power Meter -Final
28.
Final Electric
- .i -FTC.
e_
29.
Final Heating & Air Conditioning
30.
Final Gas Pipe -Test
31.-
Final Plumbing
32.
` Water Service -Final
33.
Gas Service -Final
34.
Solar Domestic -Final
35.
Landscape Sprinkling System
36.
Sound Attenuation
37.
Handicap Regulations
38.
FINAL STRUCTURE & BUILDING
'
39.
Special Requirements Completed
40.
Electric Release to Edison
41.
Gas Release to Southern California Gas Co.
42.
-
CERTIFICATE OF OCCUPANCY
No Date
l
ADDFNjF BIALDp ' 195 E 17TH ST
DNxEWSNAAIEIFaIowN:HUDDLESTON, DONALD I TR
o AUUNm2161 SAN JOAQQUIN HILLS RD
NEWPORT BEACH,CA 92660
APPL.MADING ADDRESS
ARCHITECT OR ENODIEER:
ARCK OR M'S ADDRESS:
CONM CTOWS NAME:
CONTNACTOWSMARDC
ADDRESS:
UMT' CITY OF COSTA MESA — BUILDING PERMIT
PERM NO: B 077346
PERMIT NO: B 077346 PLAN CHECK NO: 01545-96 S GOVT: N SUPP: N
CONSTRUCTION TYPE: II PERMIT TYPE: STR PURPOSE: REP
utw- JOB DESCRIPTION REPLACE EXISTING SPANNERS WITH NEW SQ FT: 5,000
uM:
CLAIM VALUE: 5,000.00 CALC—VALUE: 5,000.00 _.GROUP OCC: U-2 /
LIC N0 -
UM:
LICENSED CONTRACTORS DECLARATION: I homt y alim uM Me y of perPw, Net I am Dote oder monmoons of Chapter B
(mmme«bmC ,h Socoocm TODD) of Division 3 of the Summse ad Professions Cde, erd my loema u m M bona end aRw.
CIT'/ LIC. NO, uc. CLASS: LIC. NO, EXP
Done: Con mat.;
OWNER BUILDER DECLARATION: 1 hereby affirm uder penally of pmpa that I em attempt hom the Comadon Limina few fm the
_ fdbe+p reeaon (Senior 10314 Business eM Prdasaiona Code: My Uy or maty wlidm regmms a pam m to m strud. a.. improve.
vtdsr, «repel any avudure: prior b d uwece. Ww m,uires the opple em In a pend to Ede a si0 m etmemem thin M «aha
Imivad IAinaem . the prmvorn d the cwradon LIwme Law ICMge 9 (mmnetsbmp wan Sanm 7000) d DNebn 3 d the
ewtem apt Prdem'vn Codel or that M or eAe a mempl Ih«dmn aid the beau 1« the aleped exemption. Amy violator of Section
7031.5 by my appicam for a pemh wbjeds the apps cant to a av) pertaty of not m«a than fere homed dols [MD.
❑ I, as owner d the Iom,ery or my employees Mh wa0m as 1Mi sole mmponsimn. WI do the wok, and to armor u m intmtd
«oled le ads (Section 70e, Busima end Pmleeemfe
iona Code: The Coebactm Uose w does not appy to m owns of properly
who bolds o're r m thereon, ere, ad wfisudor work o does sNmeel M or henor tmaph he a own her employees, provided Ihh
et mm
i,
ea
newe m intended «offend f« sab. C. however, the Wikbp or inmomomm a soki within one year d mmpbtm. Ce
owmrbmddar wiA haw IM Wdm of prmmp M or eM did rat bold or improve f« the ,urywa of sale).
1. m .10 IM popery. em eztiveirNy mmtrwkmp wish licensed mmtract«s to comtrud the rojeci (Samon 70M, Bum as vol
Profaaaimm Cads: TM C wom Licemm Lew dine m appy to owmr d wopony who bolds «prw
Lnes thea
ed who
oommcm ler wW pwe ajwah a amrwor(e) Ibemed punumt to a =soon Limine Lew).
❑ 1 em ettgl mpur�yde SdQam: B.
Date: 4I A-'31 l Omwr:
T
I d0 hereby teary Cw 1 am styes d vol a will the ropuirami m d C mi to c McNh and S r= li25505 25533, ed
2553e. ed ink 1 « arty Mon Wikirq mmpml will l —y iq (cimW one) mad to klmpy whh eek ed the rp ptmomn m
a mnnh I«mmrmion«mdiftution boon the Ai3eTy R%neyemanl Dinmid. Raddenlid imdmwbn eppf W bon vis ezenq mom thaee
movieiona.
Dow: Apgloam:
WORKER'S COMPENSATION DECURATION: 1 hereby aHmm m fer,aeaRy of perjury ons of the lolowirp dWuums:
❑ I have ed W meisen • camiute a1 omsenl to.04mwra ler warms' wmpommticm, o Pm&itei l« by Seton 3mo d the labor
Code. for IM pert. of the w for which ton. permh 1. liw d.
❑ nave and w ma'vaen w«w+• mmp.malmm im«arm, m remand by swm 37W d N. L.bm code. W the pofm nm cilM
work 1« eharlm dus prmh is mined. My earken' mmpe maticn insurance auric ek poky rumba me:
carrier:
pdtry Numbs:
Rn a mdkon mad eoM mnpAwd r rhe pert u roc «e hmdmmee
eon "'op; «Am.)
�{] I mnh drat m the pdarmenca d the eek M which thb pemra u ueied. I #tel roe employ ery n eiy m. m m tp
Munm
subject to Ue wak.W comeoaMm W. d CeWo miq uepp aDnee dm A I douk wblw 10 the wanyen'
co oe tsbtm omdeim. d Bwi37W d IM on labor Coda. 1 dol ItrNmoith cANN with Cosa _
Date: T� f—D i 1(J Appicam:
WaminO: Fa9um b scan emr sm mm dan mvsrapa Is unewAd, aha Wrsll st0/ct an r ro rnrrrwpwltlu and
dM Ono rpt W arw hr thousand dolor (Sf61{=1 kt sWlpbn ro do cost of mrrpeusNon, damn as as pvmrldsd for In
Scdm 91116 of rhe la , Code, IM.L aid aRmtWe /em.
CONSTRUCTION LENDING AGENCY: I helaby affirm under penalty of perjry the honer u s omwmaion hwd aprcy for the
ped os of the wank W wadm the, pmol is owed (Swum 3091, ck,. c).
LENDER'S NAME:
LENDER'S ADDRESS:
I cw* that I haw rad the appliedim and side thk the oboe mfo matim a comes. I Spee to comply wiN a my and oomr, «d'vmeces
ed etre Wes Nest, b Wising mnw«non ad hereby sutnorba npesemlatiyp d the ayb are ,on the eboa.memiomed property
la'vnpefion mamas.
ANDREA FIS US
Pram a
Dona: AwJ 1
SOnatun 0G.me/ApeWA I/Contrw«
(515146.WP) Whae-BWdiq & Rohe, Grv* t Rle: Canary-Appboanl; Rnk�; Gakmmd-/useeor
COMMENTS: CHANGE OUT OF SPANNERS @ PUMP ISLANDS
dk dE dE lE dE*dE**df dE df dE dE dE**lf dE dE dE dE d(•d6 dE dE*dE dF dE**Kif dE**iE iE dE*1E dE dE dE dE jE*♦F*1f �F dE iE df iE iE*IE I6 iE IF dE dE dE dE d6 df iE**1E dF iE dE RE*♦E*
Z O N I N G R E Q U I R E M E N T S
S E T B A C K S
------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING---------
FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
PARKING RE • PROV: PARCEL: 42542310 ZNE: C1 REF NO:
PLANNING N TES> REPLACE 3 EXISTING SPANNERS AND UNOCAL DECAL WITH NEW ONES.
>
dE dE d6 dE dF 16 iE iE dE dE df dF dF dE dE iE iE dE dE dE dE i6 dE * iE ♦E dE dE dE dE * dE 1E dE iE df dE * dE dE dE dE aE jE iF rt if dE dE dE dE 1E * d6 dE df iE iE iE * dE * * 16 d6 if 9E * * *!E dF iE d6 dE * iE dE i6
D E V E L O P M E / N G T S E R V I C E S R E Q U I R E M E N''/ T/ S
ZONING APPROVED BY 6 DATE: `t`T—
BUILDING APPROVED BY : 8 DATE: 23•' 160.
APPLICATION ISSUED BY: DATE:
iE iE iE iE lE dE df d6 df**dE*1E 1E iE dE dE dE dE dE iE dE df df lE iE*dE*dE iE df dF
LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
PERMIT 99.75
SMIP/NON—AES
PLAN 64.84 1.05
ISSUE FEE
BUILDING—DIV—>
PERMIT
ISSUE PLAN—CHECK
TOTAL PAID
DUE
TOTALS ---- >
100.80
0.00 64.84
165.64 165.64
•00
REVENUE DIVISION
TOTALS--> COLLECTED:
165.64 OVER/SHORT:
.00
BLDG PMT PLUMBING
ELECTRIC MECHANIC
FIRE SMIP/TOT GRADING
PLAN—CHECK
99.75
1.05
64.84
dE dE♦F**dE****IE♦E4♦E****dE
dE dE dE 1E dE*dE 1E 1E jE d6 iE lE iE iE dF dE*1E aElid6*dE dE
dE aEdE*16 dE*RE*iE*iF dE*dE dE*iF iE iE*iE iE dE dE**iE*iE1E iE iE*iE
I N D I
V I D U A L F E E
B R E A K D O W N
TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST
SFC 5000 ALTER BY VALUE COMMERCIAL NOZONE 1.00 5,000.00
END OF FEES
EXPI�I _
DATE
OpONSTRUCTION AND PLANNING
APPROVALS Permit # Date
Inspector
POOL ,_ SPA
APPROVALS Permit#
Date
Inspector
1, Temporary Electrical Service or Pole
-
- 52. Pool & Equipment Location' '
2. Soil Pipe-Undrgrnd.
53. Steel Reinforcement
" "-
3. Electrical Conduit Utility-Undrgrnd.
54. Forms
4. Electrical Conduit-Undrgrnd.
55. Electrical Bonding
- -
' S. Steel Reinforcement
56. Rough Plumbing & Pressure Test
6. Electrical LIFER Grnd.
57. APPROVAL TO COVER-GUNITE
7. Footings
58. Electrical Conduit-Undrgrnd.
_-
8. Foundation
59. Gas Pipe, 0 Undrgrnd., Test
9. Water Pipe-Undrgrnd.
60. Backwash Lines, P -Trap, 0 Undrgrnd.
10. Structural Floor System
61. APPROVAL TO DECK -
-
11. Property Sewer Line & House Connection
_
62. Backwash & Receptor -Final t
12. Sewer Cap
63. Heater & Vent -Final J
13. Roof Drains
64. Plumbing System - Final
14. Rough Plumbing
155. Electrical -Final
15, Rough Electrical -Conduit
66. Solar System -Final_
16. Hough Electric Wiring
67. Fencing & Access Approval
17. Rough Wiring Sign
68. APPROVED FOR PLASTERING
18. Rough Electrical -T Bar Ceiling
69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning
FIRE DEPT. REQUIREMENT
APPROVALS Permit #
20. Rough Factory Fireplace
21. Ducts, in Structure
70. Underground Hydro
22. Ducts, Ventilating
71. Product Piping 0Gas 0Oil
23. Gas Pipe -Rough & Test
72. Underground Flush
24. Roof Framing
73. Undergrnd. Storage Tank 0 Gas 0Oil
25. Roof Sheathing
..
74. Overhead Hydro
26. T.Bar Ceiling (Structural) & Monocoat
75. Dry Chemical
27. Frame and Flashing
76. Dry Standpipe ,.
-28. Lathing & Siding
77. FIXED SYSTEM FINAL
29. Insulation
78. FIRE PREY. FINAL -
30. Drywall Nailing -
HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat"
79. FINAL INSPECTION
32, Electrical Power Meter -Final
80. FOOD CERTIFICATE ISSUED
33. Final Electric
Notes: '
34. Final Heating & Air Conditioning
-
35. Final Gas Pipe -Test
-
36. Hood or Canopy
:. t7 _
37. Final Factory Fireplace
.38. Final Plumbing
39. Water Service -Final
40. Gas Service -Final
41. Solar Domestic -Final
42, Backflow Preventer
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46, Handicap Regulations
47. FINAL STRUCTURE & BUILDING
48. FINAL PLANNING
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No Date
Applicant to fill In all spaces within heavy border lines and sign all appropriate declarations.
"CITY��OF COSTA MESA PERMI
PERMIT
TRACT NO. LOT NO. BLDG. NO.
�-.. STRUCFION
Project Address F J7zrSf
TYPE OF CONSTRUCTION
Y❑ NEW El ADD El ALTERATION
_
-
- '
4138 8/28/81
- - 44e 82
Owner Phone 9y
_
❑ REPAIR ❑ CONVERSION 111 DEM( I
`Address - - -
1AU JLt
..i
DESCRIPTION OF WORK
A.P. $
ZONE
Z0 TNG REGULATIONS
PLNTGQ. REF. =P'
- Arch/Eng. ,�-Xr - License No.e. 1,7052OTHER
-Address- -
Contractor k Phone -,921_7:
PE OF PERMIT - - -
❑ GRADING ❑ FOUNDATION ❑'STRUCTURALE
LECTRICAL PLUMBING MECHANICA
LJ TENANT 19E ❑ ❑
- BUILDING
SETBACK T.
YARD
SESIDFV
- PROPEIRTVNLINE
- -
. Address Q
LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Charter 9 (com-
f
RIGHT
mencing with section- 7000) of Division 3 of the Business and
❑ OTHER
Professions Code, and my license is In full force and effect.
REAR YARD (TO
P/L)
PROJECT DESCRIPTION
License Class License NO.
SQ. FT.
PKG. SPACE REO.
PROVIDED
_
Date Signature
�-CONSTRUCTION TYPE
+'
V
STREET WIDTH
PARK FEE$
WORKERS' COMPENSATION DECLARATION -
.00CUPANCY
ZONING APPROVED BY DATE
I hereby affirm that I have a Certificate of consent t0 self -insure or a
VALV ATION CZ ZONE
certificate of Workers' Compensation Insurance, or a certified copy
-
-- -- --
SPECIAL CONDITIONS:
thereof (Section 3800, Lab. C.).
GRADING CU.,VDS. ACRES
Policy No. -Com pan y
r-1 Certified copy is hereby furnished, -
REMARKS:''
lertlfied copy is filed with the city Building Division.-
.EMPTION FROM WORKERS' COMPENSATION DECLARATION
aza
(This section need not be completed if the permit Is for one. hundred
- - -
-- -
($100) or less). -
-
I certify that In the performance of the work for which this permit is
Issuetl, I shall not employ any person In any manner so as to bee me
PLUMBING _PLAN CHECK
ELECTRICAL
PLAN CHECK
;objecctt 1p t h a W�orr ke�rrV C/o m pensat lo Ca r i
BATHTUBS SHOWERS
.
DateCd�4 lgnat ure! -
NOTICE.. If after' making this declaration, yo urtl ome subject
TOILETS URINALS- -
GENERATOR
_
0-1 KW_1-1O,KW
to the Workers' Compensation provisions of the b Cotle, you must
'"
TRANSFORMER
forthwith comply with such provisions or this permit shall be deemed
LAVATORIES DOUBLE LAVS
APPLIANCE
10-50 KW_50+-KW
revoked.- -
KIT. SINKS - DISHWASHERS
MOTORS-
'0:1-HP_1-10'HP-
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the per.
SERVICE SINKS SUMPS
.(INC. SOLAR)
10-50 HP_ 50 + HP _
formance of the work for which this permit is Issued (Section 3097
FLOOR SINKS FLOOR DRAINS
FIXTURES
OUTLETS SWITCHES
Civ. C.).
