HomeMy WebLinkAbout720 19TH ST - Building Permits1
(714) 754-5273 • Fau (714) 754-4856 • vnvw.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
.lob nddress: 720 W 19TH ST
Suite:
Viciniry: SOMEONE CARES SOUP KITCHEN
Parcel Number: 42226125 Zoning:
Applicane WHITNEY, ROBERT _- -- "�- - -"— ISSUED BY:
Address: P015396 ,���i%����J-J-�.��-�� �� �
Status: ISSUED
Applied: 03/28/2001
Issued: 03/28/2001
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����/ �� Phone:l (949) 548-0769 � ? ��-
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NEVJPORT.BEACH , CA'j'�� � �, Zip: 92659 � � � � �.
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Address K�TCHEN INC � � ��/-�-,c��-��'_=����A � �1 �
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SETBACKS
MAIN STRUCT
ACCESSORY
PARKING
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�,�REROOF WITFi B.U:R�CAP FOR
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NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Calitornia 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 780 days, or it 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
requlred inspectlona and final approvel must be obtained. Failure to obtain Inspections and final approval will result in the expiration.of this permit.
FOR INSPECTIONS CALL: (7/4) 754-5626
2468d8 (B�OD)
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WORKERS' COMPENSATION DECLARATON: ' '
I hereby amrm untler pena�ry oi perjury one of ihe tollowing tledarations: '
❑ I have end will mainlain e certificate o1 consent to selbinsure for workers' compensetlon, es pmvided for by section 3700 ot the Lebor Cotle, for the peAormance ot the
work for whiCh this permit is issued.
I have antl wlll mainta�n workers' compensetlon insuranne, as required by section 3700 of the Lebor Code, lor ihe pedortnance ot ihe work for which this pertnit is Issued.
My workers' compensation Insurenc ar r end polic number ere:
Carrier. � PoliCy Number: � � �% o � �
(Th/s secf/on need not be mplefed i! the parmit s velued a one hundred dollers ($f 00) or less.) , .
❑ I certily thet in Iha pe�ortnence o w tory�hicl his perm�t is issueA, I shell not emplay eny person in any menner sa as to bacome ubj ct to t�e workers'
compensetion laws of Celifomia, en r t 4t It should became sub�ect to the workers' compensatlon provisions ol5ection 3700 of e bar Code, I shall torthwith
comply with t�ese pfovisions.
Applicant Signeture: Dete: �
WARNINCi: FAILURE TO SECURE WORKE ' COMPENSRiION ERAGE IS UNLAWFUL M1D SHRLL Sl19JECT Ml EMPLOYEP TO CRIAUNAL PENALTI AN GVIL FINES UP TOONE HUNDREU
THWSAND DOLLAFE (51 W,000). IN ADDIT TO THE PENSATION, DAMA6ES AS PROVIDED FOR IN SECTION 310fi OF THE UBOR COD , IM PEST, ANO ATTORNEY'S FEES.
LICENSEDCONTRACTORSDECLARA ON: �f
I hereby eNirm Iha� I flm IlCensed un �visi s Sp 6r 9(commencing with Section 7000) ot Division 3 of ihe Business and Profe sio Co , antl my license is In full
force and ettect. Lic. # Cless #
Con[rectors SlgneWre: Date:
CONSTRUC710N LENDING AGENCY: �
❑ I hereby eHirtn that ihere is e construction lending agenc.y tor the peAormance at Ihe work for w�ich Ihis pertnit is issuetl. (Sec 3097, Civil Code).
Lenders Neme: Lendels Address:
Signature: Date:
OWNER-BUILDER DECLN7ATONS:
I hereby attirtn Ihal under penalry of perJury that I em EXEMPT FROM THE CONTRACTORS LICENSE LAW tor t�e lollowing reeson (Sec. 7031.5. Business antl Protessions
Code: Any city or county Which requires a permil to consWct, alter, imprwe, demolish, or repair any sirucNre, pdor to Its issuance, also requires the eppliwnt for such pertnit
ro file e sipnetl statement [�at he or s�e Is Iicensed Dursuent to the proNsions W the Con�rectors Ucense Lew (Chapter 9(commenGng wilh Sedlon 7000) 01 DlWsion 3 of Ihe
Business antl Protessions Code) or that he or she is exempt theralrom end t�e besis tor tha ellegad exemptian. Any vialation of Section 7031.5 by eny applicaM tor a pertnit
sub�ects the epplicant to a civll penalty o1 no� more then five hundred dollers ($500).):
❑ I, as owner of ihe prOperty, or my employees with weges as their sole compensatlon, WILL DO TME WORK, anG the structure Is not Intenaed or oHered far sale (Sec.
