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_ CITY OF COSTA MESA
B!/ILDING DIV►SION
77 FAIR DRIVE, COSTA MESA, CA 92626 •(7'14) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
FOR INSPECTIONS CALL: (714) 754-5626
PERMIT NUMBER: 610-00167
PERMIT TYPE B ROOF2 STATUS: ISSUED
APN: 42531112 DATE ISSUED: 06I71/2010
ISSUED BY: KJB
JOB ADDRESS: 397 LA PERLE LN CM Suite/Unit:
Viciniry: � . 4
Squares: 0 - � � - . Valuation: $5,000.00
SCOPE OF WORK: REMOVE EXISTING COMP AND HOT TAR ROOF. COVER WITH 30 YEAR COMP SHINGLES. ROOF PITCHE IS 3:12
AND 5:12. REPAIR AND REPLACE SHEATHING AS NECESSARY. � � �
OWNER: NELSON, RUTH MENNINGER TR Address: P O 80X 208 � - - Unk: A-8
PHONE: - . _ � � , � Ciry/State2ip: PALOS VERDES, CA ,
APPLICANT: CAUCHOIS, R4YMOND � - Address: 17171 ROTTERDAM LN UniL :
PHONE: 714-962d250 ., - City/StatelLip: HUNTINGTON BEACH, CA- -
CONTRACTOR: ACCURATE ROOFING ., _ � . . . . License No. 726093
Address: 17171 ROTTERDAM LNUnk: � PHONE: 714962d250
Ciry/State/Zip: HUNTWGTON BEACH, CA - �� - � 92647 CELL: � ,
ARCHRECT:
ENGINEER:
FEE SUMMARY
Reroof Plan Check:
Reroof Permit Fee:
Reinspection Fee:
Bldg Std Admin Fund
TOTAL FEES
- License No.
License No.
$o.00
$111.25 , ` �
$0.00
$1.00
PHONE:
PHONE:
HOURS FOR CONSTRUCTION ACTIVITY; EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279
Morday thru Friday - 7:00 am thru 7:00 pm. Saturdays - 9:00 am thru 6:00 pm. Prohibitied all hours - Sundays and the followirg Federal holidays:
New Years Day, Memorial Day, Independence Day, Labor Day, Thanksqivirq Dav and Chnstrnas Dav
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: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
COOEi. INSPEC110NTYPE UATE IN7171AL5 COOEN INSPECTIONTYPE DRTE INTITIRL
1616 Fixed System Final Fire Prevention 206 Final Mechanical
7266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof �� �� 210 Final Eleciriral
201 Final Bbck/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 22o Final Planning Approvai
203 Final Sign 222 Final Sile �
204 Finat Demolition 250 Final Builtling/Occupancy
WORKERS' COMPENSATION DECLARATION:
I hereby affrm under penalty of perjury one of ihe following declaretions:
❑ I have and will main[ain a certifwte of consent to self-Insure for workers'
compensation, as provided for by section 3700 0( the La6or Cotle, for the
peAormance of ihe vrork for which this permit is issued.
❑ I have and will maintain workers' compensalion insurance, as required by
section 3700 of the Labor Code, for the pedormance of the work (or which �his
pertni[ is issued. My workers' compensation Insurance carrier and policy
number �a+re�' 1 1` �j
Carrier J1 ����.%fl
(IDissecYionnee�pot0em�le(¢y��he�eiryQrs�lu a(o eh�tlre0{lpllars(5f00)orless)
Policy Number: �` f � � U U
❑ I cerli(y �hat in the pertormance of Ihe vrork for which ihis permit is
issued, I shall not employ any person in any manner so as to become subject
to the wor (ers' compensation laws of California, antl agree that if I should
be e bject b the workers' compensa�ion provisions of Section 3700 of
t i b Co , I shall forthwith comply with these provisions.
�.v �/�-/ �
, ApP6tan1'sSignaWre Da�e
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLAR4TION:
I hereby affrm Ihat I am licensed under provisions o( Chapter 9(commencing
wi[h Section 70 Q) of Division 3 of the Business and Professions Code, and
my lice e is i/ full force and eflect. �57
Lic b � Class # � J
ontratlor's SlgnaWre Date
CONSTqUCTION LENDING AGENCY:
❑ I hereby affirtn Ihat ihere is a consWction lending agency for Ihe
peRortnance of tha work for which ihis pertnit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lentler's Adtlress:
Da1e
OWNER-BUILDER DECLARATIONS:
I hereby a((irm Ihal under penalry of perjury Ihat 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
consWct, alter, improve, demolish, or repair any structure, prior to its
issuance, also requires the applican� (or such permit to file a signed statement
lhat he or she is licensetl pursuant to ihe provisions ot the Contractors
License Law (Chap�er 9(commencing with Section 7000) of Division 3 0( the
Business and Professions Code) or lha[ he or she is exempt therefrom an0
the basis for the allegetl exemption. Any violation of Sec�ion 7031.5 by any
applicant (or a permit subjects the applicant [o a civil penalty of no[ more than
five hundred dollars ($500).):
❑ I, as owner of ihe property, or my employees with wages as their sole
compensation, WILL DO THE WORK, antl ihe structure is not in[ended or
oHered for sale (Sec. 7044, Business and Professions Code: The Contractors
License Law does not apply to an owner o( 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 oRered for
sale. If, however, the builtling or improvement is soltl within one year ot
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 EXCLUSIVELV CONTRACTING WITH
LICENSED CONTRACTORS to construct the projec[ (Sec. 7044, Business antl
Professions Code: The contractors License Law dces not apply to an ovmer of
property who builds or improves thereon, and who contracts (or such projecl vrith
a coniractw(s) license pursuant to lhe Contractors License Laws.).
❑ I am ezempt under sec.
Business and Professions Code (or this reason:
305]-a6(3/0])
Ovmer 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 SAFEN PERMIT CERTIFICATION:
❑ I hereby certi(y that no excavation five (5) or more feet in depth into which a
person is required to descentl, will be made in connection with work authorized
by this permit, and that no builtling strucNre, scaftolding, falsework, p tlemolition
or dismantling thereof, will be more Ihan thirty-six (36) feet high. (Chap. 32, Gry
2, M 2, Sec. 341, T�le 8, Cali(omia Administrative Code).
❑ As owner-builder, I will not employ anyone to do vrork which would
require a permit fmm the Division of Industrial Safety, as noted above, unless
such person has a permit to do such vrork from [he division.
Appliwnfs Signalure Dale
Division of Industrial Safely Permi[ Number.
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will Ihe applicant or present or future building occupan[ 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 Heal[h and Safery Code requires, with some
exceptions, lhat a Business Plan be filed with the Costa Mesa Fire
Deparlment by every business which has a[ any one time dunng a reported
year a quantity ot hazardous materials equal to or greater than a weighl of
500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas
at stantlartl temperawre and pressure).
2. Does or will the applicant or present or tu[ure building occupant need to fle
a registra[ion form (or acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 ot 1he Califomia Health and Safety Code, with some
exceplions, requires registration with the Costa Mesa Fire Department by
each business which at any one time has on hand a quantity of acutely
hazartlous matenals equal ro or greater than a weigh[ of 500 pountls, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
temperature antl pressure).
3. Does or will the applicant or present or future building occupant need to
prepare an RMPP (Risk Management and Preven[ion Program for acutely
hazardous materials)? ❑ Yes ❑ No
(Sec[ion 25534 of the Califomia Health and Safety Cotle pmvides that the
Costa Mesa Fire Department may require the preparation, certi(cation and
fling with the Fire Deparimen[ of an RMPP by businesses which are required
to regisler acutely hazardous materials with the Fire DepartmeN.
4. If an RMPP is presently required, has Section 25534 of the Calitomia
Health and Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or will Ihe applicant or present or future building occupanl require far
Ihe work which is ihe subject of this application a permit for such construction
or modifica�ion from Ihe South Coast Air Quality Management DisMcl or (rom
any other air pollution control distnct or agency? ❑ Yes ❑ No
(Section 65850.2 of the Califomia Govemment Code requires that the requested
infortnation be fumished on applications fa non-residential building pertnits).
fi. Will any parl of the faciliry to be constructed untler this permit be wilhin
1000 feel (rom the outer boundaries of a school? ❑ Yes ❑ No
Qf'yes", ihe (acility must meet Ihe requirement of Sections 25534 and 42303
of the California Health and Safery Code).
7. If a permil from the South Coast Air Qualiry Management District or o[her
air polWlion conUol distric[ or agency is required (or the work which is Ihe
subject of this application, have all of the disclosures prescribed by Califomia
Health and Sa(ety Code Section 42303 been made? ❑ Yes ❑ No
8. pf "yes", anach ceAifcate of compliance from the appropriate air pollution
control oKcer).
CERTIFICATE OF COMPLIANCE: I certify that under penalry of perjury the
information given above is correcL I agree to comply with all state laws and
ciry ordinances regarding Hazardous Malerials and Emissions.
Sgnawre Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify untler penalty of perjury [hat I have read this applicalion and state that
the information given is correcL I agree to comply with all state laws and ciry
ortlinances relating2o builtling consWction, and authorize representatives o(
the City o( Cosia Mesa to enter upon the above-described property for
inspection purposes. I agree no[ to occupy or allow occupancy of any building
authorizetl by thi permit until fnal inspection.
n f Legal 0 Dale '\
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oxthxsr�weiv�u�wvn: CANTRALL DAVID L
mwrcss P O HOX �108
r PALOS VERDES,CA 90274
�- 642-9280
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ca+m�crarswu�: HERTZ POOL 6 SPA
CWINACTORSY11W0 23385 VIA SAN GABRIEL
�ooaess: LAGUNA HILLS
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UCENSED COMflACfOPS OECLAP�TION: I Mnby alfrm p�y e
(Cammanvq wil� &eclbn ]OW) tl Gyisun 3 d Ihs Pmtmovu
emuc.No.:067622 uc.cuss: uc.No.:
I —7� IQ � � �� . i
�T CITY OF COSTA MESA — BUILDING PERMIT
PERMIT NO: B 078679 PLAN CHECK NO: 02924-96 L
CONSTRUCTION TYPE: PERMIT TYPE: STR
ucxo: JOB DESCRIPTION : 7— PILASTERS FOR POOL FENCE
urr:
(714)770-5285
uc.�o.: 600926
UM:
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EXP: OS/97
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(5151�B.WP) WlNs-Buildip 8 Salaly. G�sam +M: Cerwy-Appicem: P"vik-qwwxro: Gddxnod-Aswoor
PERM NO; H 078679
GOVT: N SUPP; N
PURPOSE: ADD
SQ FT: 525
CLAIM VALUE: 525.00 CALC—VALUE: 525.00 GROUP OCC: R-3 / \
COMMENTS: PILASTERS TO CITY STANDARD (EARTH TOOTH DEPTH) �
if 44 iE iE iE 1E k iF iE if iE 1f iF IF M 1E 1f 1E if 1f iE ik ik i! 1E if 1E 1k 1k ik ik if k ik 1E iE 1f 1t 1E if 1k ik iE 1k 1f 1f 1k if If ik k 1i 1k k 1E i! 1F IE 1E 1f iE 1E 1E 1h 1E 1E iF 1k 1E iE k!k iF 1E 1f 1E 1F iE
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 ---------- --------- ACCESSOAY HUILDING ---------
FANT: 10 FT IN REAA: 6 FT IN FRNT: FT IN REAR: FT IN
LEFT: FT 1 IN RGHT: FT IN LEFT: FT IN RGAT: FT IN
PARKING REQ: PROV; PARCEL; 42531112 ZNE: R2MD REF NO:
PLANNING NOTES> 132 LF OF S' HIGH SOLID PVC (SIMULATING WOOD) FENCING WITH
> 6' HIGH BLOCK PILASTERS APPROX. 15' O.C. AROUND EX. POOL,
1EiE k if fE i! 1k 1E 1E 1Eif if iE if if iF 1E if if 1E iE iE If iF iF 1E 1t 1F iF 1F 1f 1E iE If IF �kk k 1f 1E iE if iE iE af if 1E ff �t1k 1f iFif it if if if 1E iF �t 1E 1F 1F if ik �1E iE 1E it i! 1E if if �f iE it it it iE
D E V E L O P M E N T S E R V I C E S R E(j U I R E M E N T S
ZONING APPROVED HY .