Lender's Name
Lender's Address
_
DRINKING FOUNTAINS
GAS TUBE SIGNS
-
CLARIFIERS
POLE LIGHTS
-- ,
OWNER BUILDER DECLARATIONINTERCEPTORS
1 hereby affirm that 1 am exempt from the Contractor's License Law for
SWIMMING POOL P TRAP
POLES
METERED SUB
he following reason (Section 7031.5 Business and Professions Coder
Any city or county which requires a permit to construct, alter,
WATER SERVICE ALTERATION
•PANELS
MAIN SUB
-
improve, demolish or repair any'structure, prior to Its issuance, also re-
quires, the appllcant for such permit to file a signed statement that he
GAS SERVICE OUTLETS
SERVICE
AMP
IS licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9 (commencing with Section 7000) of Division 3 of the
WATER HEATERS BTU OUTPUT
usiness and Professions Code) or that he is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031.5 by
SEWER CONNECTIONS
any applicant for -a permit subjects the applicant to a civil penalty
iot morethan five hundred dollars ($500).
_
SOLAR TANK COLLECTORS
�, as owner of the property, or my employees with wages A their'
__.e compensation, will do the work, and the structure is not intended
r _
ISSUE FEE
3
or offered for sale. (Section 7044, Business and Professions Code: The
Contractor's License Law does not apply to an owner. of a property
who builds or Improves thereon, and who does such work himself or
SOLAR PIPING SVS.
.
ISSUE FEE
APPLICATION'APP
ROVED BY DAT �'
through his own employees, provided that.suchimprovements are not_
-
intended or offered for Sale. If, however, the building or improvement
MECHANICAL PLAN CHECK,
SUMMARY OF FEES -
is sold within one year of completion, the owner will have the burden
of proving he did not build or improve for the purpose of sale).
SYSTEM 0-100.000 BTU
BUILDING
O` !> iS
❑ I, as owner' of - the property, am exclusively contracting with
7044, Business
HEATING
AND DUCTING
100,000 + BTU
PERMIT $
SMIP $
licensed contractors : construct the project (Section
and Professions' Code: The Contractor's License Law does not apply to
PLAN CHECK $_2'
- -
PERMIT
- ISSUANCE $
a
owner of property who builds or improves thereon, and who con-
REFRIGERATION 0-100,000 BTU
PLUMBING $
tracts
theC from Such projects with a contractor(s)s llcesned pursuant to
`_e - \
SVSTEMr`. '' -
100,000:+sBTU -'�y
PLAN CHECK
- GRADING. $
the Contractor's License Law). - i x 'S �-. �
❑ 1 am exempt under Section B. & P. C. for this
„•-• r � 1,
BOILERS BTU
� f
t
ELECTRICAL $
$,
reason -
SYSTEM REPAIR, ALTERATION
EXHAUSTSYSTEM MULTIPLE
PLAN CHECK $
MECHANICAL $
MICROFILM $J�
_ - TOTAL.FEE'$
LESS
Date Owner -
I hereby certify that have read this application and state that the above
information is Correct. I agree to comply with all city and county
,PLAN CHECK $
_ EAD-
VANCE PC $_
ordinances and state laws relating to c utructlon, and hereby authorize
-,
representatives of this city to ep upon t e dbove entipn d
-
property for } f purg �' _
��. /
FEE
Signature Date-
//�/�/
Drivers' License or SS 7F
_ ISSUE FEE..FINAL
-$
CMF 0865-46 White -Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor
TL
81/
CONSTRUCTION AND PLANNING
APPROVALS Permit #
Date Inspector
POOL & SPA
APPROVALS Permit #
Date Inspector
1.
Temporary Electrical Service or Pole
-
- 43.
Pool & Equipment Location --
- -
.
Soil Pipe-Undrgrn •' -
44.
Steel Reinforcement - - - -
3.
Electrical Conduit Utility-Undrgrn
45.
Forms - -
- -
4.
Electrical Conduit-Undrgrn
46.
Electrical Bonding" -
5.
Steel ein orce
47.
Rough Plumbing & Pressure Test
6.
Electrical UFER Grn
48.
APPROVALTO COVER-GUNITE
-
7.
Footings _
-
49.
Electrical Conduit-Undr rn
8.
Foundation
50.
Gas Pipe, ❑ Undr rn, Test
9.
.Water Pipe-Undrgrn
51.
Backwash Lines P-Trap,0 Undr rn
-
10.
Structural Floor System
52.
APPROVAL TO DECK
-
11.
Property Sewer Line & House Connection
53.
' Backwash & Receptor-Final
12.
_ Street Sewer Connection
54.
Heater & Vent-Final
13.
Rough Plumbing _
-55.
Plumbina System _ Final-
14.
Rough Electric-Conduit
56.-
Electrical-Final
15.
Rough Electric-Wiring -
-
57.
Solar System-Final
16.
Rough-Heating & Air Conditioning -
_
.58.
Fencing & Access Approval
17.
Ducts, in Structure _
59.
APPROVED-FOR PLASTERING
18.
Ducts, Ventilating
60.
POOL/SPA SYSTEMS FINAL
19. Gas Pipe-Rough & Test
20. Roof Framing
21.
Roof Sheathing-
NOTES:
22. Frame and Flashing
23.
Insulation -
24.
Lathing & Siding
25.
Drywall Nailing
26.
Plaster Brown Coat
27.
Electrical Power Meter-Final.
"
28.
Final Electric
-
29.
Final Heating & Air Conditioning
-
" 30.
Final Gas Pipe-Test
31.
Final Plumbing
32.
Water Service-Final
33.
Gas Service-Final
34.
Solar Domestic-Final
35.
Landscape Sprinkling System
36.
Sound Attenuation'
-
37.
Handicap Regulations
38.
FINAL STRUCTURE & BUILDING
,Q-E �OSeX�t
7M 4104F WWZ
39.
Special Requirements Completed
40.
?Electric Release to Edison
-
41.
Gas Release to Southern California Gas Co.
42.
CERTIFICATE OF OCCUPANCY
No Date
Applicant to fill in all spates within heavy border lines and sign all appropriate declarations.
CCTV 0`COSTA MESA - PERMIT
TRACT NO. LOT NO. BLDG. NO.
- -
-
/
CnNSTRUCTION PERMIT S(7
Project Address � tY s
TYPE OF CONSTRUCTION
❑ NEW ❑ ADD ❑ ALTERATION
❑ REPAIR ❑ CONVERSIO ❑DELISH
%�
(-CNV`'
4137
-
6/28/81 $4e3t'�
Owner 0 Phone
'Address - -
j��'`OTHER
DESCRIPTION 6F WORK V
.
ZONING REGULATIONS
A.P. 90�
ZONE PLNG. REF. # -
Arch/Eng. License No.
_
Address
Contractor r Phone -
PE OF PERMIT
❑GRADING ❑ FOUNDATION El STRUCTURAL
❑ TENANTXELECTRICAL OPLUMBING ❑M\ AL
B
SETBACK ST.
SIDE YARD -"
.LSI, Vq
���r�lk-PING
P V LINE
'
_
Address r -
LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I am licensed under provisions of Charter 9 (com-
7000) iDivsion- 3 the Business
❑ OTHER
`1
r RIGHT
mencing with section of of and
Professions Code, and my license s in full force and effect.
REAR YARD (TO P/L)
PROJECT DESCRIPTION
License Class License No.
PKG. SPACE REQ.
PROVIDED
54. FT.
�'
Date Signature
/v
STREET WIDTH
PARK FEE $
WORKERS' COMPENSATION DECLARATION -
OCCUPANCY ONSTRUCTION TYPE
ZONING APPROVED BY
DATE -
hereby affirm that I have a certificate of consent to self-Insure,or a
VALUATION �(SOn' , NE
certificate' of Workers' Compensation' Insurance, or a certified copy
- -
SPECIAL CONDITIONS:
thereof (Section 3800, Lab. C.).
GRADING CU. VOS. ACRES
_ _
Pnlicy No. Company
-
REMARKS:'
ertifled copy is hereby furnished.
ertifled copy is filed with the city Building Division.
-
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
-
(This section need not be completed if the.permit is for one hundred
$100) or less).
_
certify that In the performance of the work for which this permit is
issued, 1 shall not employ any person in any manners as to betpme
PLUMBING PLAN CHECK
ELECTRICAL PLAN
CHECK
subject o the Workers Compensation Calif -
BATHTUBS SHOWERS
SOFT, qQ FT
w 1y •�
Date/
f came subject
mak ng this declaration,
If after making thisproviionsyou_
TOILETS URINALS
GENERATOR 0-1 KW—
1-10 KW
b
to the Workers' Compensation provisions ns of the Lab6r Code, you must
to the
forthwith comply with such provisions or this permit Shall be deemed
LAVATORIES DOUBLE LAYS
TRANSFORMER
APPLIANCE 30-50 KW -50 + KW
revoked. - - -
KIT. SINKS DISHWASHERS
'MOTORS 0-1 HP
HP
CONSTRUCTION LENDING AGENCY
-1-10
I hereby affirm that there is a construction lending agency for the per-
SERVICE SINKS SUMPS -
-
(INC. SOLAR)- 10-50 HP
50 + HP
formance of the work for which this permit is_iss uetl (Section 3097
_
FLOOR SINKS FLOOR DRAINS
FIXTURES OUTLETS
SWITCHES -
Civ. C.).
Lender's Name
Lender's Address
_ _
DRINKING FOUNTAINS
GAS TU13E'SIGNS
'-Z
OWNER BUILDER DECLARATIONINTERCEPTORS
CLARIFIERS
-
POLE LIGHTS
I hereby affirm that I am exempt from the Contractor's License Law for
SWIMMING POOL PTRAP--
_
POLES METERED
SUB
the following reason (Section 7031.5 Business and Professions Code:
Any city or county which requires a permit to construct, alter,
WATER SERVICE ALTERATION
PANELS MAIN
SUB
improve, demolish or repair any structure, prior to Its issuance, also re.
quires the applicant for such permit to file a signed statement that he
GAS SERVICE OUTLETS
-SERVICE
AMP
Is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9 (commencing -with Section 7000),of.-Division 3_of the
-and
WATER HEATERS-- BTU OUTPUT
-- — -
— -' - - - —' -
Business and Professions Code) or that he is exempt therefrom the
basis for the alleged exemption. Any violation of Section 7031.5 by
SEWER CONNECTIONS
.,applicant- for a permit subjects the applicant to a civil penalty
tot more than five hundred dollars ($500).
SOLAR TANK COLLECTORS
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. (Section 7044, Business and Professions Code: The
SOLAR PIPING SVS.
ISSUE FEE
3 -'-
Contractor's License Law does not apply to an owner of a property
APPLICATION APPROVED BY
DATE
who builds or Improves thereon, and who does such work himself or
ISSUE FEE
I
through his own employees, provided that such improvements are .not
MECHANICAL PLAN CHECK
.
SUMMARY OF FEES
Intended or offered for sale. If, however, the building or improvement
is sold within one year of completion, the owner will have.the burden
of proving he tlitl not build or Improve for the purpose of sale).
HEATING SYSTEM 0-100,000 BTU
BUILDING._
dA
�• �,�
❑ I, as owner of the property, am' exclusively contracting with
AND DUCTING
PERMIT $?
SMIP $
licensed Contractors to construct the project (Section 7044, Business
100,000+BTU
PLAN CHECK $�_2-. �2- PERMIT
and Professions Code: The Contractor's License Law tloes not apply to
-
ISSUANCE $
an owner of property who builds or Improves thereon, and who Con-
REFRIGERATION 0-100,000 BTU
PLUMBING $
tracts from such projects with a contractor(s)�lice_sned pursuant to
SYSTEM, -
GRADING $
the Contractor's License law). - N, - • t
_ 100,000 +BTU
q-1 f . s
PLAN CHECK $
❑ 1 am exempt under Section B. & P. C. for this
BOILERS BTU
I
_
ELECTRICAL $
$
reason
SYSTEM REPAI R. ALTERATION
EXHAUST SYSTEM MULTIPLE
PLAN CHECK $ - -
MEC HANICAL $
-'
MICROFILM
TOTAL FEE $
LESS AD-
Date Owner
I hereby certify that I have read.th.s application and state that the above
Informat.on is Correct. I agree to comply with all city and county
PLAN CHECK '$
VANCE PC $ _
ordinances and state laws relating to construction, and hereby authorize .
,i -
representatives of this City to e r upon the above ntio Btl
property ror urp
FINAL FEE $�,_3.z.
'..gnat U rees�fi Da[e�aLj3
ISSUE FEE
-
-
Drivers' Li}ens or CC
CMF 0865-46 White -Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor
CONSTRUCTION AND PLANNING
APPROVALS Permit #
Date Inspector
POOL & SPA
APPROVALS Permit # Date Inspectorg
1.
Temporary Electrical Service or Pole
43.
Pool & Equipment Location -
2.
SoilPipe-Undrgrn
44.
,Steel Reinforcement -
3.
Electrical Conduit Utility-Undrgrn
45.
Forms
4.
Electrical Conduit-Undrgrn -
_
46.
Electrical Bonding
5.
Steel ein orce
47.
Rough Plumbing & Pressure Test
6.
Electrical UFER Grn
48.
APPROVAL TO COVER-GUNITE
7.
Footings
49.
Electrical Conduit-Undr rn '
8..
Foundation
50.
Gas Pipe, ❑ Undr rn, Test -
9.
Water Pipe-Undrgrn
51.
Backwash Lines P -Trap,❑ Undrqrn
10.
Structural Floor Systam
52.
APPROVAL TO DECK - -
11.
Property Sewer Line & House Connection
_
.53..
Backwash & Receptor -Final
12.
Street Sewer Connection _
54.
Heater & Vent -Final
13.
Rough Plumbing-
55,
PlumbFna System Final-
14.
Rough Electric -Conduit
'$6.
'Electrical -Final
15.
Rough Electric-Wirin
-
57.
Solar System -Final -
16.
Rough Heating & Air Conditioning
b8.
Fencing & Access Approval
17.
Ducts in Structure
59.
APPROVED FOR PLASTERING
18.
Ducts, Ventilating
60.
POOL/SPA SYSTEMS FINAL
19. Gas Pipe -Rough & Test
20. Roof Framing
21,
Roof Sheathing
NOTES:
22.- Frame and Flashing
23.
Insulation
24.
Lathing & Siding
25.
Drywall Nailing
- -
26.-
Plaster Brown Coat -
27.
Electrical Power Meter -Final
'
2B.
Final Electric
29.
Final Heating & Air Conditioning
-
30.
Final Gas Pipe -Test
31.
Final Plumbing
32:
Water Service -Final_
33.
Gas Service -Final
34.
Solar Domestic -Final
35.
-Landscape SprinklinQ System
-
36.
Sound Attenuation
37.
Handicap Regulations
38.
FINAL STRUCTURE & BUILDING
70
-
O $-
39.
Special Requirements Completed '
4Q.-
,Electric Release to Edison
41.
Gas Release to Southern California Gas Co.
42.
CERTIFICATE OF OCCUPANCY
No. Date
Applicant
to fill in all spaces except those within
heavy border lines and sign all appropriate declarations.
-
e CITY Of COSTA MESA", - - - - • '
'CONSNUCTION PERMIT —
-PE IT NO. -
E — ]%O
TRACT NO.
LOT NO:
BLOG.177-
Project Address
Applicant's Mailin Address -
TYPE OF CONSTRUCTION LJ NEW LJ ADD LJ ALTERATION LJ REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHER I
A -P,#
- Zone -
Owner's Name - _ hone -
Address S
DESCRIPTION OF WORK O E ��� H�
/l..