7044, Business antl Professions Coda: The Contractors License Law does not apply to an owner of properry who builds or improves theraon, and who dces such work
hlmself or herseN or ihrough hls or her own employees, providetl thet such improvements ere not Intended or oflered for sale. If, however, the builtling or improvement Is
sold within one year of completion, the owner-builtler will heve ihe burden o� proving that he or she tlid not build or improve tor purpose ol sele.).
❑ I, es owner of the property, am E%CWSIVELY CONTRACTING WITH LICENSED CONTRACTORS to constmct the project (Sec. 1044, Business and Protessions
Code: The comracrors License Lew tloes rat apply to an owner of propeny who 6ullds or imD�oves thereon, enA who contracis lor such prolect with e contrector(s)
licanse pursuant to the Contrectors License Lews.).
❑ I em exempt under sec. Business entl Pmfessions Coda for this reason:
Signeture: Date:
Owner ID vanlled by tlnvel's license. ❑ Ves ❑ No Drivers License No. Expires:
Vedllcation of Ownership by (rype oi document, I.e. - properry tax 6ill or daed):
DIVISION OF INDUSTRIA� SAFETV PERMITCERTIFICATION:
❑ I hereby cetlify that no excave�ion five (5) or more feet in depth Into which e person Is required to tlescend, will be made in connection wi�h work authorized by this
permil, and �hal no building sWcture, scallolding, falsework, or demolition or dismanNing thereoi, will be mora chen thirty-six (36) feet high. (Chap. 32, Grp 2, Art 2, Sec.
345, Title 8, Celifomia Atlministrative Code).
❑ As owner-builder, I W�II not employ enyorre lo do work which would require e pertnit from the Division of Industrial Setery, es noted ebove, unless such person has a
permit to tlo such wo�k from Iha division.
Signature: Date:
Division of Industrial Safety Partnit Numbar:
:ARDOUS MATEHIALS AND EMISSIONS CER7IFICATION:
Will the epplicent or p�esent or future Gullding occupant need to lile entl certify a Business Plen for emergency response to release or threatened relaase oi a hezardous
meterl817 ❑ Ves ❑ No
(Sectlon 25505 of the Celitomia Healt� end Satery Gode requlres, with some exceptions, ihet e Business Plan be filetl with ihe Coste Mesa Fire Depariment by every
business which has at any ona time dunng a reportetl year e Quantity of hazar0ous materials equal to or greater than a weight o1500 pountls, or a volume of 55 gallons,
or 200 cubic feet of compressetl ges at stantlard temperatu�e antl pressura).
..........................................................................................._.............................................................................................................................................................................................. ........._............. ..........................._......................
Does or will ihe epplicant or present or future building occupant nead to file a repistration fortn tor aatety hazardous materials7 ❑ Yes ❑ No
(Sectlon 25533 ot Ihe Calitomia Health and Sefary Cotle, wlth some e:ceptions, requires registretion with t�e Costa Mesa Fira Dapariment by each business which et eny
one time hes on hend e quantiy ot acutely hazertlous metedals equal to or greeter than a weight ol 500 pounds, or e volume at 55 gallons, or 200 cubic leet of
compressetl gas at 510ndartl tempereture antl pressure).
............_._ ................._.......,...... _........................_..........................__................................_._..................................................._............................................_._........._......_........................._........................_........................
Does or wlll t�e aOPlicant or presenl or tuture bulitling occupant need to prepara an RMPP (Risk Management end Prevention Program tor ecutely hazartlous materials)i
❑ Yes ❑ No
(Section 25534 of the California Health end Safery Code provides thet the Costa Mesa Fire Department may require the preparetion, certification and filing with the Fire
Depariment ol en RMPP by businesses whlch ere required b reglster acutely hezardous matenels wl�h Ihe Flre Department.