HUILDING APPROVED BY :
APPLICATION ISSUED BY; ��
�r�r�r*�r�����r*�r�r*�r�r**�r�r**
LEGALIZATION:N F E E S U M M A R Y
DATE:
DATE:
DATE:
*r�e*�**it �t
STRUCTURAL SEGMENT:Y
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
PERMIT 23.75 � 50
PLAN 15.44 �� �. �, SMIP/NON—RES
•�, . �
HUILDINGEDIV—> PERMIT ISSUE PLAN�CHECK TOTAL PAID DUE
TOTALS----> 24.25 0.00 ',�,�,15.44 39.69 39.69 ,00
REVENUE DIVISION TOTALS--> COIiI.fiCTED: 39.69 OVER/SHORT: ,00
BLDG PMT PLUMBING ELECTAIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
23.75 'i, , .SO 15,44
1F 1E 1E 1E k i! k iF iF k if if iE 4 fE fk 1k k 1k ik 1! 1E 1F �F iE 1f 1E iE 1E k!f fk iE fE iE 1E 1E ff if 1k i! if if if if iF k iE k 1E if if 1f if 1E 1f 1f if 1E k k iE 1E iF if iE iF 1F ik iF ik iE 1F 1f 1f 1Elf 1! iF
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
SFR 525 ALTER BY VALUE RESIDENTIAL NOZONE 1.00 525,00
!�END�OF FEES
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APPROVALS Permit # � Date Inspector qppROVALS Permit # Date Inspector
/
1. Temporary Electrical Service or Pole 52. Poo� & Equipment �ocation '
2. $oil Pipe�Undrgmd. - 53. Steel Reinforcement • �
� 3'�Elgctrical Condoit Utility�Und,�gmd. 54. Forms � -
"'4'. Electrical Conduit:Uridrgrnd.- 55. Electrical Banding .i
�5, Steel Re��forcement� 56. Rough Plumbing & Pressure est
'•6.,",Electritel UFER Glntl. 57. APPROVALTO COVER•GUNITE
.1='7;CFooting5 �� -, '�_Z��p 6C�/�G 58. Eloctrical ConduibUndrgmd. I
'.�;8. Foundation �" 59. Gas Pipe, O Undrgrnd., Test _
:� 9. Water Pipe�Undrgmd. :. 60. Backwash Lines, P-Trap, O Undrgrnd.
10. Structucal Ftoor Syster''� 61. APPROVAl.TO OECK
17. Property Sewer Line & HouseConnection 62. Backwash & Receptor•F.iQal �
12. �Sewer Cap = ' 63. Heater & Vent-Final .
-� �
13. Roof Drains . • 64. Plumbing System � Final ,
14. Rough Plumbing 65. ElectricabFina�
75. Rou9h Electricai-Couduit � . 66. Solar System�Final � - •
16. Rough ElectriaWiring 67. Fencing & Access Approval �
77. Rough Wirin9 Si9^ T . � 68. APPROVED FOR PLASTERING
18. liough Electrical-T Bar Ceiiin9 69. POOL/SPA SYSTEMS FINAL �
19. Rough Heating^& Air Conditioning - PIRE DEPT. REQUfREMENT -
. . � r r r. y . .
20. Rough ,actory Fireplace • - - �� � . ' - �-• .. AppROVALS •� Permit # •
Y Y y�
27.'Ducts, in Stryctu{e � .. .. " - , 70.�Undergrt_�o.ur�d Hydro ' ��'
22. Ducts, Venti�ating + - -� 71. Produit Pi in {7'Gas O Oil
P 9
23. Gas'Pipe�Rou9h &'Tesc - ,:, � _ _ ' _ 7y, Undergro,und Fau"sh. . .
24.:Roof Fr�ming• .« .__ .. �_ Y - � 73. Undergend. Storgt�T Tank O Gas ❑ Oil
25. Rodf Sh;�athing � y _ � �-� _ � �: • 74, Ovetheaa Hydpo`'' �-�,,
26. T-Bar. C¢iling (Sviuctural) & A�onocoat - �: a � _ 75. Dry Chemicul y �� ! - -- ,� '+ �
27."Framea�d Flashing.' ' _ _ 'S _ 78. Dry`StaadpipeF � � ' �
� ;`, b
: 28.ILathing & Sic�ing_ , , - - •- •r 7h FIXED�3YSTEiW:FINPlL
�. r
29. Insulatipn � ' " � _ ' " r`-' ' � 7$. FIRE PREV. FINAL ' "
.�
� 30. Drywall�Nailm9 �r. 1 �- � - -HEALTHDEPT.-REQUIR:EMENT
31. Plaster 6r'owp Coat `, . ' r, . �.k � 79. FINAL:It�SPECTION ; �
� - _. _ ,. --��;----
_ 32. �Electricaf Power Me{eCFinal � ', 8p. FOOD CERTIFICATE VSSUED
33..Final EI$ctric_ =: i rt � r ` . 7�. � Notes: _ �
- 34. Final Heating'& Air`Consiitioning_; - � �� ' �- " r�'��_
�
. 35.'Final Gas Pip�Te"st �. ' -r' ^ ^ ' . . - ". n =- -•- - � -
. � ^ rr � -
. � -, � .. M1 � - : � . . . .
. 36. � Hoad or-CanoPY F. � - - s ^ ��. _ -
37. �Final"Fabiorv FirepYac7 _ - � '� � � ' ',
: � ... _ .
� 38. Final PlUmbing = �� �,_, �� � �_. , �;. � � -
, 39. Wat2r Service�Finat'- � ' - • `- �T. ' _
' a �fi i -
� 4Q. �as Service-Final � t _ ,. -`� T , " '
. �>- .��. -.C' � t ,
_ 41. Solar pomesticFinal : ' .:� ., ^ . _ "
� y r
'� 42. Backflow Prevente� ; � " ` , , -
43. Backflow Irrtgation= ' ' • � l� �
44. Landscape Irrigatio,`n, Sys[em: ,- , G . ; ,- r . , - " - _ ,
45..Sound Attenuation: - � T - - � ^ - - i .
,� y' _ - v.
46. Handicap,Regulations _ .�,; , " � ��
47. EINAL STRUCTURE & BULLDING ' • , _ '
_. ,
46.`FINA�PLANNING�. _ = �' ' :
.!
49. Electiic Release to Edison + "�
� r
50. Gas Release to Southern California Gas Co . -
51. CERTIF�CATE OF OCCUPANCY . ' _ � . : -
No Date
\ --
�..__ _ -
,_ AGO���ant lo fill in all spaces except lhose wit�in neavy bortler Iines antl si9n all appropriate tleclaralions.
�I7Y OF COSTA IVIES'A� CONSTRUCTION PERMIT UN�-r
.rProject A�dress 3`Y�7 Lh PEl2�t L/tNE �
'Appliwni's Mailing Address � ,
G er's Nam�e p ��� `�_ �h�/tREL�- phone
Address =-4-.:� Lh �r LE L/`/�E.
Arch.•,�Eng. .: �T 6/ T I/- �E <hE License No.
Address Se� E is � s r.t�r.�Po�r R a<<, l4
Address (mailing) — �
City License No. � y� _
LICENSED CONTRACTOR DECLARATION I
1 hereby aifirm that I am Ilcensea untler provisions ot Charter 9(tommentlng
wltn section 7000) ot Division 3 of the Business antl Protesslons Cotle, antl
my Ilcense is in lu olrc/e/�9 ntl eitect. �%
Licon CI N�'• // �CQCSP`N��
Date 1L� %i' 7 c'anwr . �.y'/� � �/L �
"1RKER5'GOMPENSATION DECLARATION
rreoy a(tirm that I have a ceriificate ot consent to selt-Insure or a tertificate
Workers' Compensation Insurance, o� a certl(ietl co thereof (Section
3800, Lab. G.) /O "/( /% -t� .
Polity NO. H�� � lZV ompa
BCertifietl mpy is hereby fumishetl. � � .
CertiNetl wpy ii ith the city B' Oiv' ion.
Date� v � ApO�icant �
E%EMGTION FROM W RKERS' COMP NSATION DECLARATION
(This sec[ion neetl not be completetl if [he permit is far One huntlre� (5300) ar
I¢55).
I certify that in the perto�mance of Ihe work fOr which t�is pCrm�t is issuetl, I
shall no[ employ any Oerson in any manne� so as to become subject to the
Workers' Compensation Iaws of Calitomia.
Date Si9na[ure
NOTICE: Ii, aiter, makin9 this tleclaration, you shoultl become subject to the
Wotke�s' COmpensation p�ovlsion5 Oi Ihe Labor Cotle, you musl fortbwlln
comply with such prOviSions Or tnis pe�mlt sM1all be deemetl revOketl.
CONSTRUCTION IENDING AGENCV �'. . - �• �
I hereby atflrm that there is a construction lentlin9 agency for the'per(ormance
of Ihe work fOr which [his permit i5 issu¢tl (SeGtlOn '9097' Civ. C.)
Lentler'S Name
Lentler'S Adtlresz - .
