HomeMy WebLinkAbout2150 MAPLE ST - Building Permits CITY OF COSTA MESA
t. ►• �@ BUILDING DIVISION
Y•0-•; 4, 8 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
�• P.Is I ; • PERMIT E03-00370
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
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Job Address: 2150 MAPLE ST Status: ASD-,
Suite No Applied: 05/13/2003
Vicinity: KETCHUM LIBOLT PARK Issued:
Ss
u
S/5/03
Parcel Nunmber: TPN00133
Applicant: SANDOVAL, EILEENISSUED BY: /-ei
Address: 2121 S LYON ST - - .
, Phone: 714-434-0104
SANTA ANA,CA'-' Zip: 92705 -
%� - _ ,
Owner: CITY OF COSTA MESA . .
Address / ATTN:RECREATION"
,,„ ,
Phone: 714.754.5300
/./,f _-/ Zip' V
Contractor ' HONDO COMPANY, INC.
Address: 2121"S LYON ST
Phone: 714-434-0104.' .
,SANTA ANA,CA ' ' Zip: 92705
License: 373104
. \
, SCOPE OF PERMIT
ELEC PERMIT FOR/LIGHT STANDARDS IN CONJUNCTION WITH"SITE IMPROVEMENT FOR A NEW PARK
(KETCHUM-LIBOLT).PERMIT FOR LIGHT POLES,NEW PERIMETER WALLS AND ALL ON-SITE
FINISH WORK.3 LIGHT POLE PKGS
REF:B03-00051
FEE SUMMARY;"
. Quantity _ - Quantity
ISSUE FEE ' $0.00 Temp Dist System I Lighting $0.00 0 '
Temp service test \' " $0.00 . Busway/100 ft $0.00 - 0
•
Res.a/c package $0.00 Standing Section $0.00 , 0' ,
New Res(1-2 units) ;- $0.00 0 - Misc Electrical Equipment $0.007',; 0
New Res(3+units) =$0.00 0 - Transformers up to.1 kva/kw $0.00, 0
Pool/Spa. -', 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 < c0 over 100 kva/kw $0.00 0
Non Res Appl , $0.00 0 ' Low Voltage Equipment $0.00 0
Res Appl ' , x$0.00 0 _ Low Volt Wiring System/Ckt $0.00 0,
Service to 200a A --�-, $0.00 , ' 0- ' . Misc.Conduit $0.00 ' 0 /
Service to 1000a - $0.00 ;, 0 Misc.Conductor - $0.00 , ' 0 '
Service over 1000a "$0.00 . 0 , ," Circus(gen or ride) $0.00 " , 0
Motors to 1 hp $0.00 - 0 - Circus(mech ride"or lights) $0.00' 0
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 Fe_a $0.00
Motors over 100hp $0.00 0 - _ _ -
Communication drops $0.00 0 Investigation Fee $0.00
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 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-+6 WO
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
0 I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
ork for which this permit Ls Issued.
�I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: "SrAi1= Aynfr Policy Number: 75255/403
(This section need not be completed If the permit is valued et one hundred dollars($100)or less.) ,
o I certify that In the performance of the work for which this permit is Issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws II mia,and agree at if I shout becom subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with ihes s.
Applicant Signeture.n2 G-rr, d-07 Date: s-
/3 U3
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLIARE($103.O00),IN ADORION 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 Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
rows and erect.uc.a1 1/O 4' • Class II A g 0_27 0/2 6_3:-
Contractors Signature: fesw .-_ ..,04.11-1xr./ Date:'I, it 241-0
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued.(Sec.3097,Civil Code).
Lenders Name: Lenders Address:
Signature: Date: ,_
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penally 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 properly who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). '
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. $.Yes 0 No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed): _
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
o I hereby certify that no excavation fie(5)or more feet In depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and 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).
._....._..___ _ form
f.._.- --07e1-0-No
_ _._—__
2 Does or will the applicant or present or future building occupant need to file a registration for acutely hazardous materials? ❑Ves ❑No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Flre 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).
..� e applicant
ra.__.fo__�._ _ __
3 Does
essr will 0 applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Dees ar will the applicant or present or future building occupant require for the work which is the subject of this Application apennit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes 0 No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If"yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
-if __...__._..i._ _._..._..a _ __.____ _ __.i_ _ f.