N an RMPP is presaMly required, has Section 25534 ot ihe Celitomis HeaNh end Satary Cotle been fully complietl wfth? ❑ Ves ❑�No � ���������������
......_ .................__..............._,–_.................................._..............................._�..........................._.................—................................._".................................................................................................._.._......................._...
Does or wlll the epplicam or present or fumre building occupant require tor ihe work whic� is �he subject of Ihis a plication a permi� tor such construction or motliticetion
fmm the South Coasi N� �ueliry MenagemeN Dlsind or trom any ather alr pollution contml tlistdct or agencyt � Yes LJ No
(Section 65850.2 0l the Calitomia GovemmeN Cotle requires ihet the requested inlortnation �e lumished an applications for nomresidentiel building permits).
.................................._............,.............._................................................................................._.........................._._...................._..................................__............................. ....................... ............_.......................................__.......
Will eny pan of the faciliry to be constructed under ihis pertnit be within 1000 feet trom the outer boundades of e school? ❑ Yes ❑ No
Qf "yes", the faciliry mUst meet ihe requlrement of Sections 25534 entl 42303 of the Califomia Health end Safery Cod
......._ ....................._.......................—.................................__.._..."'__—.._......................_..__......................_.....................__................................
7 If e pertnit fmm ihe South Coast Air Oualiry Menagement District or olher eir pollution coNrol distria or egency
epplicatlon, heve all oi tha disclosures Drescribed 6y Califomia Healih end SefeiY Code Section 42303 been mede7
8 pf "yes", ettech certiticate of compliance
CERTIFICATE OF COMPLIANCE: I cer
regarding Hazartlous Materials end Emi:
Signature:
CERTIFlCATE OF COMPLI � E AN IJT}1
correct. I egree to comply ith ell s te laws
ebove-described orooe fo� inso tion oumi
CODE I. INSPECTION TYPE `
1616 Fixed System Final Fira Preventlon
1266 Pool Spe Final
200 Final Re-Roof
201 Finel Block/Fletaining Well
202 Final Factory Fire Place
203 Finel Sign
204 Final Demolition
ol this
31 un' er pena�ry ol perjury the information given ebove is corract. I agree Io comply wilh all state laws and ciry ordinances
Date:
OI10F ENTAV: I certify under penalry of perjury ihat I have read ihis application end state that ihe infortnation gNen is
;ity ordinances relating to buil0ing construction, en0 euthorize representatives f the City ol Costa Mesa to enter uDon the
I agree noi m acupy or ellow occupanty of any building authonzed 6y Ihis �t umil finel inspection.
��'
1[IIIDSLS CODEt
206
208
�IGL�y V 210
212
220
222
250
INSFECTIONTYPE �
Finel Mechaniwl
Finel Plumbing
Finel Elecincal
Final Flre Preventlon
Finel Planning Approval
Final Site
Finel Building/Oaupanty
��� aess a ea�nu/a 7 � 0 W 1 9 TH S T
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� MERLE HATLEBERG
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�•'� SAN CLEMENTE CA 9'L672
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LENDEP'S NAYE
LENOER'S ADDNE49:
I eenEY IM I hero raeE Nu eppfration md ume Ihe� tlw ebwa'vdamdion 6 wnW. I N� to oomPN with ell caY aM mm1Y advwios�
W Me Iexw reWip b butldip mutrWion and heraby euhpce �epwaNd'rau cithu tiry ro eMx upan IM ebo.a�mW iwad pvpary
la impetlion qrpma�.