OWNERBUILDER OECIARATION
I hereby atflrm that I am exempt from Ihe ConVactor's Li<anze law (or the
followinq �eason ($eclioq �031.5 Business antl Pwfessional Cotle: Any dfy or
county which requires�a'permit to wnztruct, aller, improve, tlemoiish or repair
, any SVucture, priot to its is5uance, also requires [he applicant for such•permit
�, to tile a signetl statamen[ [hat he/sne is licensetl puriudnt to [he proviSiOns ot
'�. ^ Conlractor's Licen'sc Law (Chap[er 9(commencing with Section ]000) of
�ision 3 ot Ihe BuSinesS antl Professions Catle) o� tha[ M1e/5hG iz exempt
,refrOm anE the basis for the alleged exemptlon. Any viola[iOn of SectiOn
.J31.5 by any ap0licant fo� a permit subject5 th¢ applicant to a civil
�nalty o( not more than five huntlretl tlollars (E500).
LJ I, as owner ot the oroperty or my employees with wages as their'sole
mm0ensation, will Oo the wo�k, antl the StrUctwe is not int¢nOeC o� off¢r¢tl
for sale (Section ]044, Business �antl Pwfessional Cotle: •The Contiactor'S
LicenSe I.dw tloes not appty to an owner of a property who buil�s o� improves
th¢reon, antl wM10 tloe5 such work himseH/herself or [h�augh hIs or h¢r own
Cmployee5, provitl¢tl tha[ such improvements a�e not intentletl or offeretl'for
sale. It, nowever, the bWltlin9 or improvement is soltl wi[�in one year oi com-
pletlon, tne owner wi11 have the burtlen oi proving ne/she tlitl not builtl or im-
�rOveforthe Ourpose otiale�.
U I, as owner oi the prooerty, am excluslvely mntracting witn Ilcensetl <on-
t�actors t6 con5[ruct the pro�ect (Section ]094, Business and Protesslon5 Cotle:
The Conlrattor's License law does not aPPly to an owne� ot O�oOerty wh0
builtls o� ImOroves lheteon, antl who contraGts fo� such prolects wilh a con-
Iracto�(sl Imense pursuant [o IhC ConlraGtor's License Law). I am aware tha[
proof Of Neir Worket's Compensalion Insurance ihoultl be prOvitletl lo me.
❑ I am exempt untler Section B. & P. C. for this reason
Date Owner
I h¢reby certify IhaL I hav¢ reatl
informatlon is coriqcL I agree to (
Si9nature-�
Drivers' Lfcen e or 55
CMF 0865-46, rev. 10/84
the
above
iances
repre-
v tor
8P ��) `�►b I ' iiis � "
TYPE OF CONSTRUCTION NEw noo
❑ CONVERSION ❑ DEMOLISH ❑ OTHER _
--DESCRIPTIONOF WORK/USE OF BLDG.
7VPE OF PERMIT �RADiNc
, ❑ TENANT ❑ ELECTRICAL
❑ OTHER
PROJECT DESCRIPTION 5�. FT.L
CONSTRUCTION TVPE V U VALUATION $
GRADING CU. VDS. A(
0
ALTERATION LJ REPAIR
iiFOUNDATION L.rSTRUCTURAL
PLUMBING ❑ MECHANICAL
Remarks:
Bar Sink
Backflow Preventer
Backflow Irrigation�
Rat6tuha _ '
rinking Fountains
loor Orains
loor Sinks �
es Service S--OuHets
itercepmrs _
itchen Sink ''
avatories " '�
-Trap
.00f Dreins ' -
Reinspection Fee $15
Boiler
Duc[ � Under Ground •
Duct - Structural
Duct - Ventilating �
Exhaust System ❑ Multiple
Firepl/FacL BIL IC80 �
Heating System & Ducting
❑o-i oo,000 eTu o i oo,00g
Heinspection Fee � $�5
White - Builtlin9; Cana�y - Applicant; Pink - Accounting; Goltlenrotl - Assesso�
PLUMBING
Showers
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
Solar Piping �
Solar Tank
Swimming Pool w/Spa
Urinal
Warer Closet '
�� Water Heater '
Auto-Wash
Leundry Trays
Issue Fee
1ANICAL
Hood or Typel ❑
Canopy Type I I ❑
\
Refrigeretion,System
❑0-100,0�
System Re Alterati
Fi ampers
Registers
Issue Fee
A.P. # . y2s�
S Main Building:
TFront a's � �
ARear , �5' �
C Right 5�
SLett ���$'�
Ping. Fef. # (,��2 -
Planning Notes:H�LD
Automatic Washer
Construction Pole
Cooking Unit
Dishwasher
Dryers �Gas ❑
Fan . ,
F.A.U.
Fixtures
Oevice Boxes �
Outlets
Switches
Garbage' D isposa I
Generetor �0-SJ!
5 3
FEES Reinspection Fee
DEVELOPMENTSER
2oning Approved By_
BuildinB APProved By
Appliwtion Issued Bv_
$ 3
�654 12/02/87
'� � `�.� Zone
Accessory Building:
��� .
- '7j'7� � Parking Req./Provided 5
ELECTRICAL
Transformer � 75-50KW
❑ 50+KW
Meter LJup to 700 amps
Mecer ❑over700amps
Sub Panel
Motors �0.1 HP O1'
InaSolar09-1 P��16-15+
�9, _'u
a
FEES
- r e ugnc
Raage;
Sign
. Standing,Seciions �
❑5:75 KW Tiesh Compactor
' ! �
- $75 luue Fee $ 3
1/SRKfFIFEM/fALI _ . /7�7-f
BUILDING PERMIT 5
PLAN CHECK $
PLUMBING $
PLAN CHECK 25% $
ELECTRICAL $
PLAN CHECK 50% $
MECHANICAL $
PLAN CHECK 25% $
FEES
a $MIP $ 6• Sq
S PERMIT
ISSUANCE $
ENERGV P.C. $ -
GRADING $
MICROFILM .$ �[ Q/�
TOTAL FEE $ ✓ � � {�:�
2
O
N
I
N
G
R
E
Q
�
CONSTRUCTION AND PLANNING POOL & SPA �
APPROVALS Permit # ' Date Inspector p�ppROVALS Permit # Date Inspector
1. Temporery Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. �/,�� �� L� 53. Sceel Reinforcement �
3. Elecirica! Conduii Uiilliy-Undrgrnd. ' 54. Forms �
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding �
5. Steel Reinforcement (^y y 8'j rj, (�% ' 56. Rough Plumbing & Pressure'Test
6. Electrical UFER Grnd. G.N • 57. APPROVALTO COVER-GUNITE
7. Footings ' G, �1/ • 58. Electrical Conduit-Undrgrnd. `
8. Foundation 1 8"1 G• N' 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, O Undrgrnd.
10. Structural Floor System �, 61. APPROVAL TO DECK .'.�
11. Property Sewer Line & House Connection ' 62. Backwash & Recep[or-Final •'
12. Sewer Cap 63. Heater & Vent�Final •
13. Roof Drains 64. Plumbing System - Final ,
14. Rough Plumbing 5. Electrical-Final
15. Rough Electricai-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 APPROVALS Permit # -
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating� � 71. Product Piping O Gas ❑ Oii
23. Gas Pipe-Rough & Test 72. Underground Flush �� �
24. Roof Framing 73. Undergrnd.StorageTank �Gas ❑Oil
25. Roof Sheathing �� 74. Overhead Hydro �
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical R�
27. �Frame and Flashing �� b� 76. Dry Standpipe - �
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation � � &� �� 78. FIRE PREV. FINAL
30.DrywallNailing � � y� �� �,� HEALTHDEPT.REQUIREMENT '
31. Plaster Brown Coat � 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED �
33. Final Electric Notes:� , yy�
34. Final Heating & qir Conditiod �� A .
[
35. Final Gas Pipe-Test . , d � � y�,
36. Hood or Canopy r��'d�
N
37. Final Faccory Fireplace 88 �„ rt�' �
38. Final Plumbing - �' p �, _ �
/ r
39. Water Service-Final -� " � (�� � �
i Z2 .r
40. Gas Service-Final � � V
41. Solar pomestic-Final • • ; y � ��
�
42. Backflow Preventer � � �� �J ( � �
� � � ��,
43. Backflow Irrigation . -� �� % j µ � S
44. Landscape Irrigation System r`'� n. Il� `� i a
45. Sound Attenuation �i " �" �r '
� �
46. Handicap Regulations �'� % ' � u'
. -i e� r. /�
47. FINAL STRUC7URE & BUILDING � � � ' '. '.n '=' ..� i ^'d
�i . �1 n.
48. Special Requirements Completed v� ��i �` � !
49. Electric Release to Edison �U •^� �
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY +� �
No. Date , � • ,
APD���ant to fill in all ipaces except t�ose wit�in neavY bortler linas anE sl9n all aperoprlata tleelarations.
ciTY OP COS7A MESA .CON TR UCTION PERMIT PEqMIT NO. ' TRACT NO. 'LOT NO. UNIT N0.
ProjedtAddress �i Z.� �G �,
Applicant'sMailing ddress -G- 0% lOb Ivi • ry S
Owner's Name �A"v � ''^ 0.�'L p/hone SYB- f/if3
Address 39i La {�PK�c �K iiiSf� ��5�
ArchlEng.� LicEnse No. f/ 5 2S�
Address
Convacror's Name ^(�'t Q^^ Pho e �� ' � 6
Address(ma�'��� �� � x I�U�S�q✓i ��7i9�
City License No. � �J � S �
I.ICENSED CONTRq�TOR DECLARATION
I hereby al/irm that � am Iicensetl untler provisions of Charter 9(commencing
with section ]000) of Divlslon 3 of tha Busineis antl Professlons CoOe, antl
my Iicense is in lull fQrca antl efiect.
Ucense el s i2 LI e se n �b Z
Date �� �'% � S9 at yl
WORKERS' COMPENSATION DECLFRATION
hereDy attirm that I ryave a certifitata of consent to self-Insure or a cmtlticate
.t Workers' Compan�tlon Insurance, or a certitietl copY tnereot (5 ction
3800, lab. C.) �
Policy No. �UK�U�,.�.n. � Compan �
Certifietl coOY is hereby turnlshetl.
Certitietl copy i}flletl with [he city Buil Div' f
Date' ��1%�• APPlicant �-
EXEMPTION FROM WORKERS' COM7ENSATION DECLARATION
(TniS seG[iOn neetl no( be comple[etl if the parmit iz }or One huntlratl (E300) or
Iczs).
I certity that in [h¢ p¢rformance o/ the woik for which tM1ls pe�m�t IS I55ueU, I
Shdll not employ any p¢�Son in any mann0r 50 as to becom0 Sub�ect lo th!
WOrkeri' CompenSaliOn Ldws oi Ca1lfOrnia.