S
Main Building:
Accessory Building:
Z
-
TYPE OF PERMIT�as GRADING •FOUNDATION TRUCTU RAL
❑ TENANT l.� ELECTRICAL ❑PLUMBING ❑MECHANICAL -
❑'OTHER -. ' -
PROJECT DESCRIPTION SQ. FT. OCCUPANCY
CONSTRUCTION TYPE VALUATIONS 1�A0-'�
+
ZONE - GRADING CU.YDS. ACRES
E
T
Front I
O
N
_ _ A /, �� 7 I
Arch/Eng / License No. C-
Address, _
' IV -6 -7
Contractor's Nam ho�
'
Address (mailing) _ ��
/1 n�
City License No. Os i
A
Rear -
-
N
C
Right ..
G
K
$
Left -
R
E
Ping. Ref.+ - Park. Fees $' '-
Q
U
Remarks: + _
•^
Parking Req./Provided
-
i
LICENSED CONTRACTOR DECLARATION
I herebyaffirm that 1 am licensed under provisions of Charter 9 (commencingR
with section 7000) of Division 3 of the Business and Professions Code, and
my license is in full rte and effect.
License r I #ss Ice n O
1 (/
Use sof Building:
-
-
E
I PLUMBING ; FEES
_ -
Planning Notes:
h1
\
Date Signature , �
ORK RS' C MPENSATION DECLARATION' ..
.-'.,..hereby affirm that I have a certificate of consent to salt -Insure or a certificate +
X Workers' Compensation Insurance, oeca certified copy thereof (Section
0, Lab. )
bPO icy No. 4C Vey 01:2 l{IPy LEL: oNAtJ]' �iliS
Certified copy Is ereby furnished. I 1 !
Certi i - II with [he'CItY$�Div}$io i❑
Date ApplicantL/ /
Bar Sink
Showers
'
N
re
Backflow Pventer I Service Sink' I
- - - - - -
I
T
S
Backflow Irrigation Sewer Ca
9a P
ELECTRICAL ,!
FEES
Bathtubs Sewer Connection
Automatic Washer Transformer ❑ 15-50
50,+ KW
Construction Pole Sub. l
i
_
Clarifiers Solar Collectors {
• Dish Washer': ".I"
i
P I --
'-$Olar Piping,
-` Cooking Unit 't
- -" - Meter ❑yup to-100'amps --
-�
- -
EXEMP ION ROM WORKERS'COMPENSATI DECLA ATION 4 -
(This section need not be completetl if the permit •Is for one hundred ($100) or
less) IG' k1
I certify that in the performance of the�wprk for which this permit is!issued 1
Drinking Fountains
9
Solar Tank ' ,
Dishwasher
: Meter Cover 100 amps'.
( i
Floor Drains
,
Swimming Pool vv/Spa
Dryers ❑Gas: ❑Electric ,Sub Panel I
'
shall' not employ any person in any manner so as to become subject to ,Lite
Workers' Compensation Laws of California., 1
Date Signature
NOTICE: If, after inaking this dedlaratlori, you should become subject to the
orthwith
-workers'-Compensation provisionsrof+the Labor Code, -you must forthwith-
comply •with such provisions or lhls..permit shall ,be deemed revoked. I
comply
CONSTRUCTION' LENDINGc,AGENCY '. '
I hereb affirm that these is a construction lending agent for the 7 Civ. ante
y' 9 y P
of the work •for which. this Kermit �-Is issuetl-'(SecHp
Nam., n -309.7_ Civ. CJ
-'
Lender's Na ' ' V "� 1
OWNER BUILDER DECLARATION I I = {
I hereby affirmUhat I am exempt from the' Contractor's License 'Law fonthe
following reason (Sectlon'7031.51 Business and ' Professional Code: Any city or
county which requires a permit to construct, alter improve, demolish or -repair
,any structure, prior to Its -issuance, also requires Ilia applicant for such permit 1
'to file a signed statement"that he/she is Ilcensed'pursuant to'the provisions of
(the Contractor's License Eaw (Chapter 9 (commencing with. Section 7000) of
-Division' 3.of the'Susiness and Professions Cotle)-or that he/She;is exempt
-•refrom'and the basis for'the alleged exemption. Any violation of Section
-'31.5 by any applicant for. a permit. subjects the applicant to a civil
'3nalty of not more than five hundred dollars ($500). '
EJ I, .as' owner of tho' property'or my employeeswith wages as their sole
compensation, will do the work, and the structure is not Intended or offered_
for sale, (Section 9044, Business and Professional' Code: The Contractor's
License Law does not apply to an owner of a property who;builds or improves
thereon, and who -does such work-hlmself/herself-or through his or her Own
employees, provided that such Improvements are notllntended or offered'for
sale. If, however, the building or Improvement Is,sold within one year, of <om-
pletlon, the owner will have the burden Of proving he/she did not build or im-
rove,for the purpose of sale).
I, as owner of the property, am exclusively contracting with licensed con-
tractors to construct the project Section 7044, Business and Professions Code: '
The Contractor's License Law.(does nota I to an.owner of propertywho.
builds or improves thereon,'and who contracts for such projectwith con-
tractor(s) license pursuant to the Contractors License Law). l
011-am'exempt under Section B. 6 P. C. for this reason
' -
-
FIOor Sinks t 1 i Urinal j I
Fanl HP ❑1/•�8
Gas Service. � -Outlets' .. Water Closet -
'. - -
- .Motors❑0-1
E.A.U. �. nj hl .41 dC. Solan❑B-15 HP ❑i16-15+
- - '
In4erceptorsl l ' Water Heater _ !
..-
Fixtures'' �'- LAI { .y f Microwave •^`
'
Kitchen Smk -- ;; r. 'Water Service -_ _ _ _ _
_
_. Device:Bbxes t-, —r �s, _ --Pole'Lighr
Lavatories _ _ '
v
O utlets "�, ,j f' j Range /_/'r '•
, - .- _ _ -
- j P=Trap _ _ i .`• _
-
Switches _ /% ,� r + Sign n
- '
i C
'.Roof Drains + - , - s ' l ,_ -
_
1, Garbage -Disposal sem; �. Standinglsections �� S'
"
1
_
l _ -
T
- r i "• � I -
-
Generator ❑05 KW d'S-15•KW $ Trash Com ctor
- � 1'
'
_
- ' '
}Reinspection_Fee
_
I I ;, i 3
$25 ', Issue Fee - $
- J -.
1$25
RBinSpecti00;Fee •1 1,� .Issue Fee. %j"• '
I $' 3
•' MECHANICAL
-
-� FEES
PUBLIC SERVICES REQUIREMENTS:
i i-`+ _ _ .7
ZOning:AppfUVed By ' ate
g -• �!y
.,�
Application Approved,By Date
-
ApPlicrtion Issued Bye�' net
Boiler -, I I
Hood or Type I ! ❑ `� r r
Canopy Type 11 El
r
-
•
Duct- Under Ground
Duct - Structural
-
Refrligeration System '-
110 )0,000 BTU ❑100,000 BTU
,=
Duct- Ventilating
9
�-.
-
- BUILDING PERMIT"
- -PLAN CHECK
-
PLUMBING -
t .'
RLAN,CHECK�
ELEGTRICAL
PLAN CHECK
MECHANICAL:-
PLAN CHECK r'
.: SUMMARY OF FEE$ Y
7 , ,9 '
$u `�%r SO $MIP �:� $
$ -��• .3 7 • PERMIT ,.`
r" ISSUANCE- -,' $
_ $' '-'
r' • �- ENERGY P. $
`*+ $�
y $ ' -70 GRADING �! $
�: $r-
r' $' - TOTALFEE1 $
$I:
DSO
'
3�f 247
+
-- - _. _
Exhaust System ❑ Multiple ❑'
- _ ._
System R-epair/Alteration
Firepl/Fact. Bit. ICBG I
I ,
Date owner
I hereby certify that I have read this application and state that the above
information Is correct: P agree to comply with all city' and. county ordinances
and state laws relating t0 building construction; and Phereby authorize repre-
sentatives of'. this' city' to a ter upon the above-mentioned pro rty for
insp 0c a pu -
S+gnature Date
Drivers'!License or SS
Heating System & Ducting
❑610Q000 BTU ❑100,000BT�
--'
Reins action Fee
p $p5 Issue Fee ! $ 3
:1
-CMF 0865-46 rev. 7/83 • White - Building: Canary - Applicant Pink - Accounting;
Goldenrod - Assessor
CONSTRUCTION AND PLANNING_POOL
APPROVALS Permit Dateinspector
?A.
APPROVALS Permit #
Date
Inspector
Temporary Electrical Service,or Pole
52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd.
53.- Steel - Reinforcement
1 Electrical Conduit Utility-Undrgrnd.
54. -Forms
41:!Electrical Conduit-Undrgrnd.
55. Electrical, Bonding
5. Steel ReinforcementJ,
56., Rough 01u* nbing & Pressure Test
6. Electrical UFER Grrid.' ,
.57.- APPROVAL TO COVER-GUNITE
7. Footings-%kiz-go -,g13 :T 15e A10TF-_S
',;i
-zo
58.: Electrical Conduit-Undrgrhd.
8. Foundation
59. Gas Pipe, 0 U6drgrnd., Test
9. Water Pipe-Undrgrnd.
60.'Backwash Lin&s,-P-T;ap, 0 Undrgrnd.
10. Structural Floor System
-61.1 APPROVAL TO DECK
11. Property Sewer Line & House Connection
-t
62. Ba . ckwash & Receptor -Final
12. Sewer Cap
�63.'Heater &.Vent -Final
13. Roof Drain's
_64.- Plumbing System - Final
14: Rough Plumbing
65. Electrical -Finale
15. Rough Electrical -Conduit
66.- Solar System -Final
1.6. Rough Electric Wiring
67. 'Fencing & Access -Approval
47. Rough Wiring Sign
68. -APPROVED FOR PLASTERING
18. Rough Electrical -T Bar Ceiling
69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning
FIRE, DEPT. REQUIREMENT
APPROVALS Permit
'20. Rough Factory Fireplace
21. Ducts, in Structure
70. Underground Hydro
22. Ducts 'Ventilating
71. Product Piping 0 Gas 00il
23. Gas P;* -Rough & Test
72. Underground Flus . h
24. Roof Framing
73. Undergrnd. Storage Tank DGas 00il
25. Roof Sheathing
74. Overhead Hydro
26. T-Bar,Ceiling (Structural) & Monocoat
75. :Dry Chemical
27. Frame..and Flashing
76. Dry Standpipe
.28. Lathing §i Siding
77. FIXED SYSTEM FINAL
29. Insulation
78. FIRE PREV. FINAL
30. Dryw;l[.Nailing
HEALTH DEPT. REQUIREMENT
31. Plaster' Brown Coat.
79. FINAL.INSPECTION
32. Electrical Power Meter -Final
80. FOOD CERTIFICATE ISSUED
33. Final Electric
Notes:
34. Final Heating & Air -Conditioning
35. Final Gas Pipe -Test
__76� jo Y_ WIC "I �0 -W 67;�w 111 h-/
36. Hood or Canopy
AJ 1AMI Yr IVn e
37. Final Factory Fireplace
38. Final Plumbing
iE 11 -_30 -e3 tIEW J-0CAT0 rij Aj- N.W_ eORNI;4Z
39. Water Service -Final
LIP PLANTER-Cri PENOnyis rt4AT SICiAl pori -
40. Gas Service -Final
Jj&r PROJEcT pA5r PL dg PRo,)E:cT PAST
41. Solar Domestic-FinalPOUR
Ej"F- OF S)DIEWAL.K. F�V-rJNOS Ofy,,TOV PENnimk-
42. Backflow Preventer
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING
48. Special Requirements Completed
49. Electric Release to Edison
50. Gas Release to Southhrn California Gas Co
51. CERTIFICATE OF OCCUPANCYC,
No, Date
T
A
(714) 754.5273 • Fax (714) 754-4856 • www.d.costa-mesa.ca.us 77 FAIR DRIVE, COS I A MESA, CA 9252ti
Job Address: 195 E 17TH ST
Suite No
Vicinity:
Parcel Nunmber: 42542310
Applicant: ANITA CRUZ
Address: 1521 CAMINO LOS ROBLES
FULLERTON, CA
PLUMBING PERMIT
Status: ISSUED
Applied: 11/06/2002
Issued: 11/0612002
/
ISSUED BY:
Phone: (714) 738.1803
Zip: 92833
Owner: HUDDLESTON, DONALD I TR
Address 2161 SAN JOAQUIN HILLS RD
Phone:
NEWPORT BEACH, CA Zip: 92660
Contractor: DIAMOND POINT CONSTRUCTION
Address: 1521 CAMINO LOS ROBLES
Arch / Eng :
Address:
Phone: (714) 738.1803
FULLERTON, CA Zip: 92833
License: 657594
Phone:
Zip:
License:
SCOPE OF PERMIT
REF B01-01925.
3 BACKFLOW PREVENTERS„ 1 EXPANSION TANK, 1 SEWER CONNECTION, 1 COMM. SINK, 2 FLOOR
SINKS, 1 MOP SINK, 3 TRAP PRIMERS, 1 TOILET, 1 WATER HEATER.
QTY
AMT
FEE SUMMARY
0
AMT
QTY
0
AMT
ISSUE FEE
$23.50
0
Laundry Tub / Washer
$OAO
Backflow irrigation
$0.00'
3
Landscape Irrigation
$0.00
Backfiow Preventer
$29.40
' 01 I `'
P -Trap
$0.00
Bathtub
$0.00
0',,� '
Pressure Regulator
$0.00
Clarifier System
/$0.00
- 0
Process Piping (per 10 ft)
$0.00
Connect (Ice,Soda,etc)
$0.00
- 0
Receptors
$0.00
Dental Units
$0.001
0
-' -Septic Tank
$0.00
Dishwasher
$0.00
01
Sewer Cap for Demo
$0.00
Drain, Floor
$0.00
0
Sewer Connect
$24.65
Drain, Rainwater
$0.00
-�,0
Sewer Private Line
$0.00
Drain, Roof
$0.00
0_
Shower,
$0.00
Drinking Fountain
$0.00
0
Sink, bard.
$0.00
QTY
AMT
OTY
0
Sump Pump
$0.00
0
0
Swimming Pool
$0.00
0
0
Trap Primer
$29.40
3
0
Urinal
$0.00
0
0
Vacuum Brkr BkBow(1-4)
$0.00
0
0
Vacuum Brkr Skflow(5+)
$0.00
0
0
Wash Basin
$0.00
0
0
Wash Basin Set
$0.00
0
1
Waste and Vent System
$0.00
0
0
Water Closet (Toilet)
$9.80
1
0
Water Heater / vent
$12.30
1
0
Water Piping (Inst or Rep.)
$0.00
0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements Vfid4r California statutes and related
regulations. (Ord. No. 92.28, § 1, 1241-92) /p
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 day ,nor 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�omply 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
2"s (erw)
14
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a crti0cate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
rk for which Nis permit H Issued.
r
ave and Will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this penult Is Issued.
y workers' can nsatlon Insurance�er and policy number are:
v`p.,eEl-L1. n/ not be completed it the valued et one hundred ddfars (S 100) or less.)
dertify 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 Cellfo a, and agree that I should become subject to the workers' compensatlon provisions of Section 3700 of me Labor Code, I shall forthwith
"p`a'y comply -will Nese proWsi s.
gnatu
-
WAPNINOAILURE TO SECURE WORKERS' COMPENSATION COVE G S UNLAWFUL AND SHAH. SUSIECI'AN EER TO CRIMINAL PE! IES AN CML FINES UP TO ONE HUNDRED
THOUSAND DOl1ARE (5100,000), IN ADDITION TO THE COST OF COM ENS , DAMAGES AS PROVIDED FOR IN SECTION WOS OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
I herehy,emrm that 1 am icensetl under rovisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business end Professlons Code, and my IicensQis in full
force end effect. Lic. 4 �� Classes. 9 9 '�(' Z
q t N r "
Contractors 9nature: Dela\ 1 _
i.
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agen 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 o1 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 00 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 me burden of proving that he or she did not build or improve for purpose of sets.).