MERLE HATTEHERG
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(5t5ttie.WP) W�py.gi��iqBStlaly:�iw�-Fb:Cwry-App6ranl:Fnk-Rmenus:OdEenmtl-A�seua
PERMIT NO: P
CITY OF COSTA MESA — BUILDING PERMIT
083538 PLAN CHECK N0: N
CONSTRUCTION TYPE: PERMZT TYPE: PLU
JOH DESCRIPTION : GAS TEST FOR COOKZNG STOVE
CLAIM VALUE;
CALC—VALUE:
PERM NO; P Ot33538
GOVT; N SUPP: N
PURPOSE: NEW
SQ FT:
GROUP OCC: /
COMMENTS: FOR STOVE GAS TEST ONLY.
it�r�r*�*�r�ririt�e*�r�e�rititirx�r*x*�ex��r�r�r�ritir�r?��e�r�ritif�rit�r��r�at*it+tatit�fit�*�r����eit�,rxzxit��rititat#*it���e*
2 O N I N G R E Q U I R E M E N T S
S E T B A C K S
------------ MAIN BUILDING ---------- --------- ACCESSORY BUZLPING ---------
FRNT: FT IN REAR: FT IN FRNT; FT IN REAR; FT IN
LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
PARKZNG REQ• PROV; PARCEL; 00000000 ZNE; REF NO:
PLANNING NtSTES>
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if �)E iF ih 1f iE �k if �k it ik if it if 1f ?E!k if i! if if if if if if k 1E if ff �F j! if if if it iE �f if iE if ik -0F if it if ih #� �F'�f if iE fE ik if ff if if if it i! �f 1t i! ik fk if iF 1E iF iF fE ik if ik if iE if iE iE
D E V E L O P M.E N T S E R V I C E S R E Q U I R E M E N T'S
ZONING APPROVED BY . __ DATE:
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APPLICATION IS
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LEGALIZATZON;N
&LDG PMT
PERMIT
F E E S U M M A R Y
PLUMbING ELECTAIC�•�MECHANIC
5.50 �
DATE: (�
DATE: CJ
********* � ��
STRUCTURAL ..EGMEN.:N
FIRE SMZP/RES GRADING
25t p, � " SMIP/NON-RES
PLAN ; ,� ; �',
ISSUE FEE 22.00
BUILDING-DIV-> PERMZT ISSUE PLANdCHECK TOTAL PAZD DUE
TOTALS-.---> 5.50 22.00 0.00 27.50 27.50 .00
REVENUE DIVISION TOTALS--> COLLECTED: 27.50 OVER/SAORT: .00
BLDG PMT PLUMBING ELECTRIC MECT-i�NI�C FIRE SMIP/TOT GRADING PLAN-CHECK
2%.5� r� � ,
1E iF iF iE if iF iE jF �l! iE 1F ik?f jk 1f ?E �f iE ik ik k 1! �f ?E It iF 1f �f if if if iE iElF iFif iElElk 1t 9f 1f 1f f! i! ik iF it it iE ik 1E if i! if� if ±f iF ik 1E fE �E iE jE 1E jE iE it if iE 3F iE jf �3! iFlF j! if 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 5 C R I P T I O'.N�/=. UNZT COST 'PO'fAL COST
PLU 1 GAS PIPING SYS OFi� �1'�O 9 OUTLETS 5.50 5.50
END',O •.FEES
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86-27-1997/B1t49 DN/12].SB
RCDTIaBI-88BS111
PERlI I T a e83S3A
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COIeSTRUCTION AND PIANNING �� � POOL A Date Inspector
�-+�ROVALS Permit # Date Inspector �' APPROVALS Permit # ,
( ,;
�. •,emporary Electrical Service or Pole 52. Pool & Equipment Location
p. Soil Pipe-Undrgrnd. 53. Steel Reinforcement •
3. Electrical Conduit Utiliry-Undrgrnd. 54. Forms �
4. Electrital Conduit�Undrgrnd. - 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. �
[a Foundation - 59. Gas Pipe, O Undrgr�d.,'fest
9. Wacer Pipe-Undrgrnd. 60. Backwash Line:, P�Trap, O Undrgrnd.
10. Structural Roor Svscem � 61. APPROVAL TO DECK .
7 7. Propertv Sewer Line & House Connection � 62. Backwash & Receptor-Final •
12. Sewer Cap � 63. Heater & Vent-Final
13� Roof Drains 64. Plumbing System - Final
14. Rough Piumbing ' 65. Electrical-Final � .
15. Rough Electrical-Conduit - 66. Solar SYstem-Final
16. Rough Elenric Wiring � . 67. Fencing & Access ApProval . �
17. Rough Wiring Sign 68. APPROVEO FOR PLASTERING
t$. Rough Electrical-T Bar Ceiling � 69. POOUSPA SYSTEMS FINAL .