Date Signa[ure
NOTICE: If, aiter making t�is declara�ion, you ShOultl become Sub�ect [o the
Workers' ComDensatlon provisions of the Labor �otle, you must ronnwitn
comply with sucn provislons or this permlt Shall be acamea revokea.
CONSTRUCTION LENDING AGENCV
1 hnreby atlirm that [ryero Is a constructlon Iontlin9 a9ency for tna parformance
of lne work for W��cn [bI5 permlt Is ISSunE (SecUon 3097 Civ., C.)
LenOer's Name
Lentler'sAdtlreis- -
OWNER BUILDEN GECLARATION �
I hertby aflirm Ihal I am ozempt from the ContrdCtor'S LlcenSC Law fprthe
� following reason (Sectlon 7031.5 Buslnass antl Prptessional Cotlo: Any ci[y'or
I COunty whicn reqW/as a pBrmit to Cons[�uct, dlt¢� Improve, tlemollih o�"r¢pai�
Iany structure, prior to its issuan<e, also requires t�e applicant for such peimlt
to fiie a signetl statement that he/she iz Iicensetl pursuant to tne provlsions ot
the Contractor's Ucanse Law (Chapfer 9(commendng with SecUon 7000) ot
71vl5ion 3 ot lh¢ Bu5InB55 antl Profe55ion5 Cotle) or t�at be/She is examp[
he�e�rom antl the 4dii5 1or Ihe allegetl ¢xemOtion. qny violdUon ol Sectlon
7031.5 Dy any applicant tor a permit subjetts Ne� appltcant to a civil
,� enalty ot not mor¢ Ihan tive huntlr¢tl U011ars (f500).
I, as owner o1 (hG property Or my employee5 wit� wag¢5 as thei� sole
compenzation, will qo me work, antl tltG sl�uGtu/e is not intenaetl or o(terea
for sale (Section 7044, Business an❑ Protessional Code: The Convactor's
�IcenSe Law tloes nOt apply to an owner of a proOertY who builtl5 O/ improves
thereon, antl wno aoes su<h work himself/harsell or tnrough his or her own
employees, Orovitletl that zuch imProvements are not intentlo0 or offeretl for
sale. It, nowever, thp buildin9 or improvement Is soltl witnin ona yoar ot <om-
oletlon, the owner W�II have tne burtlon ol proving he/sne tlitl not builtl or Im-
provs lorthe Durpose O15ale).
❑ I,'as owner of lne proper[y, am ezcluslvely con[racting wlth Ilcensetl con-
traclor5 to con5t�uct (he project (Secllon ]044, BUSinoss and PrOlession5 CotlO:
Tho Con[ractor's License Law Ooes m[ apply to an owner oi property who
bulltli O/ ImOrOvaS the�eDn, antl who coMtacts �or such 0/ojeCtS wi[h a con-
traclm�sl I�cenm pursuanl [o tne Contractor'i llcense Lnw�. I'Bm aware tha[
prool o( lhelr Worker's COmPensatlOn insuranca inoultl b0 provitlatl to me,
❑ I am exertipt untlor Sactian B. d P. C. lor this rea5on
Data Owner
1 hereby certily thdt I have reaE this applicalion and state that the above
inlormatlon is corrnf� . I a9ree to compty with all Uty antl <ounty ortlinances
antl state lawz ralalyr�g to builtling coniVu HOn, antl hereby authO�lie r0pre-
sentatives o� this�C�ty to en[er upon o above-mentloneM property for
Slgnature _�7 A �w.
Drivers' License or 55 9T
CMF OB65-46, rev. 30/B8
0
TVPE OF CONSTRUCTI^ON U NEW�ADD LJ ALTERATION LJ REPAIR '� �'
❑ CONVERSION U DEMOLISH O HER A,p.�l, .
DESCRIPTIONOFWORK/USEOFBLDG. ' '
� ' S Main B I
E
TVPE OF PERMIT GRADING FOUNDATI� ST0.UCTURAL T Ffont
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING MECHANICAL 6 Rear
❑ OTHER %�
PROJECT DESCRIPTION SQ.FT.' oCCVaAN V C Ripht
K Left
CONSTRUCTIONTVPE � 'VALVATION$ '� $
20NE GRADING CU.YDS. ACRES Ping. Ref. $b
qemarks: �� � � Planning Notes',
i
Preventer
Irrigation
Drinking Fountains �
Floor Drains '
Floor Sinks �
Gas Service Outlets
Interceptors
Kitchen Sink
Lavatories
P—Trap
Roof D�ains
Reinspectian Fee � $15
Duct- Under Ground
Duct � S[ructural '
Duct � Ventilating
Exhaust System ❑ Multiple
Firepl/Fact. Bit. ICBO 51�'+ �!
Heating System & D�cting
❑4700,000 BTU 0100,000
Reinspaction Fea � $15
Whlte - Bulltling; Canary - Appll<ant; Plnk - Accounting; Goltlenrotl - AsseSsor
ShOWers
Service Sink '
Sewer Cap
Sewer Connection
Solar Coltectors
Solar Piping
Solar Tank
Swimming Pool w/Spe
Urinal
Water Closel
Waier Heaeer
Water Service
Aum�Wash
Wundrv Travs
Isue Fea
Hoodor Typel ❑
CanoPY .Type I I ❑
Refrigeration System
Oaioo,000eTu Oioo,000
System Repair/Alteration �
Fire Dampers �
Registers '
laue Fee
S 3
Automatic Washer
Construction Pale
Cooking Unit
Dishwasher �
Fan
Fixtures
Device Boaes
Outlets
Switches
Garbage Disposal
Generator �0�5,
5
' ' � Zona . . .
Parkin9 Req./Provided
ELECTRICAL
Trensfarmer ❑ 15-50KW
❑ 50+KW
Meter �up to 100 �amps
Mecer ❑over 100 amps ,
Sub Panel'
MotorsOO-1.HP�1'f.-6 �
Inc.Solar 09�15 HP �16-15+
MiCrowave � � .
Pole Light _
Standing
Trash Co
I Rainspaction Fee '$15�' I IssuE
DEVELOPMEN7 SERVICES REQUIREMENTS:
Zoning Approved 8y
Building Approved By �
_ .. . . . _ f'�
' - SUMMARV OF FEES
BUILDING PERMIT $ SMIP
PLAN CHECK � $ - PERMIT
PLUMBING , $ ISSUANCE
- PLAN CHECK 25% S ENERG� P.C.
ELECTRICAL $ - � GRADING
PLANCHECK 50% $ � MICROFILM
MECHANICAI $ � TOTALFEE
PLAN CHECK 25% $ % ZT ,
$
FEES
$ 3
Z
O
N
I
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G
R
E
Q
M
T
S
CONSTRUCTION AND PLANNING POOL & SPA . .
APPROVALS Permit# Date Inspector 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-Undrgmd. 55. Electrical Bonding . �
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test +
6. Electrical UFER Grnd. � 57. APPROVAL TO COVER-GUNITE
7. Footings ., 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, O 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 ' 64. Pluinbing System - Final
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar SyStem�Final �
76. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign � 68. APPROVED FOR PLASTERING
18. Rough Electricat-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit # _
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping O Gas ❑ Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing ' 73. Undergrnd. Storage Tank O Gas ❑ Oil "
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. Insula[ion 78. FIRE PREV. 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
37. Final Factory Fireplace �j ��
38. Final Plumbing
39. Water Service-Final �
40. Gas Service-Final
41. Solar pomestic-Final �
42. Backflow Preventer , �
43. Backflow Irrigation • �
44. Landscape Irrigation System �
45. Sound Attenuation �
46. Handicap Regulations
47. FINALSTRUCTURE & BUILDING
48. Special Requirements Completed .
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co '
51. CERTIFICATE OF OCCUPANCY . �
No. Date
A�plicant to /i11 in au sDaces ezcept thosa witnin neavY borEer Ilnes anE sign all aoPmo�iate tleclanlionz.
CiTY.OF COS7A MESA CONST UCT[,ION PERMIT
ProjeMAGdress � CKyt
dpplicanYs Mailing Address •U • �?' ��D �; ��W L)Y'r
Owner'sName t � ..� Phonest�fr���&j
Address �1 LA Q'� � t-'`� '
Arch/Eng. - License No.
Address �
Contrector's Name � � � hone , '� 6 �
Addresslm++'�'n�l 'G, b5 (oQ �i�� �iL;�j,�
Ciry License No. � �% � �
LICENSED CONTRACTOR DECLARATION �
I he�eby at(irm [ha[, I am licensetl untle� p�ovi51on5 of Charte� 9(commencin9
witn section �000) of Div�sion 3 01 the Bu inezs antl Profeszions Cotle, antl
` my license is In f���wc�force antl etiect.
�� Licon CI • � � Ic �5e No. %Z
\ Dale ��� Signature
�. WORKERS' COMPENSATION DECLARATION .
' hereby aftirm lhat I nave a certilicate o1 consent to self-Insure or a certlflcate
� �f Wbrke�s' Compensation Inzurance, o� a cerUfi¢tl —CfOpY theteof ($e tlon
- 3800, Lab. G.) (���' ' ComPan �A 1 t ��
= PoIICY No. ,Bf���p
Certifietl copy Is hereby furnishetl.
Certlfie� cP py I fileA with the city Buil Dlvis
Oate �'�e � �� - Applicdnt
� i E%EMPTION FROM WORKERS' COMPENSATION DECLARATION
(Thissection neetl not be campletetl it the permit Is for one nuntlretl (5300) or
lezs). '
1 certlfy [hat In the �performance Of [he work for whic� tbis pe�mR is Bsuetl, I
Shall no[ employ any pe�son In any mann¢r so as to bGCome subj¢Ct to Ihe
Workers' C e Laws of California.
Dale Signature '
NOTICE: It, after.making this tleclaratlon, you shoultl become-suDject to the
WorkGrs' Comp¢n5ation provisions ot the Labor Cotle, you musl (orfhwith
comply wilh such provisions or tnis permlt shall be tleemetl revoketl.
CONSTRUCTION LENDING AGENCV
I nereby atfirm that tnere iz a construction lentling a9ency for the performance
of th¢ work for which this permit i5 ISSu¢tl (Section 309] Civ. C.)