❑ i, as owner of me property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 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 me 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 o1 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 dudng 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 hazartlous materials? ❑Yes ❑ No
(Section 25533 o1 the California Health and Safety Code, with some excplions. requires registration with the Costa Mesa Fire Department by each business which at any
one time hes on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic fast of
compressed gas at standard temperature and pressure).
....._.......__.._......_..___._._...____......_.._...... building
...............�........._"'�__............................................................................_.._........rogra.__..._.__ acutely
.............__..............sial._......._
3 Does or will the apppllcenl or present or future bulltling occupant need to prepare en RMPP (Risk Management and Prevention Program for ecetety hazardous materials)?
❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the Costs, Mesa Fire Department may require the preparation, cerlllicetion and tiling 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 compiled 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 a plication afermlt for such construction or motllliceUon
from the South Coast Air Quality Management District or from any other air pollution control district or agency? � Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
._................_..._.._........__._.__........__....................................................__�.__.._. �..._..........................____hoof? _.._ ___—........ _.._....—......._._..__.........T
e WIII any pert of the facility to be constructed untler this pertnil be within 1000 feet Iron the —outer, 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 Qualityy Management District or other air pollution control district or agency is required for the work which is the subject of this
applicatlon, have all of the disciosures presci bad by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
._.....................__............_........_....._"._....................................................._____._........_._..__..___.._..._......................................... _..................._._......_..... ....... ___.........__...................."'..............
8 (If yes , attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Masa 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.
Signatur Legal Owner(s) Date
nd/Or A nt --
CODE I INSPECTION TYPE l,/� gr!¢ 9MA CODE,0 INSPECTION TYPE DATE 6♦TMALe�
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing f//orn 3 T
200 Final Re -Root 210 Final Electric)
201 Final Block(Retaining Well 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
M
(714) 754.5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca,us 77 FAIR DRIVE, COSTA MESA, CA 92626
MECHANICAL PERMIT
Job Address:
195 E 17TH ST
Suite No
ISSUE FEE
Vicinity:
Parcel Number:
42542310
Applicant:
ANITA CRUZ
Address:
1521 CAMINO LOS ROBLES
Repair/ Alt Cooling/Heat
FULLERTON, CA
Owner: HUDDLESTON, DONALD I TR
Address: 2161 SAN JOAQUIN HILLS RD
Status: ISSUED
Applied: 11/06/2002
Issued: 11/0612002
G
*>
ISSUED BY:
Phone: (7114)73a-1803
Zip: 92833
Phone:
NEWPORT BEACH, CA Zip: 92660
Contractor: DIAMOND POINT CONSTRUCTION
Address: 1521 CAMINO LOS ROBLES
Phone: (714) 738.1803
FULLERTON, CA Zip: 92833
License: 657594
SCOPE OF PERMIT
REF B01-01925.
2 VENT FANS TO SINGLE DUCTS, 1. 3-15 HP COMPRESSOR.
FEE SUMMARY
Repair / Alt Absorbtion Unit
Repair / Alt Refrigeration Unit
Ventillation System
Evaporative Cooler
Commercial Incinerator
Domestic Incinerator
Compressors / Absorption Systems
Uplo3 hp/ 100k BTU
3To 15hp/500k BTU
15 To 30 hp / 1,000 k BTU
30 To 50 hp / 1,750 k BTU
Over 50 hp / Over 1,750 BTU
Boilers
Up to 3 h
3 To 15 hp
15 to 30 hp
30 to 50 hp
Over 50 hp
Other Mechanical Fee
Investigation Fee
Plan Check Fee
Reinspection Fee
TOTAL CALCULATED FEES
Quantity
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$27.15 1
$0.00 0
$0.00 0
$0.00 0
$0.00
$0.00
$0.00
$65.15
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requk mer s 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 r d final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754.5626
244046 (6=)
Quantity
ISSUE FEE
$23.50
Inst FAU <100 k BTU
$0.00
0
Inst FAU >100 k BTU
$0.00
0
Repair/ Alt Cooling/Heat
$0.00
0
Inst / Rep. Recess Wall HV
$0.00
0
Refrig Sys <100 k BTU
$0.00
0
Refrig Sys >100 k BTU
$0.00
0
Gas Piping
$0.00
0
Factory Fireplace
$0.00
0
Hood w/Mech Exhaust
$0.00
0
VAV Box
$0.00
0
Vent Fan / Single Duct
$14.50
2
Appliance
$0.00
0
Fire Dampers
$0.00.
-0
Smoke Dampers
$0.00
0
Inst or Relocate Appl Vent
$0,00
0
Air Handlers < 10000cfm
$0.00
",O� -,
Air Handlers> 10000cfm
$0,00
-0
Floor Furnace
$0.00
0
Floor or Suspend Heater
$0.00
0
FEE SUMMARY
Repair / Alt Absorbtion Unit
Repair / Alt Refrigeration Unit
Ventillation System
Evaporative Cooler
Commercial Incinerator
Domestic Incinerator
Compressors / Absorption Systems
Uplo3 hp/ 100k BTU
3To 15hp/500k BTU
15 To 30 hp / 1,000 k BTU
30 To 50 hp / 1,750 k BTU
Over 50 hp / Over 1,750 BTU
Boilers
Up to 3 h
3 To 15 hp
15 to 30 hp
30 to 50 hp
Over 50 hp
Other Mechanical Fee
Investigation Fee
Plan Check Fee
Reinspection Fee
TOTAL CALCULATED FEES
Quantity
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$27.15 1
$0.00 0
$0.00 0
$0.00 0
$0.00
$0.00
$0.00
$65.15
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requk mer s 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 r d final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754.5626
244046 (6=)
M
FA
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑eve and will maintain a certificate of consent to self-Insure for workerscompensation, as provided for by section 3700 of the Labor Code, for the performance o1 the
r1lN for which this permit is issued.
ave antl will malntain workers'compensation Insurance, as required by section 3700 of the Labor Code, for Ne performance of the work for which this permit Ls Issued.
-workers'sompensatlon Insurance ardor and policy number ere:�r L��--% PercyNurmber.� tion nee snot beeompleted if he peri is valued atone 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 Celli I , and agree that if 1 Itould become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
com ly-wHh•these Drovisio s. 1
Icay.Slgna ut re:qqDete'�l �j .`}�
'WING: FAILURE TO SECURE ORKERS' COMPENSATION OOVERAG S NLAWFUL AND SHALL SUBIECT ANE OVER TO CRIMINAL PE TIE ND GVIL FlNES UP TO ONE HUNDRED
THOUSAND DOU ARE ($100.000), IN ADDITION TO THE COST OF COMPE n , DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
hereby afltam-therl'sintoonsed under rov ions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business antl Professions Code, and my rise Is in full
torte end.eH�'t9c'#-^i-J CIe�S.v�N�i�7r�
Contractors Signat n : - � Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
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 DIAslon 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a Permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title B, California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has e
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present Or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
......... ___...................................... ...._.................. ........ _... _......... ... .................................. _............................... _._........................ _._._..... ................................................................. ............................. ...._............ __.................................
2 Does or will the applicant or present or future building Occupant need to file a registration fond for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
.........._........................................... ...................... .._..... ....................................................... _...._.............................. __... _...... _............_..._.._..............................._._..__._.................................................___.........................................__.
3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ N0
(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.
.__.__.._........_..............................__._.........._.......__.__............................................................._.............................._._._......................_......................................................... .....................I........._...........................................................
4 Ii en RMPP is presently required, hes 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 a plication 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 No
(Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building perils).
......_._................_._........................_................__.................._................................._..........._......_._._........................_.__.._.........._......................................................_.... .........................._......_....__...................._............_._
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 a emit from the South Coast Air Quality Management District or other air pollution control distract or agency H required for the work which is the subject of this
appl teflon, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Ves ❑ No
6 (If yes", attach certificate Of compliance from the appropriate air pollution control officer),
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Masa 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.
1 Signatur , f Legal Owners) ate
CODE If INSPECTION TYPE 2AIL INTITIdLi CODE INSPECTION TYPE
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 206 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
2G4 Final Demolition 250 Final BuildingrOccupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.usICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626
Job Address: 195 E 17TH ST
Suite No
Vicinity:
Parcel Nunmber. 42542310
Applicant: ANITA CRUZ
Address: 1521 CAMINO LOS ROBLES
FULLERTON, CA
Owner. HUDDLESTON, DONALD I TR
Address 2161 SAN JOAQUIN HILLS RD
Phone: (714) 738-1803
Zip: 92833
Phone:
NEWPORT BEACH, CA Zip: 92660
Contractor. DIAMOND POINT CONSTRUCTION
Address: 1521 CAMINO LOS ROBLES
Phone: (714) 738.1803
FULLERTON, CA Zip: 92833
License: 657594
ISSUED BY:
r.
Status: ISSUED
Applied: 11/06/2002
Issued: 11/06/2002
SCOPE OF PERMIT
REF B01-01925.
17 LIGHTS, 26 OUTLETS, 7 SWITCHES, 7 NOW RES. APLIANCE, 1 SERVICE UP TO 1000 AMP. 3
PANELS, 2 SIGNS CIRCUITS AND 1 MOTOR -10HP.
FEE SUMMARY
Quantity
Temp Dist System / Lighting
$0.00 0
Quantity
ISSUE FEE
$23.50
$0.00 0
Temp service test
$0.00
Transformers up to 1 kva/kw
Res. a/c package
$0.00
$0.00 0
New Res (1-2 units)
$0.00
0
New Res (3+units)
$0.00
0
Pool / Spa
$0.00
0
Lighting Fixts
$18.70
17
Recept Outlets
.$26.38
26
Switches
$7.70
7
Non Res Appl
$0.00
0
Res Appl
$33.25
'' 7
Service to 200a
$0.00
'0
Serviceto 1000a - -
$62.15
v1
Service over 1000a
$0.00
"'o
Motors to lhp
$0.00
- 0
Motors to 10hp
$12.30
1,
Motors to 50hp
$0.00
0
Motors to 100hp
$0.00
0
Motors over 100hp
$0.00
- 0
Communication drops
_
$0.00
0
FEE SUMMARY
Quantity
Temp Dist System / Lighting
$0.00 0
Busway /100 it
$0.00 0
Standing Section
$0.00 0
Misc Electrical Equipment
$0.00 0
Transformers up to 1 kva/kw
$0.00 0
................up to 10 kva/kw
$0.00 0
.................up to 50 kva/kw
$0.00 0
.................up to 100 kva/kw
$0.00 0
.................:over 100 kva/kw
$0.00 0
Low,Voltage Equipment
$0.00 0
Low Volt Wiring System / Ckt
$0.00 0
Misc. Conduit
$0.00 0
Misc. Conductor
$0.00 0
Circus ( gen or ride)
$0.00 0
Circus (mech ride or lights)
$0.00 0
Christmas Tree Stand
$0.00 0
' Fireworks Stand
$0.00 0
Other Electrical Fee
$0.00
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 this permit.
FOR INSPECTIONS CALL: (714) 754-5626
2446-46 (6'00)
Y
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
��work for which this permit Is Issued.
r ve and will maintain workers' compensation insurance, as required by sector, 3700 of the Labor Code, for the performance of the work for which this perrNt Is Issued.
" My workers' co ensa/ti—on Innsuranc rler and policy number are: /
CarR6�� Ee ",= - PolicyNafte--r-�� l0 " DZ01(1
,((Th&soct1on need not be completed If the perm valued atone hundred dollars ($100) or less.) "'�-----r'
❑ 1 cartity that In the performance of the work for which this permit is issued, 1 shall not employ any person In any manner so as to become subject to the workers'
compensatio aws of Calllor end agree that If ho IQ become subject to the workers' componsation provisions of Section 3700 of the Labor Code, I shall forthwith
corn 1he58.provl5lo _
-ApplicanbSignb �(r
WARNING: FAILURE TO SECURE WORKERS' COMPENSAT COVERAGE IS FlX AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P TES D GVIL FlNES UP TO ONE HUNDRED
THOUSAND DOLLARE (5100,000), W ADDITION TO THE F COMPENSA ON AMAOES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES,
LICENSED_ CONTRACTORS DECLARATION:
I herob ,ay,ay ffinDL aU m licensed and r rovisions of Chapter 9 (commencing with Section 7000) of Division 3 0l' el hiBuTTas and Prclessions Code, e tl my license is in full
force and a actrteC_ Cie.
leass� p �
Co chefs ature: Date:..
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby aflinn that there Is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Cade).
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 pernit to construct, alter, Improve, demolish. or repair any structure, prior to Its Issuance, also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant fore permit
subjects the applicant to a civil penalty of not more than five hundred dollars (5500).):
❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work
himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement Is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of 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 taw 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.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Fzpires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby ceNty, that no excavation five (5) or more feet in depth Into which a person is required to descand, 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, Sac.
341, Mile 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 iron the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the Celifomia 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 ocoupant need to file a registration form for acutely hazardous materiaLs7 ❑ Ves ❑ 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 appplicant 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 Mese Fire Department may require the preparation, certification and filing with the Fire
partment 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 0l the California Health and Safety Code been fully complied with? Dyes ❑ No
5 Does or willSo the applicant or present or future building r from at require for the work which is the subject c this a�ppplication a8 No for such construction or modlficotion
tram the South Coast Air Quality Management District or from any other air pollution control d15Mcl or agency? U Yes LJ NO
(Sedan 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
_ ........._._.
6 Will an
y pen of the fedllry to be constructed under this permit be within 1000 feet Iran 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 appeermit 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
applicatlon, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
...8 (II__— .._..____......__.....__. _
yes', attach certificate of compliance from thee appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I cenily 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:
CERTIFlCATE 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 constructlon, and authorize representatives of the City 01 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.
_ Signatur I Legal Owner(s) Date
4
Anti zed A -- ate
g2REL INSPECTION TYPE PdTE gMLS 2= INSPECTIONTYPE 2&U INTIM
1816 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pod Spa Final 208 Final Plumbing
200 Final Re -Roof 210 Final Electrical 3
201 Final BIocklRetaining Well 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Sita
204 Final Demolition 250 Final Building/Occupancy
O E CITY OF COSTA MESA
BUILDING DIVISION
DEVELOPMENT SERVICES DEPARTMENT
°• ' ` PERMIT
(714) 754-5273 • Fax (714) 754.4856
ELECTRICAL PERMIT
Job Address:
Suite No
Vicinity:
195 E 17TH ST
195 E 17TH ST
Parcel Nunmber: 42542310
Applicant: FISCUS, ANDREA
Address: 16868 'A' ST
CA
HUNTINGTON BEACH
Owner: HUDDLESTON, DONALD I TR
Address 2161 SAN JOAQUIN HILLS RD
NEWPORT BEACH,CA
Contractor: BARTON ELECTRIC
Address: 10072 CLIFF DRIVE
CA
HUNTINGTON BEACH
Phone: 714.375.4700
Zip: 92647
Phone:
Zip: 92660
Phone:, 714.801.0165
Zip: 92646
License: 521649
PERMIT NUMBER
E98-01204
77 FAIR DRIVE, COSTA MESA, CA 92626
Status: ISSUED $0
Applied: 11/17/1998
Issued: 11/17/1998
SCOPE OF PERMIT
CONTRACTOR PERMIT: GAS STATION: HOOK-UP MONITORING SYSTEM AND TURBINES WITH NEW
WIRING, RECONNECT DISPENSERS. THREE MOTORS 0.0 - 1.0 HP AND 2 MISCELLANEOUS
APPARATUS NOT LISTED REQUIRING PERMIT.