19. Rough Heating & Air CondStloning FIRE OEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit #
21. Ducts, in Struaure 70. Underground Hydro
22. Dutts, Ventilating 71. Product Piping O Gas OOi�
23. Gas Pipe•Rough & Test 72, Underground Fiush
24. Roof Framing 73. Undergrnd.StorageTank OGas ❑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 SYSTE�9 FINAL
29, insulation 78. FIRE PREV. FINAL
3p, Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coai 79. FINAL INSPECTION
32. Electrical Power Meter�Finzl 80. FOOD CEflTIFICATE ISSUED
33. final Electric Notes: ��4��� 5
34. Final Heaiing & Air Conditioning ` �G� �
2Z �r7 �n-�
35. Final Gas Pipe�Test r�
36. Hood or Canopy ; • � `! � / �G�
37. Final Factory Fireplace
38. Final Plumbing I��/,� �
/ l. +!
39. Water Service�Final
4p. Gas Service-Finai
41. Solar pomestic•Final
42. Backflow Preventer
43. Backflow Irrigation ,
44. Landscape Irriqatipn System
cn r
45. Sound Attenuation . �n m
r .
46. Handicap Regulations . =• g
M
47. FINAL STRUCTIlRE & BUILDiNG ��., �-
� ;;� n
q8. FINAL PIANNING ` � �:: '
-., �n�
4g, Elearic Release to Edison ' c+
i.� y
,;.-�r�
50. Gas Release to Southern Califomia Gas Co "�-" ����
51. CERTIFICATE OF OCCUPANCY • - �
No. Date
-. . . .._. "s__._ -. Y....._�.i.,.....-.._.i_..+.M-..._�YUa4v�a<..a4.:H!'v'..,l...u:-•wu:�L.li.�^„"^"—�., w. ...1`ww�..r��r..�
,- � �itp o f �o5ta 21� e�a �
Develppmeni Services, Division of Building and Safety
CERTIFICATE OF OCCUPANCY
����-f�=�,
This certificate is issued pursuant to,the;requirements. of�tlie�Uniform Building Code, Section 308
adopted•by the City of Costa Mesa certifies thai.at�the time of iis issuance the buIlding strucrure herein
below described was ins ected an,d,,a�� ioyed�fo%o"ccv an ��as,follows:
P PP. P �Y,�__ \
Building Address _
Use
Group B
Owner of Building _
Address �Z�
720
19
BUILDING OFFICIAL-�Ori'p
"� �.z.� � . _ ... --_ _ . _ :, <
_,����is.s��_� - �� �-"���,`
�,,� _
:oristruction Fire`Z
�J >:ll!o o� r,..: `:!L:td0:2 !;3K^\
:, Hatleberg — '— =Tenar
-- ������. r„.c �t' r�'C'.-"
PRE�ET COSTA"MESA;�CA;926'26":
1� " �_ -:
,`�%�� �p _ . ,'
:�IbC3'JQc(i :','�. , s
\,a UC'�/( `� ��y� f Date''
�a. V �r� ��. _ %:��o
REQUIRED TO BE
Perntit No. IB 83706
Use Zone
3&S SOIIP SITCffid^
PLACE
MOFES40FBULp114 �I2O W I9TH ST
IXMEaBN.WEIiqAWtk MERLE HATLEBERG �
' ���g% 1048 CALL DEL CERRO #t507
SAN CLEMENTE CA 92672
(7�4) 498-8626
�vw.. Wnna.00xEst
u�cxrtccr on u+ou+�nn:
urex. on �o.'s �oo�a:
coxmACTarsx•��.
cwm�crrnre �uuxa
�oonEst
YNT:
uc. No.:
urar:
uc xo:
uKr:
LICEN9ED COMRRCfONS D�up�TION: I lweby dfim �dr pw�Y tl pwpuy NY I mn IkausE utlx prowvm d Cluqr V
��.�o .vn s.�.,�, �000� a u.e� � a m. a� w Ad«,�e we...�,d mr eos�+. v m na aR..oa .nw.