Lentler's Name
Lentlor's AOCr¢Ss �
OWNER BUILDEH DECLARATION
I hereby aftirm that I am exempt trom tne Contractor's License �Law tor the
following reason (Section 7031.5 Business antl Professlonal Cotle:.Any clty or
county whlcM1 requires a permlt to con5truct, alteq Improve, tlemolish or repai�
any structur¢, prio� to its issuance,•also �equlre5 the applicaM tor such Oermit
to flle a signetl stalement that h¢/she Is Ilcensetl pursuant to the provisions of
tne Con[ractor'S License Law (Ghapler 9(commencin9 with Section ]000) ot
DlviSiOn. 3bf [he Business antl Prote55lon5 Cotle) o/ Ihat he/she is exempt -
� [herelwm antl tne ba5is for t�e alle9etl exemption. Any violation of Section
]031.5 by any applicant for a permlt subjects the. applicant to a civil
' enalty of not more tnan five huntlretl tlollars�(E500). '
.� 1, az owner of the property or my employees witn wages az tnelr sole
comp¢nsalion, will tlo the work, antl Ihe structure is not intentle0 or o(f¢r¢tl
' lor sale (Section 7044, Business antl Professional Cotle: The Contrac[or'S
License law tloes no[ apply to an owner ot a property who builtls or impmves
thereon, ana wno tloes such work himself/narseif or through nis or her own
employees, prOviUetl lhat such imprOvemen(5 dre not Intentletl or otferetl f0�
581G: II, howeve�, lh¢ builtling or imp�ovement Is Soltl within one y¢ar 01 com-
pleHon, the owner will have tha burtlen of prOving he/sh¢ tlitl not builtl or im-
prova for [he purpose of sale). '
❑ I, as�owner o/ tne property, am exclusively contractin9 witn licensetl com
traCtorsto construct the O�oject ($ectlon 7044, Business antl Professlon5 Cotle:
The ConVactor's LicenSe Law tloes not apply ro an owner ot.property wno
builtls or Imoroves thereon, antl wM10 contracts tor such projects wlth a con-
tractor(s �icense pursuan[ to tne Contractor's �icense Law). 1 am aware that
proof o� thei� Wo�ker's Compensallon insurance Shoultl be provitled to me.
❑,I am exempt untler Section- � B. S P. C. for tnis reason
Date - Owner ' �
1 nereby certity tha have reatl this application antl state that the above .
in(orma[ion is corre . agree lo mmply with all tity antl county ortlinances
�antl-slate laws rela ng to builtling Wnstruction, antl hereDy auihorize repre-
sentatives of this c' to en[¢r u o t above-mentionetl property for
InSpectlon purp0 , y� � r �
Si9nature � ' �a�z / �
�rivers' Utense or 55 �
TYPE OF CONSTRUCTION LI NEW_��ADD, LI ALTERATION LJ REPAIR
❑ CONVERSION ❑ DEMOLISH L'J o1'HER q,p,�
-DESCRIPTION OF WORK/USE OF BLDG. -
• S Main Building:
TYPE OF PERMIT GRHDING FOUNDATIQf`j. STRUCTURAL � T Front
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING� �MECHANICAL B Rear �
❑ OTHER � A ..
PROJECT DESCRIPTION Sq FT ��p� ' C Right '
'1 OCCUPANCV � K
iCONSTRUCTION TYPE v VALUATION $ 9��� '� g Lefl �
ZONE GRADING CU. D5. ACRES . . Ping. Ref. �II'
Remarks: � / Q Plannin9 Notes:
Sink
Preventer
Irrigation
Drinking Fountains
Floor Orains ' �
Floor Sinks
Gas Service OuUets
Interceptors
Kitchen Sink �
P-Trap
Roof Drains
Reinspection �Fee
Showers .
Service Sink
Sewer Cap � '
Sewer Connec[ion .
Solar Collectors
Solar Pipin9,
Solar Tank
Swimming Pool w/Spa
Water Closet .
Water Hearer
-� Water Service � �
AuLO�WeSh �
LaundryTrays �
$15 � Issue Fee
Dut[- Under Ground
Duct-Structural • �
Duct � Ventilating �
Exhaust System � Multiple ❑
Firepl/Fact. Blt. ICBO #
�a[ing System & Ductin9
0-100,000 BTU O 100,000 BT
ReinspeRion Fee � $15
CMF 0865�46, rav. ]0/04 White - Builtlin9: Canary - Applicant; Pink - Accounting: Goltlenrotl - Assessor
Hoodor Typel ❑
Canopy Type II ❑
FEES
- Automatic Washer
Construction Pole Sub.
� Cooking Unit �
.. � - Dishwasher , -
Refrigeretion System
❑o-i oo,000 er u"O i oo,000
System Repair/Alteration
F ire Dampers
Registers �
Issue Fee
$ 3
FEES
42a6 I/28/G.:
Acressory Building: �
Parking Req./Provided
2uo�-�
Zone _ �
�
ELEC7RICAL � � �
Transformer ❑ 15-50 KW -
� 50+KW
�ryers uoas ueieccric -
Fan
F.A,U. �
Fixtures
�evice Boxes
OuUets
Switches ' -
Garbage Disposal '
Generator �0�5 KW 05-15 KW
Meter � IJ up to 100 amps
Merer �over 100 amps� .
Sub Panel
Motors �0.1 HP � 1 F, - 8 .
Inc.Solar �9�15 HP �16-15+
Microwave -
Pole Light
Range
Si9n
Standing Section
Trash Compactor
I Reinspection Fee �$15 I I Issue Fee
DEVELOPMENTSERVICESREQUIREMENTS:
Zonin9 APProved BY .
8uilding Approved By
Aooliwtion Issued Bv - �^-
. Z
O
N
I
N
G
R
E
Q
M
T
S
FEES
3
• . SUMMARV.OF FEES . - .
BUILDING PERMIT� $ SMIP $ -
PLAN CHECK $ PERMIT
PLUMBING $ ISSUANCE � 5 . ,
PLAN CHECK .25% $ � ENERGY P.C. $
ELECTRICAL $�• � GRADING . $
PLANCHECK �50% g MICROFILM $ �
MECHANICAL $ TOTALFEE $
PLAN CHECK Z5% $ � .
CONSTRUCTION AND'PLANNING POOL & SPA
APPROVALS . Permit# Date Inspector p�ppROVALS 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-Undr9rnd. 55. Electrical Bonding
5. Steel ReinEorcement 5fi. Rough� Plum6ing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Fooiings - 58. Electrical Conduit-Undrgrnd. .
'8. Foundation . 59. Gas Pipe, O Undrgrnd., Test � �
'9,' Water Pipe�Undrgrnd. . . ' 60. Backwash Lines, P-Trap, � 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 64. Plumbing System - Final
14. Rough Plumbing ' � 65. Electrical-Final '
15. Rough Electrica6Conduic � , 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 /,� ��p � FIRE DEPT. REQUIREMENT _ -
20. Rough Factory Fireplace � APPROVALS Permit # _
. 21. Dutts, in Structure 70. Underground Hydro �
22. Ducts, Ventilating 71. Product Piping OGas ❑Oi�l �
23. Gas Pipe-Rough & Test . 72. Underground Flush
24. Roof Framing 73. Undergrnd. Storage Tank � Gas ❑ Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical " �
27. Frame and Flashing -� 76. Dry Standpipe y. .
28. Lathing & Siding � - 77. FIXED SYST,EM FINAL ��
29. Insulation 78. FIRE PREV. FINAL � �
30. Drywall Nailing HEALTH DEPT. REQUIREMENT ,�
31. Plaster Brown Coat 79. FINAL INSPECTION -" �
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED .
; �,i
33. Final Electric � - Notes: � '
34. Final,Heating & Air Cor�ditioning �� �+G� � i � �_
�-s
35. Fin�.Gas Pipe-Test ' ' •
\
36. Hood or Canopy '
37. Final Factory Fireplace
38. Final Plumbing � - * '
39. Water Service-Final � - - .
40. Gas Service-Final - '
41. Solar pomestic-Final '
42. Backflow Preventer � � ` � ,
43. Backflow Irrigation � � � . �
44. �Landscape Irrigation System -
45. Sound Attenuation � '
46. Handicap Regulations � . � .
47. FINAL STRUCTURE & BUILDING . " � ' � - �
48. Special Requi�ements Completed '
49. Electric Release to Edison
50. Gas.Release to Southern California Gas Co � �
51. CERTIFICATE OF OCGUPANCY � ,
No. Date � '
. +�C .
vi
O
ciTY OF COS7A M7ESA CO/NSTR�ICTION PERMIT
ProjectAddLess �S�-7_`�j . ����� . �,�-
�AppliCanYs Mailing dress � � Jc/ " �
Owner's Name . ��'✓� � C ��', 2E�p�q¢ �C�
Address ��/�'I�r�
Arch/Eng. � License No. �
Address
Contractor's Name Phone
Address (mailing)
City License Na �
LICENSEDCONTRAC OR ECLA ATION� �
1 hereby affirm tM1at I am licensetl untler'provisions af Charter 9(mmmencing
with section ]000) of Division 3 of the Busine5s antl Protessions Cotle, and
my license is in tull fA rce antl ct. [�/ )
LicenSe Class `— � License No �� �%� % �
Date � -%' a � Signature ��
WORKERS' COMPENSATION DECLA9 TION
iereby aftirm that I have a certificate of consent to zeif-insure or a certiiicate
Workers' Compensation Insu�ance, o� a certifietl copy the�eot (Section
a800, Lab. C.)
Policy No. Company '
❑ Certitietl copy is hereby furnishetl.
❑ Ce�tifietl copy is filetl with the city Builtling pivision.
Date APplicant
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(Thissection neetl not be completetl if the permit is for one huntlretl ($100) or
Iess).
I certify that in the pe�to�mance ot the wark for which this perm�t is isiuetl, I
shail not employ any person in any manner so as to becomg subject to
Workers'�,Cpfnp-n@at�ior � aws ot Califomia /� /f
Date �� L� VT k�gnature ����.y_L
compiy wi[n sucn provisions or inis permit snaii oe aeemea revoKea.
CONSTRUCTION LENDING AGENCV
I hereGy affirm that the�e is a const�uction lentling a9en[y to� the pertormance
af the work fo� which this permit i5 issuetl (Sectian 309] Civ. C.)
Lender's Name
LentleCs AaEress � _
OWNER BUILOER OECLARATION '
I hereby affirm thai I am ezempt from the Contractor's License Law tor the
tollowing reason (Section7o31.5 Business antl Prafessional Cotle: Any city or
county whicM1 requires a permit to construct, alte�, improve, tlemolish o� �epair
any structure, prior to its issuance,�also requires the applicant for such permit
to tile a si9netl statementthat he/she is licensetl pu�suant to the provisions ot
the Contractor's License Law (Chapter 9(commencing with Sectlon 7000) o(
livision- 3 ot the Business antl Professions Cotle) or that he/she is ezempt
ieretrom antl the basis for the alleged exemption. Any violation ot Section
.031.5 by any applicant to� a permit subjects tM1e applicant to a civil
�enaltyot not mare than five nuntlretl dollars ($500). �
I,�as owner of the_property o� my employee5 with waqes as their Sole
compensation, will tlo the work, antl Ne structure is not intentletl or offeretl
for sale (Section ]044, Business antl Protessional Cotle: The Contractor's
License Law tloes not apply to an owner of a prope�ty who builtls o� imp�oves
'thereon, an0 who �tloes such work himself/M1e�selt or through his o� her own
employee5, provitletl tM1at such improvements are not intentletl or affetetl to�
sale. If,�howeveq the builtling or improvement is soltl within one year of com-
,plefion� tM1e owner, will M1ave the bu�tlen of p�Ovin9'M1e/SM1e tlitl nof builtl O� im-
'prove for the purpose of sale). •
❑ I', as owner of the Droperty, am-exUusively contracting with licensetl con-
. tractors to construct the pwject (Section ]044, Business antl Professions Cotle:
The ConVacto�'S License Law tloes not apply to an owner of property who
builtls or improves thereon, antl who wntracts for such projects with a con-
� tractor(s) ucense pursuant to the Contractor's License Law). I am aware that -
proof ot their Worker's Compensation insurance shoultl be provitletl [o me.