7 application,a permit from the South Coast res p usury Management Healtheal or and Sr airpollution controltion district03beenor agency is required mor the work which is the subject of this
have all of the disclosures prescribed by Californiala Safety Code Section 42303 made? ❑Yes 0 No
_. _ _i-_
____..__..._. ._._...
8 (If yes',attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penally of perjury that 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.
pSignal 01 Lel er(s) / Date
orized App cant Date )
VOCE I INSPECTION TYPE PATE gIDDbLS ;ODE I LNSPEC11ON TYPE DM 8llmNL$
1618 Fixed System Final Fire Prevention 206 Final Mechanical
200 Pool Spa Final __ 2081Final Plumbing
,_ _ A
200 Final Re-Root _ 210 Final Electrical (LG7/car-�
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site _
204 Final Demolition 250 Final Building/Occupancy
• ' CITY OF COSTA MESA
BUILDING DIVISION
DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
0.41 PERMIT
B02-00051
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 2150 MAPLE ST Status: ee-LSSGf-
Suite: Applied: 01/14/2002
Vicinity: KETCHUM LIBOLT PARK Issued: SA 3/O 3
Parcel Number: TPN00133 Zoning:
Applicant: SANDOVAL, EILEEN ISSUED BY:
Address: 2121 S LYON ST
Phone: 714-434-0104
SANTA ANA,CA Zip: 92705-5303
Owner CITY OF COSTA MESA
Address ATTN:RECREATION
Phone: 714.754.5300
Zip:
Contractor HONDO COMPANY, INC.
Address: 2121 S LYON ST
Phone: 714-434-0104
SANTA ANA,CA
Zip: 92705 License:. 373104
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
SITE IMPROVEMENT FOR A NEW PARK(KETCHUM-LIBOOLT).PERMIT FOR LIGHT POLES,NEW PERIMETER WALLS AND ALL ON-SITE
FINISH WORK
SEE PA-01-27.
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $200,000.00
Permit: $0.00 Claim Valuation: $200,000.00
SMIP Res: $0.00
SMIP Corn: $0.00 •
Other: $0.00
Inspection: $0.00
Total: $0.00 •
PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0
PARKING Existing: 0 Required: 0 Proposed: - 0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued.
My workers'compsd cation Carrier: Insurance carrier end policy number are: 79.25 �b Q ,�
Caer: 5Tht f�FUN 0 Policy Number:
(This section need not be completed IT the permit Is valued et one hundred dollars($100)or less.)
❑ I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws o I la,and agree at if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these si .
Applicant Signature: —LiL/ ( 41Fr/ Date: S- / ? 0 3
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL MD SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES MD 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,MD ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full
force and effect.Lie.a ((37'? `.)4r'' class a /I C 2 7 01 2 1 b 3
Contractor's Signature: J •JJ µ„4y.,._,/ Date: L S�-13, -1-
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: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that 1 am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 0(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant fore permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,end the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. AYes 0 No Driver's License No. Expires:
Verification of Ownership by(type of document,I.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet In depth Into which a person is required to descend,will be made In connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(38)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes ❑No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Flre Department may require the preparation,certification and filing with the Flre
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 Celifomia Health and Safety Cale been fully complied with? ❑Yes ❑NO
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes 0 No
(Section 65850.2 of the California Govemment Code requires that the requested Information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school?'❑Yes 0 No
(If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
__.._..t._ _ _ -- _ _ .._.._ _ ..-
7 Ifa a permit tram tae South iscast Air Quality ed by Heal or other epoeion coon 4l 303 bt n aade?y Is I Yes etl for lha work which is the subject of this
application,have all of the disclosures prescribed by CaliforniaCalfola Health and Safety Code Section 42303 been made? CI 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.