Quantity
ISSUE FEE
$22.00
Temp service test
$0.00
Res. a/c package
$0.00
New Res (1.2 units)
$0.00 0
New Res (3+units)
$0.00 0
Pool / Spa
$0.00 0
Lighting Fixls
$0.00 0
Recept Outlets
$0.00 0
Switches
'$0.00 0
Non Res Appl
$0.00 0
Res Appl
$0.00 0
Service to 200a
$0.00 0
Service to 1000a
$0.00 0
Service over 1000a
$0.00 0
Motors to Ihp
$12.75 3
Motors to 10hp
$0.00 0
Motors to 50hp
$0.00 0
Motors to 100hp
$0.00 0
Motors over 1 00h
$0.00 0
Communication drops
$0.00 0
Sub panel to 200a
$0.00 0
Pole Light Pkg
$0.00 0
Sign Circuits
$0.00 0
Temp Pwr Pole
$0.00 0
Intermed Pole
$0.00 0
FEE SUMMARY
Quantity
Temp Dist System / Lighting
$0.00
0
Busway 1100 f1
$0.00
0
Standing Section
$0.00
0
Misc Electrical Equipment
$32.50
2
Transformers up to 1 kva/kw
$0.00
0
................up to 10 kva/kw
$0.00
0
.................up to 50 kva/kw
$0.00
0
.................up to 100 kvalkw
$0.00
0
..................over 100 kva/kw
$0.00'
0
Low Voltage Equipment
$0.00
0
Low Volt Wiring System / Ckt
$0.00
0
Misc. Conduit
$0.00
- 0
Misc. Conductor
$0.00
0
Circus ( gen or ride)
$0.00
0
Circus (mech ride or lights)
$0.00
0
Christmas Tree Stand
$0.00
0
Fireworks Stand
$0.00
0
Other Electrical Fee
$0.00
Investigation Fee
$0.00
Plan Check Fee
$0.00
Reinspection Fee
$0.00
TOTAL CALCULATED FEES $67.25
COMMENTS / SPECIAL CONDITIONS
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
DECLARAMNS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of podury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the labor Code, for the performance of the
work for which this permit is Issued.
I have and will maintain Workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work O for which this permit is issued.
My worker��99'- 11c--o�Tm�qp��ensalion Insurance carter and policy number are: z�� _ �U Lk" IT
Carder: I n I C ��{ N PolicyNumber.
(This section need not be completed if Ma pemlit is valued atone hundred dollars ($100) or less.) Ny I q 131
❑ I certity, that In the penormen of the work for which IN It is issued, I shall not employ any person in any manner so as to became subject to the workers'
compensation laws of Call[am , and agr a that If I should be me,gubject to the workers' compensation provisions of Se Ion 37 0 of the Le Code, I shall forthwith
comply with those Pro 'sions. I n Q
Applicant Signature: Date: I -1 U
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION OOVERA�64S UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P TIES AND CIVIL FINES UP TOONE HUNDRED
THOUSAND DOlARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3108OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
I hereby afflrn that I am licensed unde�rgvi9
SO o Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full
force and effect. L i a I •CC.... II 1, ( _ Class p C. - 10
Contmctofs Signature: (_ ,1N1- Date: - I —.dooa
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code).
Lender's Name: Lenders Address:
Signature: 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
Coda: Any dry or county which requires a permit to construct, after, 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 Ucenso 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 civ,) penalty of not more than We 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 (Sac. 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.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or dew):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 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, wlll be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner-bullder, 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: Data:
Division of Industrial Salary Permit Number.
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the apt nI 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? Vas [INo
(Section 25 5 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mese 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).
..............................................................................................-re.........lien............................................................................................................... ..............
.
2 Does or will the aDPlicant or present or future building ocalpant need to file a registratlan forth for acutely hazertlous matenels7 Vos ❑ No
(Section 25533 01 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Der -lament 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 feetof
compressed gas at standard temperature and pressure).
....._.............................................................................................................................................................................................................................................................................
3 Does or will Ipplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes No
(Zctlon 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
Drtment of an RMPP by businesses which are requited to register acutely hazardous materials with the Fire Department.
.................. ............................................................................................................................................................................................................................
uired, ....................ed,
4 It an RMPP is presentry reqhas Section 25534 0l the California Health and Safety Cade been fully complied with? El Yes ❑ No
...................................appl..............................futu....buil...............Ipan.....quir..........................hich.................ject..f this
5 Does or will the applicant u present or future building occupant require for the work which Is the sorted of this g(iplicstlon epermlt for such construcdon or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes ❑ No
(Section 658502 of the California Government Code requires that the requested information be furnished on applications for non-resident) I building permits).
.................................................................................................................................................................... .............. .
6 Will any pan of the facility to be constructed under this Permit be within 1000 feet horn the outer boundaries of a school? ❑ Yes No
(it -yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
...................................................................................................................................................................................................................................................................................
7 It a Permit from the South Coast Air Quality Management District or other air pollution control district or agency required for the work whlch is the subject of this
,application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been metle77 Yes ❑ No
..............................................................................................................................................................................................................................................................
8 (If yes", attach cortificale of compliance from the appropriate air pollution control officer).
CERTIFICATE OF CO PLIAN : I cantly that undo natty of perjury the Information given above is correct. I agree t comply with all state laws and city ordinances
regarding Hazardou I Is m sions.
Signature: Date: 9
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: 1 certify under penalty of perjury that I have read this application and stale 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 Masa to enter upon the
above ascri ed property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this pemlit until final inspection.
/
nature qfLegal Owner(s)I I, -JS
And/ Aut oozed Applicant Tr Data
Zil 1 01aPECTIONTYPE gA¢ J=A conE! INSPECnONTYPE 11AIE IBiMA
1616 Fixed System Final Fire Prevention 206 Final Mechanflal
1266 Pool Spa Final 208 Final Plumbing a_e-
200 Final Re -Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 'Final Sign 222 Final Site _
204 Final Demolition 250 Final Building/Occupancy
2"4,46
(714) 754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us ft VAIN u"IV C, wa I m mcaA, i A em<o
Job Address: 195 E 17TH ST
Suite:
Vicinity:
Parcel Nunmber: 42542310 "
Applicant:
ANITA CRUZ
Address:
935 ALMOND DR
BREA, CA
Owner:
HUDDLESTON, DONALD I TR
Address
2161 SAN JOAQUIN HILLS RD
Other:
'NEWPORT -BEACH;CA
Contractor:
SHINE ELECTRIC
Address:
PO BOX 70299 "
SIGN PERMIT
Zoning:
Phone: 714-308-8730
Zip: 92827
Phone:
Zip: 92660
Phone: 800-273-2093
RIVERSIDE, CA Zip: 92513
License: 782471
Arch / Eng
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
INSTALL A 20.8 SQ.FT. BUILDING SIGN TO IDENTIFY THE FOOD MART
NOTES:
PLANNING & ZONING
Status: ISSUED
Applied: 10/29/2003
Issued: 10/29/2003
ISSUED BY:
Calc Valuation: $1,000.00
Claimed Valuation: st,000.oc
I
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12.21.92)
EXPIRATION: This permit shall automatically expire and become void It work Is not commenced within 180 days, or If work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
44646(6=)
FEE SUMMARY
Plan Check:
$25.19
$0.00
Permit:
$38.75
SMIP Com:
$0.50
Other:
$0.00
$0.00 .
Inspection:
$0.00
$0.00
$0.00
Total:
$64.44
NOTES:
PLANNING & ZONING
Status: ISSUED
Applied: 10/29/2003
Issued: 10/29/2003
ISSUED BY:
Calc Valuation: $1,000.00
Claimed Valuation: st,000.oc
I
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12.21.92)
EXPIRATION: This permit shall automatically expire and become void It work Is not commenced within 180 days, or If work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
44646(6=)
DECLARATIONS
j RKERS' COMPENSATION DECLARATION:
Thereby eHirtn 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.
workers' com.Rerpation Insuranceicor and policy number ere:
Carder. {'V nzl Policy Number. '9,9q
(This section need not be canplat if the permit 1 lued at one hundred dollars ($100) or less.)
❑ 1 certify that In the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of C li rola, and agree that It I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with thes' i
e pro
Applicant Signature: - / Date:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COV E IS UNLAWFUL AND SWILL SUBJECT AN EMPLOYER TO CRIMINAL PANALTIE$ D CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE ($10D.000), IN ADDITION TO THE COST OF P SATION, DAMAGES AS PROVIDED FOR W SECTION 3706OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed levrovisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busine antl P ofewilons Code, and my license is In full
force and effect. Llc. a Class a Iii Wit -
Contractors Signature: _ Date:114
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code).
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 Cade) 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, es owner ol,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 (Sac.
7044, Business end 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 dompletion, 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 Ucense Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors)
license pursuant to the Contractors License Laws.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby cavity 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 thereol, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sac.
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: Data:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 WIII 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 I -.
(Section 25505 of the California Health and Safety Coda 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 temporaturo and pressure).
_...__.—..............—............_._.....................__._...._..._.._.........___...__....................... -................. __-._.............. ............_....... __........................... _.............._..........
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some excaPtions, 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 eque to or greater than a weight of SDO pounds, or a volume of 55 gallons, or 2DO cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for eatery hazardous materials)?
❑ Yes ❑ No
Rection 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, cartification and filing with the Fire
partment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
........................................._..... ................... __............._.�..._.......—_............___............—........._._...............�...............__�........_._._.........____.._....... __........... _...... _............. __.....
4 If en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled 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 a plication epp�ermit 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 WIII any pert of the fedlity 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 It a permit from the South Coast Air Oualiry Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
...... ........___............—............___........._..............__................__............................... ............. _-.............................. ..... -................... _........ ....... _................... __.
8 (If yes", attach certificate of compliance from the appropriate air pollution control oHloer).
CERTIFICATE OF COMPLIANCE: 1 cartity 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 LCI
correct. I agree to comply with all state laws and city ordinances relating to building construction, and allthodze representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes. I agree not to occupy or allow Occupancy of any building authorized by this permit until final inspection.
SI tura Of Legal Owner(s) Date
An Or Autho ed Applicant
CODE 1. MSPECTONTYPE - 2&U INITIALS CODE 2 INSPECTION TYPE gAIE INTIM
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 BlocIdRetaining 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
Job Address: 195 E 17TH ST
Suite:
Vicinity:
Parcel Nunmber: 42542310
Applicant: ANITA CRUZ,
Address: 935 ALMOND DR
BREA, CA
Owner: HUDDLESTON, DONALD I TR
Address '2161 SAN JOAQUIN HILLS RD
NEWPORT BEACH, CA
Contractor: OWNER -BUILDER
Address:
Arch / Eng :
Address:
SIGN PERMIT
Zoning:
Phone: 714-308-8730
Zip: 92821
Phone:
Zip: 92660
Phone:
Zip:
License: 000000
Status: ISSUED
Applied: 11124/2003
Issued:: 111//2244//2003 .
ISSUED BY:
PLANNING & ZONING
NOTES:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12.21.92)
EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work Is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754.5626
2446-46 (6100)
Phone:
Zip:
License:
SCOPE OF PERMIT
INSTALL A 2�0.8) S.F. BUILDING SIGN TO IDENTIFY THE FOOD MART.
FEE SUMMARY
Plan Check:
$0.00
Calc Valuation: $1,000.00
$0.00
Permit:
$38.75
Claimed Valuation: s1,0o0.0o
SMIP Com:
$0.50
Other:
$0.00
$0.00
Inspection:
$0.00
$0.00
$0.00
Total:
$39.25
PLANNING & ZONING
NOTES:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12.21.92)
EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work Is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 754.5626
2446-46 (6100)
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
1 hereby affirm under penalty of perjury one of the following dwarations: ,
❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain workers' compensation Insurance, as required Dy section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
My workers' compensafion Insurance carder and policy number are:
Carder: Polity Number:
_(Thiysection need not be completed if the permit is valued atone hundred dollars ($100) or lass.)
lL�\/ I certify that in the perto nce al I to 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 alit rata, end agree th 1 I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these pro isio s. I '
Applicant Signature: Date:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION E IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P NALTES RAES UP TO ONE HUNDRED
THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF PFJJ TION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prolessione Code, and my license is in full
force and effect. Uc. M Class N
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code).
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 Lew (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„ r
I, as owner of the property; amt. EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sac. 7044, Business and Professions
Code: The contractors License Lew does not apply to an owner of property who builds or Improves thereon,on, and who contracts for such project with a contractor(s)
license p uant to the Contractors Ucanse Laws.). r
❑ 1 em e m under sec. Bu and and Professions Code for this reason:
Signature: c 11nb �'qp�-9F` = Date:
Owner ID v ted by drivers license. s ❑ Hd Drivers License No. �. Expires:
Verification of Ownership by (type of document, i.e. -property tax Dill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feel in depth Into which a person Is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 6, California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ 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 Is tied year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or 8 volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
__._.............__............_...............__...__.............o-r-..."t-ure......ildi.......... occupant
......................___............................_.._..................................... .._..............teri................... ...................E.................._._.........__............
2 Does or will the applicant or present or future building occupant need to file a registration forth for acutely hazardous materials? ❑Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some excetions, 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 equarto or greater than 8 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 pepare anrRMPP (Risk Management anti Prevention Program for acutely hazardous materials)?
❑ Yes ❑ No
(Section 25534 of the California Health and Safety Code provides that the Costa Mese 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 a plication e.Eereit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes U No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building Permits).
6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boun0aries of a school? ❑Yes ❑ No
(If W. 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 Qualittyy 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
B (If yes', attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I cer ity that under penalty of perjury the information given above is correct. I agree to comply with all stale laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Sig re Of Legal Owner(s) Date
An n Applicant D
CODE 1. INSPECTWNTYPE PdIF ILLS CODE INSPECTIONTYPE PATE Itis
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Well 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR UHIVh, GU5IA MtbA, GA 82b2t.
ELECTRICAL PERMIT
Job Address: 195 E 17TH ST Status: ISSUED
Suite No Applied: 10/2912003
Vicinity: Issued: 10/29/2003
ParcelNunmber: 42542310
Applicant: ANITA CRUZ _ ISSUED BY: _
Address: 935 ALMOND DR
Phone: 714-308-8730
BREA, CA - Zip: 92827
Owner: HUDDLESTON, DONALD I TR
Address 2161 SAN JOAQUIN HILLS RD
Phone:
NEWPORT BEACH, CA Zip: 92660
DgSE
Contractor: SHINE ELECTRIC
Address: PO BOX 70299
'Phone: 800-273-2093
RIVERSIDE, CA Zip: 92513 . .
License: 782471
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) 7545626
, SCOPE OF PERMIT
INSTALL A 20.8 SQ.FT. BUILDING SIGN TO IDENTIFY THE FOOD MART '
ELECTRICAL TO INCLUDE: 1 SIGN CIRCUIT.
FEE SUMMARY
Quantity
Quantity ,
ISSUB FEE
$23.50
-
Temp Dist System / Lighting
$0.00
0
Temp service test
$0.00
Busway /100 ft
$0.00
0 ,
Res. a/c package
$0.00
Standing Section
$0.00
- 0
New Res (1-2 units)
$0.00
0
- - "Mist Electrical Equipment
$0.00
0
New Res (3+units)
$0.00
0
Transformers up to 1 kva/kw
$0.00.
0
Pool / Spa
$0.00
0
................up to 10 kva/kw
$0.00
0
Lighting Fixts
$0.00
0
'..... s...........up to 50. kva/kw. -
- $0.00
0 '
Recept Outlets
$0.00
0
:.:..............up to 100 kva/kw
$0.00
0
Switches
$0.00
0
..................over 100 kva/kw
$0.00,
0
Non Res Appl
$0.00
0
Low Voltage Equipment
$0.00
0
Res Appl
$0.00
0
Low Volt Wiring System 1 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 (meth ride or lights)
$0.00 _
' 0
Motors to 10hp
$0.00
0
Christmas Tree Stand
$0.00
0
Motors to 50hp
$0.00
0
Fireworks Stand ..
$0.00
0
Motors to 100hp
$0.00
0
-Other Electrical Fee
$0.00
Motors over 100hp
$0.00
0
-
Communication drops
$0.00
0
Investigation Fee
$0.00
Sub panel to 200a
$0.00
0
Plan Check Fee
$0.00
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) 7545626
DECLARATIONS
WORKERS' COMPENSATION DECLARATION: •,
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to salt -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the
work for which this permit Is issued.