❑ I am exempt under Section B. & P. C. for this reason ,
Date � Owner -
I hereby certity that �I have reatl thi5 applicatiOn antl state that the above
infnrmatinn is mrrect. I aa�ee to comolv with dll citv antl [ounty ortlinances
Signature - - /
Drivers' License or 5`
CMF 0865-46, �ev. 30/84
enter u�on the
�
Builtling; Canary
nt ta fill in all soaces except tnose within heavy �ortler Iines antl sign a11 appropriate tleclarations.
ERM�JVO� ��/ � , TRACT NO. ' �LOT;NO.� UNI�G., .
c
TYPE OF CONSTRUCTION LJ fVEW � LJ ADO� LJ'ALTERATION IJ REPAIR �
r .❑ CONVERSION ❑ DEMOLISH ❑ OTHER� '
� DESCRIPTION OF WOR�K/USE OF BLDG. '' � t- �
. � �
TVPEOFPERMIT ❑ GRADING� ❑ FOUNDATION STRVCTURAL
❑ TENANT ❑ ELECTRICAL ❑ PLVMBING ❑ MECHANIGAL
�❑ OTHER
PROJECT DESCRIPTION Sq. FT. ocCUaANCv ,
CONSTRUCTION TYPE �VALUATION $ �
ZONE GRADINGCU.VDS. ACRES'
Remarks: � t `% � )1 � / - . ' � _
Sink
Preventer�
Floor Sinks , . - .
3as Service/, �� ,Outlets �
Interceptors .
Kitchen Sink` . . ._
Lavatories �t, � �
P—Trap,
Roof Orains •
,"
ReinspeMion Fee , $15
Duct - Under Ground
Duc[ - Structural .
Duct - Ventilating �
Exhaust System � Multiple ❑
FirepUFacc Blt. ICBO #
Heating System & Ducting , '
❑0.700,000 BTU 0100,OOOBT
aby authorize repre-
ionetl prope�ty /o�
oa�:�,�_�_�_.'� �
keinspection Fee
anp Pink - Accounting; Goltlenrotl - Assesso�
•I $15
Showers
Service Sink �
Sewer Cap � -
Sewer Connection '
Solar Collectors
�Solar Pipin9' '
Solar Tank
Swimming Pool w/Spa
Urinal .
Water Closet � �
Water Heater
WaterService �
Auto-Wash �
Issue Fee
IANICAL
Hood or Typel ❑
Canopy Type I I ❑
- ` �' t -
� , ; i : f ° .` '_� ' " '9.1
' �nFr.181987
A'.P. #
S Main Building:
TF�ont �
ARear
C RigFt
SLeft �
Ping. Ref. # �
Planninq Notes:
i � .
Automatic Washer � "
Construction PoleSub.
Cooking Unit ,
Dishwasher .
Dryers �Gas lectri
Fan� � ,
F�.A.U. � � �
rixtures �
Device eoxes
Outlets '
Switches
Garbage Disposal
Generator �05,
��"" " "�ene
Acc o i �
2
O
� � N
' . N
G
. �
Parking"Req./Provided � E
Q
' � M
T
S
ELECTqICAL -
Transformer ❑ �15-50 KWu
� � '�'50+K
Meter,l�'Iupto100am s
Meter,�bver100amps �'la
Sub Panel � "
Motors � 0� 1 H P � 1%- 8 .,,
Inc.Solar �9-15 HP �i6-75+
Microwave - �
Pole Light �
Ranae i
I I Standin9 Sections
5 KW � Trash Compactor
$ 3 '
Rainspection Fee ,$15 Issue Fee
FEES
�DEVELOPMENTSERVICESREQUIREMENTS:
Zoning Approved By
Building Approved By ���
netngeration System ' , �
❑0.100,000 BTU ❑ 100,000 BTU "
System Repair/Alteration I �
Fire Dampers � �
Registers , '
. i
' • Issue Fee . - I , $ 3
�
_FEES
. . ' , SUMMARV OF FEES -
BUILDINGPEFMIT� $ SMIP $
- PLAN CHECK $ PERMIT . �
PLUMBING $ ISSUANCE � $ .
PLAN CHECK 25% $ ENERGY P.C. $
ELECTRICAC $ GRADING $ �� '
PLANCHECK �50% $ -�� MICROFILM _ $ _J��
MECHANICAL $ � � TOTAL FEE $
` PLAN CHECK 25% $ , ' " '
CONSTRUCTION AIVD'PLANNING �,i � � �r:.� POOL & SPA,' �
�._.
� " � , Datet Inspector,; � - . Date Inspector
��PROVALS � Permit:# " , i APPRaVP4S Permit# ,
b 1 f '�'i . � .Y► .
1.`:Temporary Electrical;Serviceor Pole t j� -� 52. Pool�Equi rnent Location '
� r_
2' �Soil Pipe-Undrgrnd. ; " •��p 53. Steel'Rei yforc2ment � � ����"�
3. Electrical Conduit Utility�Undrgrnd. . 1 54. Forms� �C' �' i ' �.1�"�
4. Electrical Conduit-Undrgrnd. . 55. Electrical Bonding '�' i �
5. Steel Reinforcement �. �` � � 56. Rough Plumbing & Pressure Test . � ���"
6. Electrical UFER Grnd. � � 57. APPROVAL TO COVER-GUNITE ' ,..� x`'�
- `,'i
7. Footings '� ' 58. Electrical Conduit=Undrgrnd.
8. Foupdation . 59. Gas Pipe, O Undrgrnd., Test �. •`
, �..
9. Wat2r:Pipe-Undrgrnd:-:' } � ' �`60. �Backwash Lines, P.Trap, 0 Undrgrnd. ' ' � •
. �_.� -
. 10. Structural Floor System 61. APPROVAL TO DECK
11. Property Sewer Line & House Connectionl 62. Backwash & Receptor-Final
72. Sewer Cap � 63. Heater & VenbFinal �
,_, f �
13. Roof Drains' 1 , � 64. Plumbing System - Final .
14. Rough Plumbing� / ��� , 65. Electrical-Final ' �
15. Rough Electriral�Cond\it� ' 66. Solar System-Final ,�
16. Rough Electric Wirir{g-��z� � � _ -�� 67f�Fencing & Access Approval � �
17. RoughWiringSign � ��=� -- �`��-68. APPROVEDFORPLASTERING
18. Rough Electrical-T Bar Ceiling � 69. POOL/SPA SYSTEMS FINAL
� 19. Rough Heating & Air Conditioning ' FIRE DEPT. REQUIREMENT
I �r �
20. Rough Factory Fireplace ' APPROVALS Permit # _
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping OGas ❑Oil
23. Gas Pipe-Rough & Test 72. Underground Flush
24. Roof Framing � 73. Undergrnd.StorageTank OGas ❑Oil .
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structurap & Monocoat 75. Dry Chemical
27. Frameand Flashing 76. DrYStandpipe +� �
28. Lathing & Siding . 77. FIXED SYSTEM FINAL :%
29. Insulation 78. FIRE PREV. FINAL �
30. Drywall Nailing HEALTH DEPT. REQUIREMENT �,.
31. Plaster Brown Coat . FINAL INSPECTION � �
32. Electrical Power Meter-Final � .�'�/� . FOOD CERTIFICATE ISSUED� :`,
33. Final Electric �3 N s: � / � C �� - �� � �3���' F .
34. Final Heating & Air Conditioning . ' � �'' �
35. Final Gas Pipe-Test � �� -
36. Hood or Canopy ����"` ��
� ,.-=Y' ,
37. Final Factory Fireplace � � ''��n .r �--+
38. Final Plumbing C Sy �� �l,' �, �
�39r Water Service-Final � "` � �„', ��- - ✓
� � 'i
40. Gas Service-Final % � � � " L
.• /`fi _ l` \,�
41. Solar pomesticFinal � � � � `-f ..�
0.42. Backflow Preventer „� � � � � � � , ; _ ,
Y43� Backflow Irrigation }'�• ��!� f y , •
^44� Landscape Irrigation SYstem � . � � " , L
iJ---� �
LL45. Sound Attenuation ' � �-'.
v �' F-
46. Handicap Regulations - � � ^ '�i ✓" ,
/''}/.l „
47�FINALSTRUCTURE&BUILDING � �-'� 1� �-�' !~• �-r ��'.� '
.-� � ✓t
� 48. Special Requirements Completed L, S �� '
'r.
49. Electric Release to Edison -' %�
�n �
50. Gas Release to Southern California Gas Co �� �,.� �,
51. CERTIFICATE OF OCCUPANCY � � •
No. - Date � �
r
�
• -� - � �
i
f
�
I�
. � Apppcant to fill in all s a�e� exce t those within �eavY DorGer Ilnas ana s4 n a11 a 0655 �'�' /�'2/87 � Bo�l1 f
V 0 9 DO�oDriate Eeclaralions.