/ /
�•-' nature =his)
(s) - I R Da
�� And/Or Authorized Applicant Date
y00E r INSPECTION TYPE • PMIS MALS CODE I INSPECTION TYPE • Pal MALI
1618 Fixed System Final Fire Prevention 206 Final Mechanical
1286 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical _
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final FactoryFire Place 220 Final Planning Approval
203 Final Sign
222 Final Site
n IE
204 Final Demolition 250 Final Building/Occupancy
PROJECT ADORESS: 2150 MAPLE AV UNIT: CITY OF COSTA MESA — BUILDING PERMIT PERM NO: BP 053961
OWNER'S NAME: CITY OF COSTA MESA
ADDRESS: PUBLIC SERVICES DEPT PERMIT NO: BP 053961 PLAN CHECK NO: N GOVT: Y SUPP: N
77 PAIR DR
COSTA MESA, CA 92626 CONSTRUCTION TYPE: PERMIT TYPE: PLU STR PURPOSE: DEM
754-5291
ARCHIENGINEER: REG.ND.: JOB DESCRIPTION : DEMO RESIDENCE AND ATTACHED GARAGE SQ FT:
ADDRESS: UNIT: •
CLAIM VALUE: 1 , 000 . 00 CALC—VALUE: 1 ,000 . 00 GROUP OCC: R-3 /M-1
PERMITTEE: PUBLIC SERVICES DEPT ( 714 ) 754-5323
ADDRESS: 77 FAIR DR 4FL COMMENTS: X
C.f.i.' CA 92626 **********+E*********FP**********************x********rk****TP P*****+r** *****yk*****
LICENSED CONTRACTOR DECLARATION: I hereby allirm that I am licensed under provisions of Chapter 9(commencing with Section 2 ONING REQUIREMENTS
7000)of Division 3 of the Business and Professions Code,and my license is in lull force and el lea SETBACK S •
CITY LIC.: STATE LIC.: CLASS:
Date: signature: MAIN BUILDING ACCESSORY BUILDING
WORKERS'COMPENSATION DECLARATION: I hereby allirm that I have a certificate of consent to sell-insure or a certificate of Workers' FRNT; FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
Compensation Insurance.or a ceruteed copy thereof(Section 3800.Lab.C). LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
POLICY NO.: EXP.DATE:
'OMPANY: PARKING REQ: PROV: PARCEL: 42246110 ZNE: REF NO:
J Certified copy is hereby lurnished. 0 Certified copy is filed with the city Building Division. PLANNING NOTES>
>
Date: Applicant: *******************************************************************************
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need not be completed if the permits for one hundred($100)or less). DEVELOPMENT SERVICES REQUIREMENTS
I certify that in the performance of the work for which this permit is issued,I shall not empioq"any person in any manner so as to become
subject to the Workers'Compensation Laws of California. ZONING APPROVED BY DATE:
Date: Signature: -
NOTICE:If,atter making this declaration,you should become subject to the Workers'-Compensation provisions of the Labor BUILDING APPROVED BY : DATE:
Code.you must forthwith Comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY: I hereby allirm that there is a construction lending agency for the performance of the work for APPLICATION ISSUED B Y: I DATE: 9 ( ®
winch this Permit isisSued(Section 3037.Civ.Cl. ******************************************* * ********************* **
LENDER: **************************************************************************** **
ADDRESS: LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:Y
OWNER BUILDER DECLARATION: I hereby affirm that lam exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMI P/RES GRADING
(Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish.or PERMIT 25. 00 2 00
repair any structure,prior to its issuance.also requires the applicant for such permit to file a signed statement that he/she is licensed 25$ .
SMI P/NON—RES
pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7010)of Division 3 of the Business
and Professions Code)m that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by PLAN . 50
any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars($500). ISSUE FEE 3 . 00
I. as owner of the Property or my employees with wages as their sole compensation, will do the work, and the BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE
❑ structure is not intended or offered for sale(Section 7044.Business and Professional Code: The Contractors'State License Law TOTALS----> 0 . 00 0 . 00 0 . 00 0 . 00 . 00 . 00
does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through
his or her own employees,provided that such improvements are not intended or offered for sale.IL however the building or REVENUE DIVISION TOTALS--> COLLECTED: .00 OVER/SHORT: . 00
osale).
improvementsoldwithin one year of complelian,the owner will have the burden of proving he/she did not build or improve
forthepurpose BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN-CHECK
I,as owner of the property,am exclusively contracting with licensed contractors t0 construct the project(Section 7044,Business
UN and Professions Code: The Contractors'State License Law does not apply to an owner of property who budds 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. INDIVIDUAL F E E BREAKDOWN
o I am exempt under Section: - B.&P.C.
for this reason: L` TYPE QTY DESCRIPTION UNIT COST TOTAL COST
Date. %"" r/ ' 9 / owner. getererl `A PLU 1 SEWER CAP / DEMOLITION EACH 2 . 00 2 . 00
I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sectio 5 25505,25533,and END OF FEES
25534 and that I or any future building occupant will/will not(circle one)need to comply with said state codes and the requirements for a
permit for construction or modification from the All uality Management District,Residential construction applications are exempt from
these provisions.