I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued.
My worker 'compensation II rance carder and policy number are: /j��
Cartier: --{�O. /Yvl Policy Number: _ 99,q d a
(This section need not bo comipliffedif b1opermirls valued at one hundred dollars ($100) or less.)
❑ I certify that in the performance of the work for which this permit Is Issued. I shall not employ any person In any manner so as to become subject to the workers'
compensation laws of Calif9grilia. and agree that i should become subject to the workers' compensation provisions of Section 3700 of me Labor Code, I shall forthwith
comply With these provisi s. ) ,'1
Applicant Signature: Date: I i� �� V
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAG UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P TIES D OIVIL EWES UP TO ONE HUNDRED
THOUSAND DOLIARE ($100,000), IN ADDITION TO THE COST OF OOMPEN90ION, DAMAGES AS PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licenser provisions of Chapter 9 (commencing With Section 7000) of Division 3 of the Business nd Professions Code, and my license is In full
force and affect. Lic. « Class k
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: 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 Sectlon 7000) of Division 3 of the
Business and Professions Code)-or,that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a cMI penalty,of not more than five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Law does not apply to an owner o1 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.).
❑ 1 am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires:
Verification of Ownership by (type of document. i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made In connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has e
permit to do such work from the division.
Signature: Dale:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 WIII the applicant or present or future building axupant 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 Coda requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by evary
business which has at any one lime during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or200 cubic feet of .... and . ................................................................................................................................................................,............................._................._._.............................
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
.....___.............._._._.......___......____............_.__............._........_.......—.........._.�......._..._.__._...._.—........_....—........_.—..._
3 Does or will the appplicant or present or future building ocoupanl need to prepare en RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑Ido
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
......_.........._ ............ ..._....._................................._......_..............._..............__..__........_.__........__.........__�._.�........_......_.....__.......__....._—_......—........_.....
4 If en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No
..._...._........._.__..__._............_.__..........._.._.........___................_......._._............._................._._.__......_..._.....................................__._................................... _._................_..............__..........___......
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a pe
plication armlt for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
......_................_.........................._....................................................................................._............................................................................................................._........___..............................._................... __................_...........—.......
8 Will any pan of the Iacillty to be constmctetl under this permit be within t0001eet from the outer bountlaries of a school? ❑Ves ❑ No
(ll yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
......__........__................—............___._........_.__._........_____.8 .........__..__— __._._.......... 9. agency
—......_—_._._._._....... —.........—.....
7 If a permit from the South Coast Air Quoit management District or other air Pollution control district or a en is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Cafe Section 42303 been made? ❑Ves ❑ 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: Data:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Si lure Of Legal Owner(s) Date
I l
AnWOr AtAh^ed Applicant Da e
CODE If INSPECTIONTYPE PALE INiQ19L$ CODE.t INSPECTION TYPE RETE IBTIA
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Roof 210 Final Electrical
201 Final Block/Retaining Well 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
(714) 754-5273 •Fax (714) 754-4856 www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
SIGN PERMIT
Job Address:
195 E 17TH ST
Status: ISSUED
Suite:
Applied: 10/10/2002
Vicinity:
Issued: 10/10/2002
Parcel Nunmber:
42542310 Zoning:
ISSUED BY:
Applicant:
CRUZ, ANITA
Address:
- -
Phone: _
- - - Zip:
Owner:
HUDDLESTON, DONALD I TR
' Address
2161 SAN JOAQUIN HILLS RD
Phone:
t�. -
NEWPORT BEACH, CA Zip: 92660
Contractor:
DIAMOND POINT CONSTRUCTION
ry
Address:
1521 CAMINO LOS ROBLES
. " Phone: (714) 738-1803
-
FULLERTON, CA Zip:' 92833
License: 657594
,pA�
Arch / Eng :-\Y�'_y
Address:
-
- Phoria:
.
Zip: • _ _
.�C
ONO
License:
SCOPE OF PERMIT
INSTALL A 25' HIGH, 80 SOFT. FREESTANDING SIGN AT THE CORNER OF THE CHEVRON
STATION.
Plan Check:
Permit:
SMTP Com:
Other:
Inspection:
Total:
NOTES
FEE SUMMARY
$63.21
$0.00 _
$97.25
$0.74
$0.00
$0.00
$0.00
`$0.00
cn' nn
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
Calc Valuation: S3,500.00
Claimed Valuation: 53,500.00
A46-46
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) 7546626
lerool
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to sell-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the Performance of the
work for which this permit IS issued.
91 ?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.
y worker MP elion Insce carder antl policy number ere: y�-U
Ci O A-a� W Number
?Th s section need not be comp/et d it the permit is valued at one hundred dollars ($100) or less.)
❑ I candy 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 ,040mia, and ag 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 pro Si OPS.
NTNG: FAILURE TO SECURE WORKERS' COMPENSATI OVERAG UNLAW AND SHALL SUBJECT AN EMPLOYER TT'OO CRIM�INPL ENAL IES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLIARE ($100,000), IN ADDITION TO THE COST PENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
LICENSED CONTRACTORS DECLARATION:
I her Dy f that'I•am. icensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full
f rc attic.a N'_ C �assI -1
Contra nature: —Date:
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code).
Lender's Name: Lenders Address:
Signature: 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 Profosslons
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 civifpenelly of not more than five hundred dollars ($500).):
❑ I, as owner of the properly„army employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or atteretl for sale (Sec.
7044, Business and ProfewIons:C&`d&/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 ofered for sale. If, however, the building or improvement Is
sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sate.).
❑ I, as owner of the 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 J.
yr
❑ I am exempt under sac. Business and Professions Code for this reason:
Signature: Date:
Owner ID veniietl 6y drivers license. ❑Yes ❑ No Drivers License No. Expires:
Verification of Ownership by.(lype of tlocument, i.e. -properly tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
n
❑ I hereby certify that no excavation e (5) or more lest in depth Into which a person is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
....file..a r..gistration forth for acutely materials?������������Ve5 .......No
................................................................................................................................................................ .....
2 Does or will the applicant or present or future building occupant need to file a registration y ❑ ❑
(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 ❑ Yes or will th❑e applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)?
(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.
................_..................._......................................__......_............................ _..... ..... _................................................................ ............... ... _......... _.................. ..................... ............... _........ I.................. _............................_............_..........
4 If en RMPP is presently required, has Section 25534 0.. the California Health and Safety Code been fully complied with? ❑Yes ❑ No
5 Does or will the ep Coast
Air
or present or future building occupant require for the work which is the subject of ? a plication aaPermit for such construction or modification
from the South Coast Alr Ouelity Management District or from any other air pollution control district or agency? � Yes L.1 No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
........................................................................................................................................._................................................................................................ ..........................................I ._................................................................_................_...
8 Will any pan of the facility to be constructed under this pertnit be within 10001aet from the outer boundaries of a school? ❑Ves ❑ No
(if "yes”, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
.._....._.._._........................._........................................... _.............._........................_.........__._..._._.........._.._........__........._._.........................._............... _.............__...__...................... __............. _._............__.........__._.
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
........._._.._.........._...._.._............._........._,..._—__....__.__.........._.........._........___..........._...........__...___.......... _.......... ._........... _...... _............. _.......... _._................. _.... _......... .....__........... _.....................
8 (If yes', attach certificate of compliance from the appropriate air pollution control Officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all slate laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certity under penalty Of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Ignature Of Legal Owners) Date
r ri pd:Applloem Date
CODE r. INSPECTION TYPE gAIE INITIAL $ CODES INSPECTION TYPE 2AM MALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Root 210 Final Electrical
201 Final BlocWRetalning 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 Buili ing/Occupancy
(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
SIGN PERMIT
Job Address: 195 E 17TH ST
Suite:
Vicinity:
Parcel Nunmber: 42542310 Zoning:
Applicant: CRUZ, ANITA
Address:
Phone:
Zip:
Owner: HUDDLESTON, DONALD I TR
Address 2161 SAN JOAQUIN HILLS RD -
Phone:
NEWPORT BEACH, CA - Zip: 92660
Contractor: DIAMOND POINT CONSTRUCTION
Address: 1521 CAMINO LOS ROBLES
Phone: (714)738-1803
FULLERTON, CA Zip: 92833
License: 657594
Status: ISSUED
Applied: 10/10/2002
Issued: 10/10/2002
ISSUED BY: ` ''
Arch / Eng : -
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
INSTALL 4 BUILDING SIGNS, TOTALING 58 SQ.FT.. FACING BOTH E 17TH STREET AND ORANGE
AVENUE. FOR CHEVRON
FEE SUMMARY
Plan Check:
$63.21
Calc Valuation: $3,500.00
$0.00
Permit:
$97.25
Claimed Valuation: $3,500.00
SMIP Com:
$0.74
Other:
$0.00
$0.00
Inspection:
$0.00
$0.00
$0.00
Total:
$161.20
` \
-PLANNING & ZONING
NOTES:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void It 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
:aae<e tswl
DECLARATIONS
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury ane of the following declarations: '
❑ I have and will maintain a certificate of consent to self -Insure for workers' compen
work for which this permit Is Issued. sation, as provided for by section 3700 0l the Labor Code, for the performance of the
_
J I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which Oils permit Is Issued.
y workers' compo sation Insurance carder and policy number are:
PmrcNba'Carrt�r'7 ymn y ZGf� r HllYi f7a�%6
-(rill section need not be can a ad ff the poinut /s valued at one hundred dollars ($100) or less.)
❑ 1 certify that in the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of C-plilipmia, and agree t y If I should becorne subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with these or. l0 S. /l
Applicant Signature: IODate_/C��Y
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION C GE IS UNLAWFUL AND SHALL SUBJECT AN EM OYERiO�RIMINAL PENALTI S AN L RNES t.P TO ONE HUNDRED
THOUSAND DOLLARE($1a0,000), IN ADDITION TO THE COST OF 00jZFNSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisi ns of Ch ter 0 (commencing with Section 7000) of Division 3pl-tha.Bullness and Professions Code, and m license is in full
forcte'6+lif eH CCOlass's
ContTactoteS✓r!'Um1 !�"_Bfe, 1 1
CONSTRUCTION LENDING AGENCY:
❑ 1 hereby affirm that there is a constructlon lending agency for the periormanco 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 lot 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 =to than live hundred dollars ($500).):
It ut
❑ 1, as owner�of the, property, or my employees with wages as their sole compensatlon, WILL 00 THE WORK, and the structure is not Intended or offered for sale (Sec.
7044, Business and Professions Code: The Contractors License Lew does not appy to an owner of property who builds or improves thereon, and who does such work
himself or Derself,'oit6io66h;his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is
sold`ithin one yeai of"66mjjletioF�the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, as ownecof the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions
Code: The contractors License Caw does not appy to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s)
license pursuant to the Codtractors License Laws.).
❑ I am exempt under sec. rT Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires:
Verification of Ownership by (type of document, i.e. - property lax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made in connection with work authorized by this
permit, and that no building structure, scaffolding, lalsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec.
341, Title 8, California Administrative Code).
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has e
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑ Yes ❑ No
(Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a repotted 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).
......__.............................I........_pplic _.....o __..._. _._...............t need t _................istra..........................._._................................................................... ............_......... _........
__
2 Does or will the applicant or present or future building occupant need to lila a registration form for ecutoly hazardous meterials7 ❑Ves ❑ Na
(Section 25533 of the California Health and Safety Code. with some exceptions, requires registration with the Costa Mese 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 appplicant or present or future building occupant need to prepare en RMPA (Risk Management and Prevention Program for acutely hazardous materials)?
❑ Yes ❑ N0
(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.
........._.__ ................._.............ently__.._..._...._..a_._._—._.......................__........................._...................de be.......................................................E ........._..._.................__.._......._____......_.....__.......-.
4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Cade been fully complied with? ❑Ves ❑ No
5 Does will the applicant or present or future building occupant require for the work which is the subject this a plication aggermit for such conswction or modification,
from thehe South Coast Air Quality Management District or from any Omer air pollution control district or agency?
y? Yes LJ No
(Section 65850.2 of the California Government Coda requires that the requested information be furnished on applications for non-residential building permits).
6 Will any pert of the facility to be constructed under This permit be within 1000 feet Irom the outer boundaries of a school? ❑Yes ❑ No
(II 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 Oualiry Management District or other air pollution control district or agency is required for the work which is me subject of this
application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
._ .............._._....... ............ _.......
_.._..........._............__.__.—__._____
8 (If yes', attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Sig a re OI Legal Owner(s) Date
I Li
C-AnfflDr Aiulhhori tlIlcant D
CODE f. INSPECTIONTYPE RASE CODEr INSPECTION TYPE gATF PilmdLS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re -Roof 210 Final Electrical
201 Final Block/Retaining Well 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign It 222 Final Site
204 Final Demolition 250 Final Building/Occupancy
'OPLICATION FOR A BUILDING PERMIT
r
Tractivpr
Bloc4
LOL� � pc.
BUILDING PERMIT NO.
���
Electrical l
Permit al
lOi
BUIn9'`� W I �7 �•
Atl Idi S /
Plumbing
Permit No.
Cross A� A�zs / _
Street QeL/7���
Mechanical
Permit No.
Owner'(>•T A.�Fxie.J.J I ifas�
Type Of Project:
El New ❑After ❑ Addition
Address :Zi 0 I _dSAN J V A Q J 190 `A III L,LS
❑ Re air ❑ Convert ❑ Demo ❑ Occupancy Pmt.
'
City /Jew \p ARE ZIP Phone
A -P-
Sup. Dist./
Inso. Area
Architect/aci�o4S7�.Licenze NoSG / t �
Designer
Zo
Sol. PTL No.
Address GOb �f�[S C+'
Selba
P/L Front
C/L St.
Street Width
_TFear
Phone O
City 4.0 5 A,a)16Ec ES _ zld`?W/7
Yards
Lit
9
NL
Lnginee".QQ �/KEL Llcansa NOSE C 2
ave r0.
l9
� -
•
Park ng $paces
aqu re
Ov a
over<d—
Address 16bo ra 4C
r
CItY An��F�ES ZI� •7 Phone2M G
$tight
Haight
Stories
Stories
of
Fa it
Family
LICENSED CONTRACTOR'S DECLARATION
Park Fees Yes
C.T.
Fee
Receipt
I hereby affirm that I em licensed under provisions of Chapter 9
Required No
Zoning Approve By:
Date
I commencing with Section 7000 of Division 3 of the Business and
Professions Code and my license is in full force and effect)
Licens Cl D LicenseNumberIS74-7!!
Dat, Contractorvpi�LpeA
Misc.
Address IGLJw/OI S A
Proposed Use
PA/LA/•10a/1fr
City and Zip Phone
o1 Structure
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
Occ.
Type
Code
performance of the work for which this permit is issued (Sec. 3097,
Class
Const.
Year
Civ. C.). ,/O•'C•
USE/OCCUPANCY
SIZE SO. FT.
Lender's Name /V A/s.,�
Lender's Address
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law
s
for the following reason:
❑ I, as owner of the property, or my employees with wages as their
2.
sole compensation, will do the work, and the structure is not
intended or offered for sale.
3
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project.
❑ I am exempt under Sec. , B&PC for this reason
a
Det Owner
WORKERS' COMPENSATION DECLARATION
Total Valuation
Encroachment Permit Required ❑ Yes ❑ Na
I harahy affirm that 1 havn a certificate Of consent t0 salt -insure,
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof.
Grading Pmt.
❑
❑
Grading
Policy No _ Company
Required
Yes NO
Pmt. No.
Certified copy is hereby furnished.
'
Rough Grading
is filed with w•
O �.
Approved by'
,etCet
a Applican
CERTI FICATE OF EXEMPTIO
FROM WORKERS' COMPENSATION INS A E
,
(This section need not be completed if permit is for 5100 or less).