CITY OF COSTA MESA CO'N} ST�R)UCTc�IO.N PERMIT PERMIT NO. TRACT NO. LOT NO. UNIT NO. ' . �
r Project Address 34'� �1=YeL/ C gt ,. 3 r v� r: � � � �
AppliCant'S Maili ddress '�• �� � ' TYPE OF CONSTRUCTI�N • NEW ADD ALTERATION REPAIR
�y39 ❑ CONVERS�ON ❑ DEMOLISH .� OTHER AP �y Zo�e
Owner's Name p�� � �—Phone � � DESCRIP710N OF WORK/USE OF BLDG:
Adtlress �{� Lw t� � T� u ' ' S Main Building: Accessory Building:
E Z
�:rCh/Eng. Litense No. TVPE OF PERMIT GRADING FOUNDATIOrv S7RUCTURAL T Front � 0
Addre55 �n� � ❑ TENANT EIECTR C ❑ PLUMBING ❑ MECHANICAL B qear N
Contracror'sNam ��ti�� �• //�ti� Phone_ip.%?_Z�iG'I � oTNER ��y1,p�A� % . I
PROJECT DESCRIPTiON SQ. P7, oCCVPANCY C Right N
Addreu (ma ����� �J.� ' Gw
Y�/L�r CONSTRUCTIONTVGE VALUATIONS.,%iO� -�� S Left G
Cit License No. J R
Y 20NE GRADING GV. VDS. ACRES Ping. Ref. # Parking Req./Provid2d E
LICENSED CONTRNCTOR DECLARATION ' Q
I hereby aftirm that I am licnnsetl untler provisions ot Charter 9(commancing Remarks: � Planning NOtes: M
wlth sectlon 7000) of Oiviston 3 of t�e Huzinesz antl Professtons Cotle, antl
my Iic¢nse is in ful orc antl eflecL ' C,r'_�, / T
LiSense Class _ l�icensa No. J� S
Da[e d��rl-f ' S9 [ a.w� C' %Yt�� PLUM8ING � FEES '
W4RKER5' COMPENSATION DECLARATION BarSink ShOwe�s
,'y,�erebv altirm Ihat 1 have a certificace o/ consent to selFinsure or a certi/icate ELECTRICAL FEES
LT'' Workers' Compensation Insurance, or a certi tl copY thereot (Settion gackTlow Prevenier $ervice Sink
;`"=oo, Lab/. �) l' �f �{ r � �^ Auromatic Washer Transformer ❑ 15�50 KW
i"'�olic Nd. �dN�% �lN1d7 Com any '�- Backflowlrri ation • � ❑ 50+KW
n Y P 9 Sewer Cap Construction Pole S�b.
rd Certitietl cOpy is hereEy tumiSheC.
�� Cer ietl copy 1 � with the <ity euiltli ivisio . Bathtubs Sewer Connection Cookirg Unit Meter �up to 700 amps
Oa� ApPliwn •
EXEM TION FROM WORKERS' COMPENSATION DECLARATION Clarifi¢�5 Solar Cqll¢CtOrs Di5hwa5her Meter �over 100amp5
(Thiz section ne¢tl not be comple[etl if the Permit is for one huntlreG (SI00) or
iess). Dishwasher Solar Pip' Dryers �Gas ❑Electric Sub Panel
I certlty that in the oertormance ot the work tor which this oermk is issuetl I '
sha�l not employ any person in any manner so as to become subject to t�e Drinkin9 Fountains Sola ank Fan Mofors �0.1 HP �7'h � 8
WOrkers' Compensat(On taw5 of Cali(ornia.
Date ' Slgnature Floor Drains imming Pool w/Spa F.A.U. Inc.Solar 09-15 HP �1615*
��OTI[E: It, after making this tlectaratlon, you snoulC become subject to the
W4rkers' Com00n5allon provisions oi the LabOr COtle, you must (orthwlth PI00� Sinks U�indl Fi%fU�85 MiCrow2v¢ �
cory�plY with SIICb prOWsions or Ihls pe�mit shall bG tleCmetl rOVOketl.
CONSTRUCTION LENDING AGENCV GaSServiC2 OUtlEIs Wat¢fClOsel DeviceBOzeS
I hereby aflirm tM1at lhere Is a construction lentling agancy for t�e performance Pole Light
of tho wark for whicn thiz perTil is issuetl (Sectian 3097 Civ. C.) -
In[ercep[ors Water Heaeer putle[s Ran e
LenOer's Name 9 ' -
1 entler's Aaaress Kitchen Sink Wa�er Servite
OWNER BUILDEN �ECLARATION Swi[ches Siyn
I hereby attirm that•I am exempt from tbe Conlractor'S LicenSa Law br the LavatOries AulO-Wesh � :
lollowln9 reazon (Se<tion 7031.5 Business anG Profassional Coda: Any ci[y or GarbagC Disposal Standing Sections
�ounry which reqWres a permlt to construct, alter, improve, tlemolish or ro0air P—Trap �gundry Trays Generator �0-5 KW �5-15 KW Trash Com ttor
apy structure, prlor to its Issuance, also roquires the aOPlican[ for zuch pormit Pa
to tiia a si9netl statement ihat ho/sne is Iicensetl pursuant to tho provisions oi Roo( Drains
t4e Contractor's U�ense Law (Chapter 9(<ommencing with SncHon 7000) of
;D�e ¢tlrom anG�tho ba515 fO�dthO alrlegetl'exemp�i�On. Aoy viOlation Of $BCtIOn
�`=*rt31 5 by any appllGant fOr a permft Subj<Cts l�¢ a0Plicant to d tivfl
- �a#`halty of not more tban iWe huntlretl tlollars (E500).
�,�1 I, �s own0� of lhe prOPe�ly o� my Omploy¢Os with wdgas as thnl� Sol¢ Reinspection Fee '$15 ISSUe Fee $ 3
compensalion, will tlo che work, antl the structura Is not Intentletl or ottarotl Reinspaction Fee $15 luue Fee ' $ 3
lor salo (Section 7044, Businass antl Protessional Cotle: The Contractor's ' ' MECHANICAL FEES
Liconse Law does not appty to an owner of a proparty w1�o builtls or improvos
�Oeseon, antl who tloes sucb wo�k hlmseli/hersell Or tb�ou9h hls o� h¢� Own YPQ � � DEVELOVMENT SERVICES RE�UIREMENTS:
einployCes, provitletl that sucM1 improvements are nOt Int¢ntletl or offe�etl tOr BOiI¢� HOOd O� T
sdle. If, however, the bulltling or improvement is soltl wltM1in ono vea� of <om- C2nOpy TypB I I ❑ ZoninB %�PProved By nate
pletlon, the owner will have tho burtlon ol proving hc/sne tlitl mt builtl or Im- Duct - Under Grountl � guildinB APP�ovOd By � Date�q��(�_
prt^�ove t0� the pur005t ot Sala). {� �..— .� .. �
�.l I, as owner ol tne property, am ezcluslvely contrat[ing with II<ensetl con- Duct - Structural Refrigeration System Application laued By Datfl
«aCtoR to coq5truct [he project (Section ]044, BUsin¢55 antl PrOtession5 CoOe:
7he ConVactor'z Licenze �aw daet not aoP�Y �o an owner ot o�operty who Duct - Venfilating 06700,000 BTU 0100,000 B7U SUMMAR OF FEES ' �
builtls or improves thereon, antl who contracts for Suc� prolacls with a Com
«aclo.(sl iitense pursuant to the Contracror's Licensa Law�. I am awarn that Exhaust System ❑ MW[iple ❑ System Repair/Aiteration BUI�DING PERMIT �$ SMIP $ • SZ7
Proof o( [heir Wo�ker'S CompensaHon InSurance shoultl b0 provitletl t0 me. _ PLAN CHECK � $ PERMIT
❑ I am axempt untler Section B. 6 P. C. for Ihis reason Firepl/FacL Blt. ICBO �k Fire Dampers PLUMBING $ ISSUANCE $
Date owner Heating System & Ducting Regisrers PLAN CHECK 25% $ ENEpGV P.C. $.
i hereby certity th nave reaG t�is appiication ana state that the above ❑0.100,OOOBTU 0100,OOOBT ELECTRICAL � $ GRADING S
Information is corr t. a9ree to como�Y �+��h all Uly antl county ortlinances �
anG slate laws ral in9 to builEinq construcHon, antl hereby authorize r¢pre- PLAN CHECK 50% $ MICROFILM $
Santdtives ot thi tl [o e0t¢r v pn th0 abOv¢-TentioneG Proper[y f0r
�nspectio�rpo �rZ�L a MECHANICA� $ TOTALFEE $ �OD
Stqnatur — Oat p¢inspection Fee '$15 laue Fee $ 3 PLAN CHECK 25% $
❑rivers' License or 55 ��
CMF OB65-46, rev. 10/84 Whi[e - Builtling: Canary - AOPIIcanQ Pink - Accounting: Goltlenrotl - Asse55or
CONSTRUCTION AND PLANNING - POOL & SPA
APPROVALS ,. Permit# �Date Inspector AppROVALS Permit# Date Inspector
1. TemPorery 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
5. Steel Reinforcement 56. Rough P�umbing & Pressure Test
• 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings �-- 58. Electricat Conduit-Undrgmd.
8. FoUnda[ion • 59. Gas Pipe, 0 Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, O 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 64. Plumbing System - Final
14. Rough Plumbing 65. Elecxrical-Finai
15. Rough Electrical-Conduit 66. Solar System-Final
16. RoUgh Electric Wiring � 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVEO FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
79. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace � APPROVALS Permit # _
27. Ducts, in Structure 70. Underground Hydro '
22. Ducts, Ventilating 71. Product Piping OGas ❑Oil
23. Gas Pipe-Rough & Test . 72. Underground Flush �
24. Roof Framing 73. Undergrnd. Storage Tank �IGas OOiI
25. Roof Sheathing 74. Overhead Hydro � Fi
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical F�� � ��
27. Frame and Flashing 76. Dry Standpipe �'� '�
i ".
28. Lathing & Siding .� 77. FIXED SYSTEM FINAL `:j _. �
29. Insulation ' 78. FIRE PREV. FINAL ;�•�
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
�:.
37. Plaster Brown Coat 79. FINAL INSPECTION •
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED .
33. Fina� Electric Notes:
34. Final Heating & Air Conditioning !
35. Final Gas Pipe-Test j l
36 �Hood or Canopy � , "
37. Final Factory Fireplace � � . - :, "
� r
38. Final Plumbing ,.` �- T- '", i
39. Water Service�Final . _ /%';. � .
'.
- 40. Gas $ervice-Final � ' ' �
� �
� 41. Solar pomestic-Final � . - �
�, -
42. Backflow Preventer r ; •/ ' . + ' �
.'
� 43. Backflow Irrigation ' � " � �
. 44. Landscape Irriqation System . � � ., , � � ' , � .
45. Sound Attenuation � � �� .% ' •
i
46. Handicap Regulations � . • � ' •
,',
47. FINALSTRUCTURE & BUILDING ` ' ��� -i ,� '� -' �
,� .
48: Specia� Requirements Completed '"� ' �,
49. Electric Release to Edison � �
Yi
5o. Gas Release to Souther� California Gas Co ,
51. CER7IFICATE OF OCCUPANCY --
No Date _
r
1 _
� �.
CITY OF COSTA MESA
� CON5TRU6TION PERMIT
��v���ant to flll In ali spaces oxceot lhose within neavy
e PEqMIT NO. , TRACT NO:
Project Address �1 � � �� ���-� � �
Applicent's Mailing Addr Ss , � � ,
Owner'sNama ��• ��'�� Phone-
Addreu
Arch/Eng. Licenu No. --
Address
Contractor'sNam �� i�' hone
Addresslma'I'ngl.i��%g N �Z '�� �/�, �'/��03
d� �
City License No.