Date: Applicant:
I hereby cenily that I have read this application and state that the above information is correct.I agree 10 comply with all city and unty
ordinances and state laws relating to building co eruction and hereby authorize representatives of this city to enter upon the above.me toned
property lot inspection purposes. `
Date:( 4/ Signaeure:_ 0! °CY:T.:•E—LLB 75 .3 Tir'7
Driver's License or Social Security.: CATE: ac. 1c!4 T o_E! 071bL)
1641.46 While—Building:Green—Code Enforcement:Canary—Applicant:Pink—Revenue:Goldenrod—Assessor L
CONSTRUCTION AND PLANNING PC & SPA
APPROVALS Permit# Date Inspector APPROVALS Permit # Date Inspector
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location '....--
5--
2.
-2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement iA_
1;3. Electrical Conduit Utility-Undrgrnd. 54. Forms - i
c 4. Electrical Conduit=Undrgrnd. 55. Electrical Bonding i
S. Steel Reinforcement 56. Rough Plumbing & Pressure Test 0-
r r, --
t6._iEjectricalUFEA.Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
8.;Foundation r 59. Gas Pipe, 0 Undrgrnd.,Test ref
v
9: Water Pipe-Undrgrnd. 60. Backwash Lines,P-Trap, 0 Undrgrnd. �. _,
10.:-Structural Floor System 61. APPROVAL TO DECK f 1
11. Property Sewer Line& House Connection 62. Backwash & Receptor-Final •r'
12. Sewer Cap '• _/ , OM 63. Heater & Vent-Final 7 •-„,""
13. Roof Drains -u 64. Plumbing System - Final -
14. Rough Plumbing - 65. Electrical-Final 'l
er
15. Rough Electrical-Conduit 66. Solar System-Final !.
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical•T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace c , - -c . APPROVALS' '-1:Permit# - J
21.'Ducts,in Structure °4 C70. dndeTgreiunci Hydro +,
22. Ducts, Ventilating .: , - r.,. • •_71. Product•Piping Q•Gas I]Oil
.
23.'Gas Pipe-Rough & Test t _ c - - 72. Undergtountl FlustK -
24..Roof Framing H.
. . - �s 73s. Undergrnd.Storage.Tank a Gas ❑Oil
S
25. Roof Sheathing v+ C. ?` -74 Overhead Hydro .•
26:T-Bar Ceiling (Structural) &•Monocoat •p - v + 75. Dry Chemical +
-
27 Frame and Flashing- /{ - ! : '. 76. Dry Standpipe -L r
•
28. Lathing r& Siding ' - • '•'r,',, r _ >. .. . s 77.: FIXED SYSTEM FINAL -INA
:' -;29. Insulation !* 78; FIRE PREV. FINAL -.
730. Drywall-Nailing 1 L.HEALTH.DEPT. REQUIREMENT
7..31. Plaster Brown Coat - ' k i 79::FINAL (INSPECTION - t-
132.-Electrical Power Meier-Final, r , 80.: FOOD CERTIFICATE ISSUED _•
. r
V33Final Electric ?t I -'Notes: •' - -
-
'34.-Final Heating& AiCConditioning `C
35:=Final Gas Pipe-Testy -- 4 =S -, c
36.`Hoo{! orLCanopy . -
-. --c
-37.:Final Factory Fireplace' -
.. _ ,� -t * r. - v _
T38. Final Plumbing 1 - r t I. 2 `,
'39. Water Service-Final r .
=40xi . Gai'Service-Final ' j 1 a to pp' a
,, - - - . - 4
. _.