cm uc. wo.: uc. cuss: uc. xo.: EXP :
Dme: CMmCw:
OWNER BUILDER DECLAfl�TION: I IwWy tlhm �adw psWY d perjvy ihet I mn ammp hom IM CaV'etlm liama law ia iM
Idbxin0 rseaon (Sadion )031.4 &niwn eM Prdmecro Code: A^YW a ow+mY Mw3� rpuim� e M^^d �o mvNcl. Mr. impa+.
demdeh, a repei e�ry euunws, prior b b'svium, dw nC�+�M1e epM�N la wrJi pamu to Ne e aqned atelemml Ntl M a�M
'� lioeneed Wreuent to iM prwbiona M iM Coniredrce Liwroe le'w ICheqr 9(�m�'q �h &atlion'!OW) d Oiv'sbn � d IM
ue'v�sae erd Adea+ion+ Gode� a ihet Ir a pn u uemq IheMmn uM iM beve la tM elbped uamqon. My videlion M Sspion
031.5 W eny eppliunt �w a pumn eiSjefSa �M eppfreM to e cvi paneliy W na mors Ihm fwe MadnE AOAera �5500�.
❑ �.e,ox+wwinso�v«mr.rokn..•••n.repm.�u.:.a.w�psemnn..�amu»woA.enem..mKm.:munaw.e
a MereE ror eeb (Section �tw. Bui�ra� enE P�dma'veCode: The CaWedm L'cws lew Em nd ey�'toen ownar d qopnry
wb Wida a inpwm t�Neon. md Mc dor arh york t6n�eE a haaM a tivaqh Ae a Mr am mWym. V�4dad Nel wN
impo.emmn ero m� iiueiMeE a dMeA la We. tl, howawr. �M daV'vp a inpvwmatl o wid xnkn ane yaer d wmpblbn, �M
� ox+wLu�ltlar xiG heve �M dvden d Pa'n0 M a da dd m hdd a 6npvn la IM µvpna al del.
Q I.nwnerdlMpWdH.emurivW/cwumfnOtih6causdmNaclanbmM'utltlrP4�(SanunNM.&m'vw�enE
Vmlaauuu Code: The CVtlretlw+ linms lew Ame ml eCO�Y m en ox�r d WnDMY Wa h�Ad� a hiqwww Ilwcn sd xho
cavrecb br arli V�^i�e wvh e m+maM�) Iw�ad w�+� m tM CaNram� Llowa LeW.
em uemq under Senon: B. a P.C.. tla �uem:
9Ia: � — Owtrr: / �� �Ki�r
i eo n nr �enM �w i em ..a.. d ena u�drnena me �.ma�«m w ceuomi. He.m, w sem�r coe. s.ab�. zswe. m� ..nd
. aM tlw I a vry Mun y�ildiiq omwent v.ill / wil ml (dmb me) �d to canyy w�� uid ews mAm enE IM npuin nb lar
' IaconsuuctionamodRrelianhom�MAi ue�y a�epmwu0utrie.MriderqJmutMionnVG�ivnuaesemNhomUwa
oma: �od�v:
WONKER'S COYPENS�TON OECUNATION: I Mrsby efNm iuder pwWy d pajuy ar d IM Mbw'vip detle'etioro:
� I Aeve antl wll me"vVen a�anJreM d eduwX lo wtls�ma b waM1w�' mnpsetlbn. u po.iEW la by Serbm YlW al �M lebor
eoae. ia m. o«i�ee u u. .o� e« w:�n w. o� e m�.a.