1 certify that in the performance of the work for which this permit is
issued, i shall not employ any person in any manner so as to become
subject to the Workers' Compensation Laws of California.
PERMIT FEES
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Structural
E
Plan Check E
Exemption, you should become subject to the Workers' Compensation
Electrical E
S
provisions of the Labor Code you must forthwith comply with suchSpecial
provisions or this permit shall be deemed revoked.
Invest.
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE
THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO
plumbing
E
COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS
Mechanical E
RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTH-
ORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON
THE ABOVE MENTIONED PROPERTY F R INSPECTION PUR-
Pre -Grade
POSES , A /, ,s t'
C •/r/AM- Hp 6
Ins Pettion E
Pre -Grade
Rec. No. E
It
Issue E
Signature ofApplicant or Agent Date
A�P.ME eoNsr Gs1Ry AMGK
R/KMAR
Print Applicant's/Agent's Name ' NEsu
All spam within this box must be completed to process
Plan
Check BY:
Issuance
Approved:
CMF 0335-46 (BU -28) rev. 6/80
a
MW
COUNTY OF ORANGE
BUILDING DEPT.
.636 No. Broadway
Santa Ana, California
Phone: KI 2.6211
Permit
Application for Building Vermit
AND FOR A 7Zs
Certificate of Use and Occupancy
Date ... Nov.. --9, -1s51 ...............................
1. OWNER'S NAME......... Jefferson... 1'rop.ertiss,....IDC.................................................. PHONE:.B.eacon... 1162
MAILING ADDRESS ----- 123 --- Broadway ..........................
Name .Calif ...... Ste.e.l,--- &... Con,s.truc.t.or.s............
(Architect or Engineer)
Address.. -3833. ... MeAford ............. ................. ............
City ...... ._Los..Ange.les... 83--------------------- . ................
State
Lie No ....................................... PhoneAn&.---2.:.4194......
CITY ------ Costa.-Mes a .....................
Name Calif ...... St.e.el--- &... C.-ons.true.tor.s..................
(Contractor)
Address-----'---------.........................................................................
City
State
Lic. I
PROPOSED USE: ..... aer.V.1.C.e... s.TaLl_on.......... r..� .... -.... ...r^....... .....................................................
2. JOB LOCATN.
IO..�+l P__A....._�.1-04........................- .. 4jQ•.Sf% /....................................
(House No.) (Name of Street) (Town or School District,)I,�
3. LEGAL DESCRIPTION: Lot ..-----82...................................... Block ----------------------------- ..................... Tractly&kk1?4j4... //O? Ai 4
(Metes and Bounds Description—Use reverse side of form)
4. CORNER LOT ( X INTERIOR LOT ( ) THROUGH LOT ( ) SLOPE OF LOT ( )
i. SIZE OF BLDG.:2s,..x... 5. ---------- AREA: ...... ------------------------- SIZE OF LOT120...x--- 135-.. --------- AREA: ----..-.-------.
6. HEIGHT OF BLDG.:.13A...2.......................:...CEILING HEIGHT: ... 12!...8."_.. ------- __NO. OF STORIES ----- 1 --- _
7. NO. FAMILIES........................... _........... Size of Smallest Bedroom:........................................ Size of Kitchen....................................
R. EXTERIOR WALL CONSTRUCTION: -------- St-e.ea.....................INTERIOR WALL COVERING ............................................
(Frame, Stucco, Eic.) : (Plaster,Drtc.�
9. SETBACKS: Front Yard From Center Line of Strect...50..f.e.e.t............. ....... :.(fj....�—.../.- !..
Nearest Side Yard...... 28 ............ Rear YartVBri.anes-Distance in Feet Between Bldgs. on Same
lo. A COMPLETE PLOT PLAN IS REQUIRED, SHOWINGrALL STRUCTURES AND USE OF EACH.
11. For (a) Footing: Width..................spa"
.......Depth in Ground .............................. Width of Wall......
Accessory
Bldgs. and,
Similar b Size of Studs': ......................' ......... .... IyJalcria of Floor.........-...........
Structures:O�(J//(c) Size of Floor joists: .....................................e pacing..............:............... ....... ...:'CC
(d) Size of Rafters:... . .............................Spacing.........._.............................:'CC
12. VALUATION OF PROPOSED WORK: Including all labor, plumbing, electrical wiring, heating, fire sprinklers, painting and
sewage disposal s.... _6.x000 --------------- =----------
13. I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE INFORMATION IN THIS
APPLICATION IS CORRECT AND THAT THE CONSTRUCTION WORK WILL CONFORM TO ALL LAWS OF
THE COUNTY OF ORANGE AND THE STATE OF CAL1/ORNIA APPLICABLE THERETO.
29
Signed /- :_ •------------ -- ` +°:C
t -
Plans Filed :.............
-..../............................. n +sem
f Byxn.7:� fie - XJ�..-.' L..ti�. ���.
v......-i........-y.,,,rrf�eC. :.............................. ..................
(Authorized Agent)
FOR DEPARTMENTAL USE ONLY
FEES: CHECKING BY
� Gz0
Bldg. Permit 5......./ GROUP.....__.- . APPLICATI ALTH ............................
Plan Check 5 ........... .:........ TYPE...... ..............
�P1ttE�
ZONING........ ;7
Total - 5 .......... ...I &V DIST. C%. ��/ MARSHAL.........................
7 PLANS AND
Receipt No. /G ...... MAP ................. ... - SPEC'S................
Paid to J- SHEET NO - .... STATE ........................... _...
----' CORRECTIONS ENGINEER
ate .......................... s—...... '...... ...............
D ................ VERIFIED ........................ CAL .....................................
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ORAi 'COUNTY
BLDG. DEPT.
• 636 No. -tWoadway
,.Santa Ana, California
'
.1
N° 2024
Date......... ........................ ................ :..........
COUNTY OF ORANGE
CERTIFICATE OF OCCUPANCY
Bldg. Permit No......)6MElect. Permit No.-' A7J..Plumb. Permit Noi'_:.'r'?�-..
.orvi 0
Use of Bulldme.... ............... ........._..........-
................................ :...:)-------...---..............--------
Thebuilding _tlocated at....--........................--•-----------.........-----•–...................... ............
/9d & %ti1p (:nom, ti. 7 .
--.......................................................................–
'........................................_............................... ......................................
Lot............... ------•----........... Block ..... ........................... Tract ................. :..=�... -...... :.....--
(See Reverse Side for Metes and Bounds)
Has been inspected and found to comply with the provisions of all County of
t? ^, r
Orange Ordinances applicable thereto for a Group.......<.....:..._
Occupancy.
ISSUED TO: C. W. DONOHUE,
County Bldg. Inspector
.OWner ,of, Building), rr, By....
CC: riginal—Owner [I lel copy—Cas Co. nd Copy—Edison Co. 3rd CORY—File
5-7-50
ADDRESS OF BUILDING:, -195 E 17TREST 'UNIT:
ONNERS NAME IF IGICAN: CHEVRON USA
ADDRESS: 1300 S. BEACH BL
• LA HABRA CA
310-694-7100
APDL. MAIM ADDRESS e
ARCHnCTORENtlNEER:•.,B.,.C_ADAMS . uc.m.: C10103
ARcxoRENcsAooREss:.11022 ACACIA PKWY.. UNIT: E
G.G. CA_92805
CONTRACTORS NAME:
CONTRACTORSMAI1l11G
ADDRESS ur NO.:
UNIT
uCEN$ED CONTRACTORS DECLARATION: I hereby affirm under panty d perjury final I am licensed under provisions of Chapter 9
(commmix, with Section 7001 of Division 3 of the Buairwss and Protestations Cab, and my license is in lull forte and effect.
CITY LIC. NO.: LIC. CLASS: UC. NO.:
Dee: Connecta:
OWNER BUILDER DECLARATION: I hereby aMnm under panaly or perjury the! I am exempt from the Comrectore License Lew for IM
'blfowkg recon (Swum 7031.5 Beiheaa and Prdewsio s Cale: Arty cy or county which requires a permit to omstrucl, alta, imprse.
i nnolah, or repair any structure, prior to its issuance, also recourse the applicant for such permit to file a waned seamen that he or end
a licemed W rwuant to the provisions of fire Conrad. License Lew [Chapter 9 (mmmeairg with Section 7000) of Division 3 or the
Business end Prohnstioro Cads) or this he or elle is eempt Ihemom and the beae for Rhe alleged "sorption. Airy violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ow mare than rise hundred dollars )$5003).
❑ I, s owner of the property or my employees, with wages As thew able companslion, will do the work. and the enrctu , is nor intended
or offered for web (Section 7014, Business and Prohnno n. Code: The Contrmom License Lew does rut apply to an owner of property,
who Wilds or inproves 1Mrean, and who does such work Nmseff or Meet or though gh he or her own employee, provided the such
improvements we nal intended or alered for wale, ff, however, the building or bnpmvemenl is sold within one year of completion, the
X own o.buildar will have the burden of proving he or she did m WiM or improve for IM Wr oom of sic).
❑ I. a owner of the propend. am exduavety, contracting with licensed contractors to cmwud IM pajm (Section 7044. Business ard
Professions Code: TM Contredas Limns Lew doe not appy to an owner of property who Wilde or improve Items n And who
fa such projects with a comrmoge) Iiceend pureuanl the Contrmas ucorne lexh)I am exs undo Section: 8. & P.C., for 'reasLI6cont.l.
11114MAmar: `
ereby coni that 1 am we of and understand the requirements d Call Nealth andsty me Sections 25505, 25533, and
25534, end the I a eery More Wilding occupant will / will m (dreb s
are) ad to comply with a codes and the hich amen for
a paMbsconswclimormodifiWionfror Ahu6et—F%iy enepemm Distm. Residential construction appketiao are Bump from dse
provisions.
Det.: Applicant'
WORKER'S COMPENSATION DECLARATION: I hereby affirm under penally of perjury ahs of IM following declensions:
❑ Inas, and suit memaih.a.nffirale aaonwemm.w:eare ra wakere•canPansstim,eprovded fa by section 37ooalM lab«
Code, for the performance of the work for which this permit is issued.
.❑ Ihawsandw;t mins nenwomen•mmpemefon ie compensation
regdredbysmioe 370o dill. Labecode.fpr IM p.damancedthe
work for which thio permg is asund, My workers' companeation ieurence mrrier and polity number are:
Carver:
Policy NUTM,.
n
s Schon need m M mmor ted I IM pe cul is br au hundred dollars µ'I001 or bas.)
] I cenry IMt in the pedormence d IM work for which thio pamb b ued, I anal rat employ enY I neon in anY manrhar s u to
0�7_
jtothewonkmpeionlevedCeglomiaagreethatIdouMsubectIchewaM1aran pr els ol Section 3700 a the Labor Code. shall Ihwkh co M with rhos prw ions.Alcenroascarompwvatloncovb_a'. Ndatoll•W/1efenrodnulpsn•Itluerta hwdied Ihopsand dollen ($100,000), In aee/tlpn ro Ms prof of.
f rorrpan••f maps a pmv/ded for In
.6.37x1$ a/ th. Labor Cod, Infxe•L and mamey. leu.
CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that them u a construction lending agency for the
pedourrance of the work far which the pmml a sewed (Seton 3097. Civ. C).
LENDER'S NAME:
LENDER'S ADDRESS:
I cannily then I have read this application and ewe the the Above infamMbn is owed. I agree to comply with all city And aunty ordinances
and state laws relating to building construction And hereby authorize represnlatives of this dry to enter upon the Above-mentioned property,
fainepasfonwneae.ANDREA FISCUS
Date:
(515I.".WP) WhM-Build'ug & Safety; GreerFFb; Canery-App4cad; Pink -Revenue; Gokfiw d-Aseaeor
CITY„OF COSTA. MESA ,-SIGN PERMIT.
PERM NO: SB 078150
PERMIT NO: SB 078150 PLAN CHECK NO: 02389-96 L GOVT: N SUPP: N
CONSTRUCTION TYPE:„ _ PERMIT TYPE: STR SIG PURPOSE:,OTH...
JOB DESCRIPTION- : INSTALL 25' ILUMINATED POLE SIGN SQ FT:
CLAIM VALUE: 7,000,00 CALL—VALUE: 7,000.00 GROUP OCC: U-2 /
COMMENTS: ILLUMINATED CHEVRON LOGO 6 PRICESIGN
M1k/EMiF*1E***dE*9E*iE********dE*M9EM*M****iE 1f*dE*dEM1f*1E 1EiE 1E 9f***df iE 9E 9F4iF 1EdElE iF dE 9E*1E1E*iF 9E iE 9EdE iE 9Ekif 9E SE IE
S I G N I N F O R M A T I O N
DISTRICT: 1 TYPE:.25' HIGH FREE—STAND SIGN ILLUMINATION: INT CATEGORY: NEW
DIMENSIONS: 5FT 07IN X 14FT 03IN AREA: 80.00SjFT LETTER HT: 25
STREET FRONTAGE 1: 150,00 STREET 1; 17TH ST
STREET FRONTAGE 2: 99.00 STREET 2: ORANGE AV
PARCEL: 42542310 ZONE: C1 LOCATION > FRONT: X REAR:
.BUSINESS NAME: CHEVRON > LEFT: RIGHT:
O T H E R T O T A L S G R O U N D S I G N
THIS ACTIVITY 80,OOSQFT OVERALL HEIGHT: OFT OIN
THIS SITE 102,OOSQFT GROUND CLEARANCE: OFT OIN
ITEMS OF INFO c 1 PLANTER AREA: O,OOSQFT
ITEMS FOR ACTIVITY: 1 BLDG SET BACK; 20FT
COPY VERBIAGE CHEVRON, CHEVRON LOGO, "FAST PAY” 3—TIERED PRICING PANEL
(EX. FS TRIANGULAR SIGN TO BE REMbVED PRIOR TO INSTALLATION)
PLANNING NOTES: EX. FS TRIANGULAR TO BE REMOVED,
*iE***iEik 9E df 9Fif dlikikdf df****iE*dE 1f*if*dF 9E irk*if$E dEibiE*$Eirk*irkk*ikdh ib*dEdbdE 9E 9E*it*1F dE dEkit dE****M9F dF*dE 1E 1EiE dE irk9E*ill BF
D E V E L O P M E N T S E R V I E S R E Q U I R E M E N T S
ZONING APPROVED BY DATE:
BUILDING APPROVED BY: DATE: �6
APPLICATION ISSUED BY: DATE:
*driEdEibkdlkiEkif if**dFdF*9F 9F dbikit db*iE*iE iE**$E $E *iE
LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y
BLDG PMT PLUMBING ELECTRIC MECHANIC SIGN SMIP/RES GRADING
PERMIT 124,75
PLAN 81,09 SMIP1.47—RES
ISSUE FEE
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
TOTALS ---- > 126.22 0.00 81,09 207,31 207,31 .00
REVENUE DIVISION TOTALS--> COLLECT 7.31 OVER/SHORT:00
BLDG PMT PLUMBING ELECTRIC MEC SMIP/TOT GRADING PLAN—CHECK
124.75 1.47 81.09
�E�E�E�E9E;E�E�E�E�E�ESESE9E�Ex��E�sr�ErsE*sESE;E�E�E;E�ESESE�EESE �E*sE�E�ESE�ESE�E;Ex�E�E;EgE*sESEgE�E�r�Ex�sE�E�E�E;E�E�E;E;E*x�;E
I N D I V I D U A L _b E B R E A K D O W N
TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST
NO FEES WERE SELECTED FOR THIS PERMIT
CONSTRUCTION AND PLANNING
APPROVALS Permit #
Date • •Inspebtor
POOL & SQA
l APPROVALS Permit #
Date
Inspector
1. 0�emporary Electrical Service or Pole
--''52.
Pool & Equipment Location _
2. Soil Pipe-Undrgrnd.
53. Steel Reinforcement
_3+rElectricalConduit Utility-Undrgrnd.
n
54. Forms r•
S
; OFtrica nd uit-Undrgrnd.