41, Solar Domestic-Finals -- _ I t s f
42. Backflow Preventer rc....-t y
43. Backflow Irrigation. - •i-- _ + -' + . ''= -
-.44. Landscape Irrigation System,,';,.± ,, , , - _,•_ ,. - _ tu, -
-45_Sound Attenuation ii or - t ''!' •
r1 _. • - .n I i .1 ♦ • - Y
`46. Handicap Regulations -? C : y
47..FINAL STRUCTURE & BIN,LDING r a ` :�. :c
-482..FINAL PLANNING _r : t - : ;)
49..Eleciric Release to Edison ' + e tc - - ;
.
. I f , -
50_Gas.Release to Southern California Gas Co ' I "; ,
:51. CERTIFICATE • ;' ,. -
No Date
Applicant to fill in all spaces except those within heavy bord_er lines and sign all appropriate declarations. • _ _ _
{ CITY OF COSTA MESA a. PER T NO../- TRACT NO. ' /' LOJ NO. : BLDG.NO. , • •�
CONSTRUCTION PERMIT. jr---* (O�/ 7 •
• dH7ti : '2/ill / . i.,e :t ' T
Applicant's Mailing Address_ O P SA' Ar A 'PL• . TYPE OF CONSTRUCTION - U NEW U ADD U ALTERATION U REPAIR - -
Project Address 21 MAPLE'3Tg£, c' El CONVERSION ❑ DEMOLISH 0 OTHER . . .- 1 '
•Owner's Name r'L• uUFrlLll Phone 57 961 F3. • DESCRIPTION OF WORK - : - - , - ZONING REGULATIONS +
•
Address 310 s- SAI.foA L' - TYPE OF PERMIT' 'U'GRADING UFOUNDATION U STRUCTURAL A.P.'41.,
:•N•' - ZONE - •I I
Arch/Eng.. ' License No. - - ' ❑'TENANT 0 ELECTRICAL J'J PLUMBING 0 MECHANICAL- •' f' I .PLNG. REF.Myr I 'BUILDING' ' • +
Address .•❑ OTHER I • • •.SPTgACte rn et
TO BUILDING REAR YARD (TO P/L) I.
Contractor's Name OulNL2. ' Phone 155.1 941$ PROJECT DESCRIPTION SQ:F7. - ' OCCUPANCY c. . PROPERTY LINE
Address listening) • "--.16'g SAMBA PL• • CONSTRUCTION TVP - • VALUATION$ LEFT SIDE YARD RIGHT SIDE YARD •_
, ZONE ' GRADING CU.YDS. .ACRES _ !KG.SPACE REQ. 1 PROVIDED •
License No. _ '' _ • - - - - ^ '
LICENSED CONTRACTOR DECLARATION I Remarks: •• ' , STREET WIDTH PARK FEE'S
I hereby affirm that I am licensed under provlslons of Charter 9 (commencing ' - - i
•
' with section 7000) of Division 3'of the Business and Professions Code,and . - t 1• SPECI• AL CONDITIONS: ' -
myalcense Is In full forte and effect. I ' - - •License Class Olass - - License No PLUMBING •
•
Date Signature ' I • Bar Sink t Sewer Cap ' i '• I l ELECTRICAL I. j
.t RKERS'COMPENSATION DECLARATION , ' - - '
n",>vrebk.affirm that have a Certificate of consent to.Sel Hnsure or a certificate .•'t ° .� - -_._ __. ._ ._ __ Automatic Washer..- ;.Meter Clover 100 amps.. =
•, Workers' Compensation Insurance, or a certified;copy thereof (Section 88ckflow Preventer" • -',- - -Sewer Connection' - •� i-'- - "1'
3800, Lab. C.) , - -" " I Construction Pole I :Sub Panel iI. 1
7 I I 1 Backflow irrigation • { Solar Collectors i I i
PoIIc i No. ' Company ' ' ' • - - - _ • : • - I '
• I Bathtubs rp' 1 Cooking Unit Sub Pole , I 1
ElCertified copy Is hereby furnished. ( • 1 { I Solar Piping , 1 I , I ' ,
Certified copy Is filed with the city Building Division. : I • ' ,J _Solar Tank ' • ' Dishwasher 'Motors 00.1 HP 0115-8 - ' I
' Date ' ' Applicant j Clarifiers i •l_ - _ 1 _ . 4..