LICENSED CONTRACTOR DECLARATION
I hereby a/firm tha[ I am Ilcensetl untler prov�slont of Charter 9(commencing
-'th saction 7000) ot Dlvision 3 of the Business antl Professlons Cotle, antl
Iicenza Is in full fo e ana ef ct.
:ense�ciass �'� Lice e Z 2�' q 7�
oaceTc y �i c '�—
WORKERS' COMPENSATION DECLA ATIOJ
I h¢reby afflrm tnat 1 hav¢ a certifiwte ot conp�nt [0 5aH-InSuru or a certlficate
of WorkerY Compensation Inmrance, or a cerUfletl coDY �hereof ( ectlon �
3800, Lab. C.) .
Policy No. Company
eCertlfietl <opy is hereby furnishetl. •
�Da[�e I(i iletl with the city B i' tli
Applic
E%EMPTION FROM WORKERS' CO P NSAT1 N DECLARATION
(ThiS sa<tlOn neetl not b¢ completetl i( th permN is for Onn huntlreE (E100) or
less) l
I certHy that In tha performante of th¢ rk }or which thl erm�[ IS ISSuOtl I
shall not emplOy any p¢Ron ar 5 d bP e subject to t�e
Workerp, COTPerls� �pn �Si9n r ur lifo a.�
Date w �b �� '�t
NOTICE: If,�afler making t�is tle arati , you oultl becoma sub7ecl to t�a
Workers' Compensation provi5ion f ne W r Cotla, you.must forthwlth
comply with suth O�ovislons or perr� t shall bn aeemetl revoke0.
CONSTRUCTION LENDING AGENCY
I hereby aHirm lhat Mare Is a conSVuction lentling agency�for the performance
ot tne work far which this permit is.issuetl (Section 3097 Civ. CJ
LenCer's Nama' -- --
l,:ontlor's Atltlress
OWNER BUILDER DECLARATION -
� hereby affirm t�at 1 am azompt from [be Contractor's Licensa l.aw for lno
nllowing reason'(Section 7031.5 Buzinass antl Prolesslonal CoOe: Any Aty or
.ounty whi<h roqulras a permll to construct, alteq improve, tlemolish or ropalr
env structu�e. o�lot to Il5 ISSudntl. alm �eOuires lhe aoolitant lor such oo�mlt
antl tha ba5i5 for tne :
any applicant for a
not mora lhan tive hun
LJ I, as ownor ol tho.propor[y "or my amployees wi[h wagos as tnolr sole
componwHon wlll Uo tha work, antl the ztr4cturo is not Intentled or oNeretl
for sale (Sec4lon 7044, BuSiness antl Profeuional Cotlo:' T�o Conlractor's
Llc¢nse Law tloes not apPly to an owner of a property who bulltls or improves
thereon, antl,who tloos,sucn work himzelf/h¢rietl or through his or hnr own
emD�oy ees, provitletl t�at such Improvements are,not intentletl or oflareC tor
SLIa. I/, howBvO/, Ihe Oulltling or Improvome�� Is soltl wil�ln one yea� of com-
platlon, lne owner will have lhe DUrEen ot proving he/iha tlitl nol builtl Or IT-
�rove fort�e purposa o}Sal¢�. �
I, as owner of Iha property, am eztlusiveiy �ontracting witn Iicanietl con-
tractorstd construct tha Orojacl (Sectlon 704{, BuSinasS antl Profeisions CoOe:
�The Contractor's lJcensa Law does nOt app�y to an owne� o! p�operty who
builOs or Improves thereon, antl who Contra�ts for SUG� pro�e<ts with a con•
Vactor(s) Iicensa pursuant [o tne Contractor's L�censa lawl.
❑ I am axemD� undar Sectlon—_ 8. 6 P. C. tor this reason
Date Owner' '
1 hereby cartify that I have reatl thls appll�t�on antl ztata that the abova
informatlon it corract. 1 agree [o comO�Y '���h a�l city ana county ortlinances
antl�state laws ralatin9 �o builtling constru<t�on, antl hereby authorize raDre-
zentatives ol' s clty' t en � upon the above-mantloneO proparty for
InSDectlor� u�sr�� � �� . 7._Q— 5(L
an0 si9� all appro0riale tleelarations.
TYPE OFCONSTRUCTION L1NEW U ADD U ALTERATION IJ REPAIR
❑ CONVERSION ❑ DEMO H❑ OTHER p,p, �6
DESCRIPTION OF WORK � ^ � /� �` �
' �C S Main Building:
E
TVPE OF PERMIT GRADING FOUNDATION STRUCTURAL T Front
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MEC NICAL � 8 Reaf
❑ �OTHER -�On —[ A
� C Right
PROJECT DESCRIPTION 5�. FT. � oCCVPA Cv—
CONSTRUCTIONTYPE V LUATIONS �3d S Left
20NE GRADING CU. VOS. � ACRES ping. Ref. #
avmarks: !/�rf � � Parking Req./Provii
Use ot euilding:
3ar Sink
3ackflow Preventer
3ackflow IrrigatiOn �
3athtubs
Clarifiers
Dishwasher
Drinking FOuntains
Floor Dreins �
Floor Sinks
Gas Service Outlets
Interceptors "
Kitchen Sink
Lavatories �
P—Trap
Roof Drains
Reinspection Fee $25
Bailer' �
Duct - Under Ground
Duct - Stru[mral
0
ExhaustSystem ❑ Multiple
Fiiepl/FacL BIL ICBO 41E
Heating System & Ducting
❑ 6100,000 BTU �� 100,000
0
Dyl �e V' LI a o 9� � � �7 I I Reinspection Fee �, I $25
MF 0865-46 rev. 12/83 White - Bulltlin9: Wnary - APpllcant; Pink - At<ounting; Goltlenroa - Assessor
Showers
Service Sink
Sewer Cap
Sewer Cannection
Solar Collectors
Solar Piping
Solar Tank
Swimming Pool wlSpa
Urinal
Wacer Closet
Wa2er Heacer
Water Service �
Issue Fea
Hoodor Typel ❑
Canopy Typell ❑
FEES
$ 3
Notes: �
�
Automatic Washer
Construction Pole Sub.
Cookin9 Unit
Dishwasher
Oryers ❑Gas ❑EIeC
Fan
F.A.U.
Fixtures
Device Bozes
Outlets
Garbage
5621 �3/OB/84
Zone
Accessory
Park.Fees $
�ELECTRICAL �
Transformer ❑ 15-50�KV
❑ 50+KW
S
Meter Dup to 100 emps
Meter �over100amps,;,
Sub Panel
Motors �0.7 HP 01 h- E
Int.Solar �9-15 HP �lE
� MiCrOwave
Pole Light ��;
35.50 TI
FEES
"� �' '
aign �_. -
� Standing Sections � , ,�'�
5-15 KW Trash Compactor ,'
� Reinspaction Fee � $y5 �ssue Fee
FEES
PUBLIC SERVICES REOUIREMENTS:
• ZoninB APProved BY •
Buildin9'APProved BY t . �
Refrigeration System ,
❑0-t00,0008TU ❑100,OOO,BTU
System Repair/Alteration '
�� Issue Fee �• $ 3
(/p � MARV O F
BUILDtNG PERMI�S�
PLAN CHECK � $
PLUMBING, ' $ �
PLAN CHECK 25% ,$ 1
ELECTRICAL � $ �
PLAN CHECK 50% $ �
MECHANICAL $
PLAN CHECK 25% �$
O
N
1
N
G
R
U
1
R
E
N
E
N
T
4�
� J� � .
)Ste �• - -
r' .�
ES �
SMIP ' . g •' �r -?S�
. r�
PERMIT '
ISSUANCE �; 5 � ;
ENERGV P.C: "$� , "'
GRADING ; $ � " � �
MICROFILM ,$"��� ' �-�j55---
TOTALFEE $�
.. _ . _? /-�= C'
/ _'_'
��'CONSTRUCTION AND PLANN, . OOL & SPA � � �
� Date � Inspector - - Date Inspector ,
APPROVALS Permit # APPROVAIS Permit #� r =
1, Temporary Electrical Service or Pole � 52. Pool & Equipment Location . -
�• 2� Soil Pipe-Undrgrnd. � 53. Steel Reinforcement - .. '
� 3. Electrical Conduit Utility-Undrgrnd. � 54. Forms ' ; � .
4. Electrical Conduit-Undrgmd. � 55. Etectrical Bonding -' . -
5. Steel Reinforcement 56, Rough Plumbing'& Pressure Test " � ,
6: Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings � ' 56. Electrical Conduit-Undrgrnd.. - �
8. Foundation 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgrnd. ' 60. Backwash Lines, P-Trap, � Undrgrnd. '
10. Structural Floor System � 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection � � � 62. Backwash & Receptor-Final .
12. Sewer Cap -63. Heater & Vent-Final � �
13. Roof Drains 64. Plumbing System - Final -
` 14. Rough Plumbing 65. Electrical-Final �� � •
��, 15. Rough Electrical-Conduit 66. Solar System-Final " - � -
i 6. Rough Electric Wiring 67. Fencing & Access Approval - .
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING -
18. Rough Electripl-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL ,
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT ' � '
20.'RoughFactoryFireplace APPROVALS Permit#
21. Ducts, in Structure 70. Underground HYdro � � �
22. Ducts, Ventilating 71. Product Piping � Gas ❑ Oil � ' ,
.� 23r?Gas Pipe-Rough & Test ` 72. Underground Flush '
2,�. Roof Framing . 73. Undergrnd. Storage Tank 0 Gas ❑ Oil �
5� Roof Sheathing 74, Overhead Hydro -
. 26. T-Bar Ceiling (Structurap & Monocoat 75. Dry Chemical ;
; 27. Frame and Flashing 76. Dry Standpipe �
28. Wthing &$iding 77. FIXED SYSTEM FINAL
.29, Insulation � 78. FIRE PREV. 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 ' � � � � � -
37. Final Factory Fireplace ' � � , . ' �
38. Final Plumbing �. . . � � • � " -
39. Water Service-Final - , � . �, - -
40. Gas Service-Final . . - '
41. Solar pomestic-Final ' - .
42. Backflow Preventer . . � �
43. Backflow�lrrigation . � , , � . , �
44. .Landscape Irrigation System - - � ,. , ,�
45. Sound Attenuation " - � � . ' �
46. Handicap�Regulations � , . � � .
47. FINAL STRUCTURE & BUILDING 'K' _ S BU%L / W
48. Special Requirements Completed �
�
49. Electrie Release to Edison . 0_' � �
50. Gas Release ro Southem California Gas Co W i � J� �%C
51. CERTIFICATEOF OCCUPANCY • �, , � ��_Q%c�.
No. Date _ , � � .. -