55. Electrical Bonding -
i-5,c2tael Reigforcement
56. Rough Plumbing & Pressure Test
Np C',gctric rrl?�ER Grnd.
57. APPROVAL TO COVER-GUNITE
4'
Fpptings �
58. Electrical Conduit-Undrgrnd.
-
95 Foundation
59. Gas Pipe, 0 Undrgrnd., Test
9. Water Pipe-findrgrnd.
- -
60. Backwash Lines, P -Trap, 0 Undrgrnd.
10. Structural Floor System
61. APPROVAL TO DECK
11. Property Sewer Line & House Connection
-
62. Backwash & Receptor -Final
12. Sewer Cap
63. Heater & Vent -Final
13. Roof Drains cc
54. Plumbing System - Final
14. Rough Plumbing
65. Electrical -Final -
15. Rough Egctrical-Conduit
-
66. Solar System -Final ,
16. Rough EWctric Wiring
'1
67. Fencing & Access Approval
17. Rough Wiring Sign
68. APPROVED FOR PLASTERING
18. Rough Electrical -T Bar Ceiling
69. POOL/SPA SYSTEMS FINAL
19. Rough Heatin & Air Conditionmo
, r^,�c GGNNCG^ F
r•ir-,i t ': :!
_2 rr*fslfiF�JE�T_J�EBUI�EMEN'�. 17.
1* •n ND.O n * >
�1PP�7�t 1LSs'
R r,n,-,
20. ou-gh F-' to F aplac jxMG�c; 1.
c»,.,
_IIInC ; S
21. hDu irfztrtfctuf§* c-'sm T7m S0
' ;E.: r-i,tiFF'7[*1 'S
rJN +: S
:�
r"
r]0.�_Qxdgrgriqund iTV.Wf _ -K
22.•Buc , Ve tti( tin - F., �,tn ir"-r,
'[�^C:'S ;'�K
C91 .�-Protfuet P!pin( :f•Gas i1
23. Gas �4Ype!Rodjh &'fest NOOKS
r" m '.1
......Fag
7
G
s 2 rer round FI � ^
a' _" v 9 ,r > a K J
. may. F
24.: ot7 Fr q'ting .jy F- .-c4rrc9z
(<'. ' i
OE -Fn .:x >
y.73.f-UincTeeMrnd.Storage TaZo ',Cias!Ooil
25. Rodf,Sh®thing £x: vn,VIM
r
> '4: G
H •• * --1
�4 erfic�H, ro O
SC fi
26.' �?,-Bar CeiJjng lStr ural f•Fi'i�fof'�j 9S
E• .>.
>, {�--XY , �
R
75. Y Cllemica4 C_.. HO
27.^lirameand Flashit�ir* sa
nx * a'
>7 6. Standpipe o- Cr
28. Lathing8_Si@n9n* '- '•S
-_ r,_.o.<
yL"x,x`
17. hIXED SYSTEMr-•tE:n NI�7 '
O*
29. Insulatidi4 v MICru ' '" -yo
-mo i -
78. 'RE�'REV. FINAL ' * >
m
30. Drywall ,N,ailRg "oo nto
x* r. 0* rr4 0
C; Zr
,=;.., •,;�_
S HEAL't•'1 EPT; EQI�IG{E-MEN N
31. Plaster 8rowd"Coat * MF, Ta�9.
FINAL INSPEC
i
32.,rE,lectrica'C os2rI'�er-F''~ F
Ste.'*"
d10. Ff�tJRTCERTI FICATE� UEDK,Q
t,
33.ina1;EIE2Iri(:> if C
�Heating-8t
"' x
Note t;, n hi; * O N
34. Tin Airl" i ning'-
.+. �-:t'• 14o O
`�N a
v'
1 't' az S
_I �t tv F+ , 1-• q fi m
:- :
35. ,f,inal r Gap_flipe•: •Tect r.. `- -i t:: y
S � !-+ t•/�
' � D ='-, t7.+ d i-
36. tloo or`S',anopv ;r SS •'NNCr
2Jsx r`.% I
'.,} r`'; T[£*1 r� * [••:
37.`Pina4aetoryFir eDi'etx O l
Fo• * i',Q
N K a
38.`F•to r .mu ;iingplu bin
* ooFF .• •. cJO
'rCS •v I
,K GH vt C- * 'r
, ter tcr
39.}}ae
=
H
i,���10,_ cli
y 40. Gas ggervice-PAial * `Sat 0'Q
a f.� * 0 F. 7n 0 "]
,:`a __• * n
, 5 w r: *
wi,
i.. F-, ...,E :K •a; v
- 41. Solar Domestic -Final c�pi.",.-�C�
,t*1I*1 f-� � � �
i fr N ^." rC'� K � Doz
c
42. Backflovv Preventer" FfJ n
C'. c '7 x.Ti Or -i
^ t*a :K i
xCtn r.H r. .•+
-" "
S m0< x F•
r .S
43. Backflow lrrigption�. S.l
U. Q.71
x
c V _
44. andsca§ IrWgatioj,.Sys1e xtitlt
•'S� * n
*
G' O K xN
r
X15. �ound Htae liiatio F ¢x
c�nH n
* H V it
Q6. Handicap'Regulatiois ""^ r
SN Y
* ^x S
tg7.'FINRL STRUCTURE &'n,E'1'ILDING
-'1--
i48.
48. "FIN ,L PLANNING* r
r , k S SSC
:�N S� v
!Tl"
i rri M i
-•I '>G, t, N
'49.'Ele&.icReleaseto dist
E. -,j I
I~• - mC •c',w
t r.
-50. Gas to Southern California Gas Co
.L, F,
r U'
57. CERTIFICATE OF OCCUPANCY
No Date
'" '
PROJECT ADDRESS: AYE E 17TH ST UNIT:
OWNER'S NAME: pACIFIC SOUTHWEST REALTY
ADDRESS: CO
%CORP TAX H2O -12 #174
P O BOX 2097 TERM ANNEX
LOS ANGELES,CA 90051
ARCHIENGINEER: PETROLEUM CONTRACTORS INC REG.NO.: NONE
ADDRESS: 2020 WEST SEVENTEENTk ST UNIT:
LONG BEACH CA 90813
PERMITTEE: PETROLEUM CONTRACTORS INC (213)432-7996
ADDRESS: 2020 WEST SEVENTEENT{i ST
LONG BEACH 13
LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am Ii se orae, visions heal r 9 ommencing with Section
7000) of Division 3 of the Business and Pmlessi ns Code. and r y C s in n orce effect.
CITYLIC.:g�0�`Q�J9710 STATE LIC: 93742
^ole�Q Signature: _ —
Fill COMPENSATION DECLARATION: I herebyaffirm t . I have a Ricans of consent to sell -insure or a certificate of Workers'
,opensatiominsurance. or a certified copy thereof (Section 38 Lab. I.
POLICY ND.: 705129-89 EXP. D T . 91
COMPANY: STATE FUND
❑ Certified copy is hereby furnished (X/Certified Copy is' ad J f the J�gODivissiiioo�n
Date: 9/ Applicant: %iW/✓ 1
EXEMPTION FROM WORKERS* COMPENSATION DECLARATION: To chon n d not be completed if the permit is for one hundred ($100) or less).
I cenify that in the performance of the work for which this partner is • e I shall not employ any person in any manner so as to become
subject to the WorkersCompensation Laws of California.
Date: Signature:
NOTICE: If, after making this declaration• you should become subject to the Workers' Compensation provisions of the Labor
Code, you must forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civ. Q. r
LENDER:
ADDRESS: '
OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason
(Section 7031.5 Business and Professional Code: Any city of 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/she is licensed
pursuant to the provisions of the Contractors' State License Law (Chapter 9(commencing with Section 7000)of Division 3 of the Business
,nd Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
r applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).
I. as owner ol'. the property o, my employees with wages as their sole compensation, will do the work, and the
❑ structure is not intended or offered for sale (Section 7044• Business and Professional Code: The Contractors' State License Law
does not apply to an owner of a property who builds or improves thereon• and who does such work himselUherself 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 will have the burden of proving he/she did not build or improve
for the purpose of sale).
I, as owner of the property, am exclusively Contracting with licensed Contractors to construct the project (Section 7044, Business
❑ and Professions Code: The Contractors' Slate License Law does not apply to an owner of propelly who builds or improves thereon
and who contracts for such projects with a contractor(s) license pursuant to the Contractors Slate License Law). I am aware
that proof of their Worker's Compensation insurance should be provided to me.
❑ I am exempt under Section: S. 8 P. C.
for this reason:
Date: Owner
I rte hereby cenify that am aware of and understand the requirements of Cahlornia Health and Safely Code Sections 25505, 25533, and
25534 and that l or any future building occupant witur ill not (circle one) need to comply with said state codes and the requirements for a
permit for construction or modification from the Air Quality Management District. Residential construction applications are exempt from
these provisions. ,
to comply/wiiltall city and
Pink—Revenue: Goldenrod—Assessor
CITY OF COSTA MESA — BUILDING PERMIT PERM NO:,E 05115
PERMIT NO: E 051151 PLAN CHECK NO: N GOVT: N SUPP: N'
ZONSTRUCTION TYPE: 1 PERMIT TYPE: ELE PURPOSE: OTH
SOB DESCRIPTION ; ELECT WORK FOR GASOLINE DISPENCING PUMPS SQ FT:
7LAIM VALUE: CALL—VALUE; GROUP OCC; B-2 /
ZOMMENTS: FIRE S HEALTH PLANS APPROVED
Z O N I N GS E R T E B Q A U C I K R S E M E N T S
------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING---------
FRNT: FT IN REAR; FT IN FRNT: FT IN REAR: FT IN
LEFT: FT IN RIGHT: FT IN LEFT: FT IN RIGHT: FT IN
PARKING REQ: PROV: PARCEL: 41915101 ZNE: REF NO:
PLANNING NOTES>
IP iF IE }F iF 1f JE 1e iF iE iE RE IF iE 3t 1E iF 1E iF iF k if IE iE 9f 1F iF iE iE k iF ieiE iF iP * IP IP iEiE iE iE iE iE iE iF BE if iF iF 9F iF * iF * iE iE ie iF 9P 9P iF 9E 3F BE * is iE * iF * iP * * iE iE iE aE iF
D E V E L O P M E N T S 'ER V I C E S R E Q U I R E M E N T S
ZONING APPROVED BY DATE:
BUILDING APPROVED BY DATE:
APPLICATION ISSUED BY: DATE: 2,12 1.
IF±E3E*9E iE IE iF If iEiE 3E if iE 9k lE It iE IE iE*iE iE iF if.IE lE *�E iE iE 1E iP �f
IF M 3F 9f )f IE IE TF 1F 1E iF * 4i iF Ih lE IE IE 1F lF * IE 3E Bf BE IF %iF IF iF if iF if lE RE is 9E iE iE 9E * iE IF it IE BE iE k * iF iF iF iF IE * a� 3f• RF * �e 3F iF iF IE iE ie iE * of iF Ba iF iE * iF iE if iE 9f
LEGALIZATION:N F E.H S U M M A R Y STRUCTURAL SEGMENT:N
PERMIT BLDG PMT PLUMBING ELE29TR5CC MECHANIC FIRE SMIP'/RES GRADING
PLAN tot SMIP/NON—RES
ISSUE FEE 15,00
BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL' PAID DUE
TOTALS ---- > 29.50 15.00 0.00 44.50 44.50 .00
REVENUE DIVISION TOTALS--> COLLECTED: 44.50 OVER/SHORT.; 00
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
44.50
iF if k it iF If Bf iF if iE * * iF If * iE * iP Rf• iF aE 3f it iF tE aF it 9t iE iE iF tF of ie it JF iE iF k iF 9F iF k 9F iP M k iF * iE it * * it iF ib iE iE iE 1F * iN 9F if iE * k iF 1F iE iF iE IE if iF iS iF if 9F
I N D I V I D
U A L F E E B R E A
K D O W N
TYPE QTY D E S C R I P
T I O N
UNIT COST
TOTAL COST
ELE 10 RECEPT/SWITCH
1 ST 20 EA,
,75
7.50
ELE 2 MISC APPARATUS
NOT LISTED REQ PERMIT
11.00
22.00
END OF FEES
01 00081311-00081311 TOT
DATE: 02/25/91 TIME: 12:27
CONSTRUCTION AND PLAID S
DOL & SPA
APPROVALS Permit#
Date
Inspector
APPROVALS Permit#
Date
Inspector
1. Temporary Electrical Service or Pole
52. Pool & Equipment Location
'�:--
2. Soil Pipe-Undrgrnd.
l
53. Steel Reinforcement
• 3. Electrical Cond6!t Utility•Undrgrnd r
54. forms
•�
10,4. Electrica_ 6nduit-Undrgrnd. : -2
55. Electrical Bonding
-8. Steer -Reinforcements
56. Rough Plumbing &Pressure Test
6. Electrical LIFER Grnd. n
57. APPROVAL TO COVER-GUNITE
J. Footingi-
58. Electrical Conduit-Undrgrnd.
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6. FodnlYq'
59. Gas Pipe, 0 Undrgrnd., Test
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-
9. Water Pipe-Undrgrnd. -. - r
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60. Backwash Lines, P -Trap, 0 Undrgrnd.
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10. St, ucturil Flooi�System It
61. APPROVAL TO DECK
11!. Property Sewer Lini& Hoose Connection
62. Backwash & Receptor -Final
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12. Sewer Cap: s:n i
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63. Heater &Vent -Final
13. Roof Drains _7: ° l` '�-
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64. Plumbing System - Final
14. Rough Plumbing " N,.
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65. Electrical -Final
15. Rough Electrical -Conduit;.?
66. Solar System -Final
16. Rough Electrid-Wiring
67. Fencing & Access Approval
17. Rough Wiring Sign
68. APPROVED FOR PLASTERING
18. Rough Electrical, T Bar Ceiling
69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning
FIRE DEPT. REQUIREMENT
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'APPROVALS". Permit # '"
20.•Rough Factory FFreplace x r. 1 -
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21: Ducts, in Struaureq
;70. Underground Hydro
22. Dusts, Ventilating-
Produc%iping ErGas OOil
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23..Gas Pipe`Rough &'Test
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.72. Underground Flush,
24.-, Roof Framing .-> :-
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?737-Undergrnd:Storage,Tank•OGas OOil-•
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25. Roof Sheathing`
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X74; Overhead Hydro:,
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26r_T-Bar Ceiling (Struotural) &'Monocoat
x
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75 -,Dry Chemical
27., Frame and Flashing"y
76' Dr Stan4' e - ;: ''
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' 28. Lathing ,& Siding •�^' 'i
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77.= FIXED SYSTEM FINAL J .L
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29. Insulation
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78:FIRE PREY. FINAL u 3
30. DrywallJVailing L-
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HEALTH, REQUIREMENT
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' 31. Plaster Brown Coat'
79! FINAL INSPECTION t_
32. Electrical Power Meter -Final - r
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:80..FOOD CERTIFICATE ISSUED
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33.'Final Electric i1 y
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'.34, -Final Heating &Air.nditioni
Cong•
35.rFinal Gas Pipe -Test ¢
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37. -Final Factory Firep%ace� ;- -
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-38. Final Plumbing
-.39.
.39. Water Service -final•
;40. Gas Service -Final ,r sir ,
-41. Solar Domestic-Final-
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42. Backflov✓ Preventers
43. Backflow Irrigation
.44. Landscape I`rripation System,,.. ,=' tz;
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,45.' -'Sound Attenuation •- •T''
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46! Handicap. Regulations
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47.•FINAL STRUCTURE & BUILDING
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48. FINAL PLANNING r
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:49. Electric Release to Edison
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50.,Gas.Release to Southern California Gas Cc
51. CERTIFICATE OFIOCCUPANCY
No Date