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION ' I Dishwasher •• ' 4 Swimming POI;Mini { Dryers ❑Gas ❑Electric
(This section need not be completed If the permit Is for one hundred ($100)pr Inc.Solar j09-15 HP 016-1St
Iecertify;that in the performance o rk forty I• t is •-milt Is issued I - Fan• ' , I i .Microwave ' .
DrinkingFountains Urinal 1 : ' 1 I
shale not employ any person In ny ma net ?. o D Co esubject to the - I I - F.A.U. 1 j •' ,Pole Light I 1 s '
Dorke(.f'-C mpAnIt ion(Laws of Call I f Floor Drains{ I '^ Water Closet, • {
ate i-' -15 S Signature • /j _ I I Fixtures A ' I ,Ran a... _ .I. .��.. .
,-NOTICE:If,-after making this dell tion; you sho •-•-:come su.ject to the Floor Sinks !- -4.-----1-- 1` • --- Water Heater - -?'• — g - ;
Workers'? Compensation. provisio lof the Labor Code,-you,must forthwith. I • - I i j
Comply with' such -provisions r_this permit .chair be'deemed] revoketl.r ! :: "Gas Service I`•Outlets I r.. Water Service , �7 ' Device Boxes 'Sign •I j • i •
CONSTRUCTION;LENDING AGENCY: l j e - • - ' • V - • _ , • O( Outlets '• I i I
I hereby affirm that there is.a construction.lending agencyfor the•performance) 1 V; Interceptors ) ;, I • :, _ 1 ,e I : „•
• I ' Standing Sections
of the work fon which-1 this• permit -is 'Issued (Section-3097 Civ: C:) 1 - ._ - - I •
'
Lenders Name.' ' ' - ' ' Kitchen Sink' :• - (• j d • 1 ' ' • . t Switches I : Trash Compactor 1 i 4 I 1
Lender's Address' - - t' ' I _ Gerba a Di oral • I • I 1
? , 1 Lavatories.. n• 1 9 Disposal 1
OWNER BUILDER DECLARATION , : - : - t. ' 1
I :zreaso that I amt exempt;from the Contractor's"Llcense Lew for the' _ I - I t- ' Generator 00-5 KW 05-15 KW • I •
following reason-(Sect un 7031:5 Business and ter,improve,
Any city or ' . P-Trap+ • • I ,
county Which.requires a s issue to construct,alter emolish'or repair I - R . . - - . , - .
- Transformer ❑15.50 KW
I any structure, prior to its'Issuance, also requires the applicant for such permit ROOfjDrains t I y . { - • 1 ;
itq file a signed statement that he/she is licensed pursuant to the provisions of . - , . : - I - 05U+KW ' Reinspection Fee
1 Contractor's License Law,(Chapter 9 ons Co nting wlth.Settien 7000)of { • + !pe $15
.I reon 3•of the Business and Professions•Code) or' he/she)5-exempt ' Showers i - ' -- I .- I Reinspection,Fee • $15 - 1
i tirefrorb and the'basis for the alleged t subjects the
violation'of Section • - _ , - _ Moser Cup to 100!amps 1 I Issue Fee •$ 3
',7031:5 by any applicant for a permit subjects the applicant to m tivli service Sink 1 n I • Issue Fee�, $ _ 1 .
•
openalty of not more than siva'hundred dollars(ESoo). , I 3 6v Zoning Approved By ' ' "Date yu I, as'owner of{the,property Or'my employees with wages las their sole - - - --` ' 4 I I ' '
compensation will do the work,and the structure Is not Intended or offered j • I - I ;' , ..- MECHANICAL , ! Application Approved BY l ,nate 1 ,
for sale?(Section 7044) Businessland i Professlonal.Code::The'Contractor's , � p
: License Law does not apply to an owner of a property.who builds or Improves { Boiler' , 'i ' •" I ' • - Refrigeration System 1 • I I -'�v'�
1 thereon,fand who does'such work himself/herself or through his or her own • - ' Application Issued By • ; I „Y7 •Date
• employees, provided that such improvements are'not intended or offered for ! - ❑0.100,000 BTU 0100,000 BTU I
sale. If, however,the building or improvement is sold within oneiyear of con). ' Duct Under Ground l SUMMARY OF FEES
I elation, the owner'will have the burden of proving he/she did not build or im- . - - 1 •
,
' Urove fort the purpose of;sale). 1 , I I •• , 1 Duct-Structural c ' System Repair/Alteration 'BUILDING PERMIT $i f SMTP • ! $
I,as owner Of'the property,'am exclusively tentratting wlth,licensetl con- t - - - , -
tractorstoconstructtreeproiect.(Section 7044,Business and Professions.Codo:_: _ Duct-.Ventilating -•-- - . .. . .. . . _ _. ._._ .__ - _ PLAN CHECK• S $' PERMIT ' ,
, The Contractor's License Law ddoes not apply to an owner of property who - I • - I ' ,1/ ISSUANCE ' $ I ' i i
builds or improves'thereon, and who contracts for such projects with a con- I I Exhaust;System 0 Multiple 0 1 I PLUMBING I $' �- I I ' 111 1 I
tractor(s)license pursuant to the Contractor's License Law). ( - •
ll I GRADING ' $ '
0 I exempt under Section B.& P .f:r is reason Firepl/Fact.Blt. ?CBO /h .I PLAN CHECK; $I
1 .ELECTRICAL I $i : 'I ; $
11 Date ' '3 • Owner - Heating System U Ducting l ' •
PLAN CHECK' I ${ ` ' • l MICROFILM $ ' I I
/-Inhereb certify that•? haver thlslwith
Ion antl sta u 'at-the above • 00-100,000,BTU'0100;OODB •-r ' '
, Information is correct. I agree comply all citytand ounty repre-
ordinances 1 1� !MECHANICAL $� 1 1 : TOTAL FEE t $ 1 I I
' anditate laws relating to building construction;and hereby authorize r ' Hood or 7 e I Oj - ' ' : I i I ! •
1 sentatives, this' sty t e to upon the above-mentioned property for yP Reinspection,Fee i • $15 i I LESS - I ,
I I 1 PLAN CHECK' ( $ l .I I
l. inspection pu , j 1 ; Canopy• -TYPe I I ❑• 4 + { ADVANCEDTC : $
Signature o . -�((tp) Date,--- 1 1 i I : ,
• � 1 .• Registers 1 + Issue Fee 1 $ 3 i
1 Drivers' cense or SS$ - { 1 } • FINAL FEE, I $ 5, 00
•
CMF 0865-46 rev.12/82 White-Building;Canary-Applicant;Pink-Accounting;Goldenrod -Assessor
-'
L
• CONSTRUCTION AND PLA G •-' ;:12-::j>_-,....- r PP( SPA -.' -
_APPROVALS ; Permit# Date inspector ..! APPROVALS` -."Permit# ' - bate Inspector .
rr 1, TemporarylElectrical Service orPole • '' ;n 5.": - - :52: Pool &:Equipment L• ocation .4 _ I-.i;- -
2. (Soil Pipe-Undrgrnd:: : ,. ._O ; r- tz . _ '53' Steel Reinforcement
3: Electrical Conduit Utility-Undrgrnd' 'L r - `- r , 54;'Forms'F. • -
4- 1 , t _ ` r� '4 Electrical Conduit-Undrgrnd'.__•:: Fc .
ir , i:551 Electrical.Bondin - -
5: Steef,Reinforcement ' ' ,I :'t ; r 1 .:C 4 ' ` ' 56. Rough"Plumbing.&Pressure Test : ' - 7`'
6: 'Electrical (JPER'Grnd., I 'I k'' I - ,, 5,i .: :•' ';57 APPROVAL TO COVE R-GUNITE : , "I „ : ;
7, Footings I ' I `I- <L r - -58. Electrical Conduit-Undrarnd - , .
8- Foundation ' I� ' F ' ' r ' " `t< 59- Gas Pipe;O-Undrgrnd.,Test ' •
9, Water Pipe-Undrgrnd. I ; i - -_ ,60- Backwash Lines,,P-Trap,0 Undrgrnd.
10. Structural Floor System ? •' - - 61. APPROVAL TO DECK •'
11. Property Sewer Line& HouseConnection' - -t ir 62. Backwash'&!Receptor-Final_ • -
12. Sewer'Cap i- y i- 63. Heater & Vent-Final
13- Roof Drains -, 64, Plumbing,System- Final
14. Rough Plumbing • ' - • 65. Electrical=Final - - -
o, '
i 15: Rough Electrical:Conduit "--�-I --j '� --�' • 66., Solar:System-Final I • - - -
I .ii1a et6.'
"Rough Eleciric,Wiring: ,, ' - - 'r ;};--I-V 1-r;T i-..i. i s 67: Fencing& Access:Approval, - i
•
2 -17.',Rough Winrig'Sign:' ` ` i ! ' '0 ' -• : ^� `- . •` - X68, APPROVED FOR PLASTERING - ,
18: Rough:Elect ical-T`Ba%Ceiling : I 1 69.' POOL/SPA SYSTEMS FINAL
ii ' 19.,Rough;Heating&'AirConditioning • _ 'I FIRE DEPT. REQUIREMENT -
20. Rough;Factory Fireplace I ' I, is I � I ' ' APPROVALS Permit#
c
21. 1D-ucts, in Structure2 ' I ' I 1' ,. I I I •
i I 70.. Underground Hydro 1
' .122. Ducts, Ventilating 'r 1 . ' I '' I ( I I • I X71,, Product Piping 0 Gas 0011
;1.23. Gas.Pipe-Rough&Test I I 1 �p
C 1 ':;I ; fi- '7-y3 //�/1{ 72.1 Underground Flush
24, 'Roof Framing. ' 1 •j i:,,- 11 " I ! i " rJ. i :_ 1 -''; 73-! Undergrnd,Storage Tank 0Gas 0 Oil
• ,;(25, Roof Sheathing , ' ' ' - ` ! I - 'c: t I. �, 74.1 Overhead Hydro
L ,
-26. T:Bar Ceiling (Structurail,& Monocoat- I ' ; -, I • ,' ' •
1 ' ' 75.1 Dry Chemical . . - , -
{ _ - - -
• •
27. Frame and Flashing. '. j i ; r l I 1 176. Dry Standpipe . -
' 28. Lathing& Sidings ' � , • ' 77. FIXED SYSTEM FINAL
r 429_ Insulation •' ` j I 1 '78- FIRE PREV. FINAL
' - -30. 'Drywall Nailing ! '> ' .' 1 II ' I Notes:.
-. I<•_31, Plaster Brown Coat ' I ,I (' I I i , I I I 1 '
32.IElectrical'Power Meter:Final i; i i I 1 1 ! .. 1 '
t33.Final Electric ' ' 1 I lI- _ '_ •I I _ I I _ , ' . ..
34. Final Heating&'Air Conditioning I I • 1 1 : '
' ,- 1 L .. _
35. Final Gas.Pipe=Tess. i- ;1 11 : 9�y>93; � - '-
36. Hood 9r,Canopy'E:.; 12 :•„.1. n1' 1,1 i t ' . _ 14 -
37, Final ,,actorle Fireplace^ 0 1 II 1 : ic_ I ' - ' Li I ' I I , , . -
38. Final Pit/ill' I ' ` ' 3; HI 1 ' I 1 I i
�Si 1 - -
39, Watere{vice-Finals I Iii ' • , 1 ` 1 I I ! - - , .
r e 1 I •- t 1 E I I . -- I ' .. - • - 4
40. Gas Service-Final ! i i 2 ; ' 1 ! I 1 , 1 ' , • 1 •
• I, I , , i ! .1 1 • I I I I ! I • . I
41. Solar Domestic-Final I (I (-- '1,--t-. -+ -�-'r - -- ' - •- r -
42, Backf lowj Preventers _ f i m; ' : I _i _-;_ - : _ f _ --!- -�- ,
43. Backflows lrrigaiioni f I- �l
44. Landscape IrrigatiomSystem ! _ ' ', ! -
45- Sound Attenuation ' I ' i ' 1 I I i ' ' ,
46- Handicap'Re•guletion's I ;. I 1 H V 1 i. F $
47, FINAL STRUCTURE & BUILDINGI • 4.-- ' I I c -
„
48. Special Requirements Completed K I i 1 ' •
49. Electric Release,to Edison: 1 ,. ;-T-,__ -r ' _- I -;_ _ _- -- - --
50. Gas Release to Southern California Gas Co i 1 1 ! I I 1 • I
51. CERTIFICATE OFIOCCUPANCY, w L -. - _�_ ti_ _
No ;1 II ' Date I I 'I I , I, I
I _�_- -- - -1- - - _