❑ � nn..�e .il ma�x.n wa4.n• mmc�a, �n^o.. e� nm� w swim aloo a m. leEn caG.. m. �n. v�a�. a �ne
wak la wfiiN tlie V�b u iaW. MY waken' mnprutlion'v�wrta�q w�ir rN D�Y nunbr en:
c�..:
rdrr r�n..:
. rctrcn ne.d na w mnwlree I w v�� u ror an M.�Asd dmala R�m/ u� YnJ
� f I mnh' Net in iM M���unca d iM wak Ia whFJi thu O�e u murE. I Mell mi emPM �Y Pa*o^ In anY menner o n b
becmw wbjee �o Ihe yarYvs' compwabn Wn d Cefdarve, end epres tIW tl I dwuld beomr abjw to IM r.vM�'
comperue�bn pm++om d Sodion e)00 M IM labor COAs. I NeY lathwi�� camVN MN tMm piw+aiau.
w.m�np: F.9un ro..cun wort.n� cnnp.n..aen aw...p. �• unrwrw, me.�m� m/.cr.n �rnnror.r ro cnmlrl pwultl�..ne
drn nn., w ro on. mnm.e rno�.w amm. fsiatoaoA „.wrwn m m. mn e� ce�m.n..uon � � c�.r.e rei in
s�ctlan 91G6 0l IM leEor CWM, Infwc uW.rtamry". rwa
CONSTRUCl10N LEHpNO AQENCY: I Ar�by dfilm uMr peneEy d parjry thel Ihws u e mrWiuCion 4ndvp lpen.y br tlM
pMpmuios d IM xvk lor rfiitli N's prmi h eaW (Ssqion �41. Cv. Cl.
LENDEP'S NAYE
lO1DER'S ADbPE44:
I cMM �het I M�a meE Nia eRbutim W nW ihet Ns eEovs'vdanwion u cartw. I i�M lo oomDN rmh eA rYyW wbM ad'uw�ow
end etate lexe rele�iq toWYLip �miffiunon ud hmaby uNar¢s repreaentBlivet d INs tiry lo mlx upon IM ebove�manluned p�opMy
Iw inapmion W�W�s�
MERLE fiATT£BERG
o.m: —���
(5151�6.WP) \ MTGe-�l'�8961My:O�wmFb:Cvury-�p�SCW:
CITY UF CUSTA MESA — BUILDING PERMIT
P£RMIT NO: IB 083706 PLAN CHECK NO: N
CONSTRUCTZON TYPE: PERMIT TYPE: OTH STR
JOB DESCRIPTION : FOR CERTIFICATE OF OCCUPANCY
CLAZM VALUE:
CALC—VALUE:
PERM NO: IB 08370E
GOVT: N SUPP: Y
PURPOSE: NEW
SQ FT:
GROUP OCC: B /
COMMENTS: X.
�t***itx�*�t**�t�t*�t*at*itx�it*at**�t�t#�ti��t*�+t�t�*>�***�t*�t�r*at�r*�t�t***�+f�tie�**�t-******at+t#r*���t�at,t
2 O N I N G R E Q U I R E M E N T S
S E T B A C K S
------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING ---------
FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN
LEFT; FT IN RGHT; FT IN LEFT: FT IN RGHT: FT ZN
PARKING RE�1: PROV: PARCEL: 00000000 ZNE: REF NO:
PLANNING NOTES>
i � %
it iE iE �1F iE if �E 1E ik ff if if iF if if iF iE iF iE iE �IF 3E±E jE iE ?E iE if * iE iE ik 3f iF iF �li iE if if iF 9e jE iE iE jf i6 iE 3E 9E iE �If �14 iE 3f 36 iE i(� 3E 3f if 3E if 3E 34 3f if jh 3! 3}, � iF if if�lf # if :� 3E iF
D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N�T S •%•
ZONING APPROVED BY DATE: • "`
BUILDING APPROVED BY : DATE: ' '-, �"
APPLICATION ISSUED BY: ������ DATE: l� I .:
*'x�itififif'�afi�if'x'afir*if�c'i!'iiir�x'ir*3FiF�F�iF3F�iF3F3F�F�TiF�F3F)'Fif3FiF �F��iF�F��t�t'x'�afie'r.x'jf*3FiF. . ;3Faf�f
LEGALIZATION;N F E E S U M M R Y STRUCTURAL SEGME T:Y
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
PERMZT 92.00
PLAN
ISSUE FEE
BUZLDING—DZV—> PERMIT ISSUE PLAN—CHECK
TOTALS----> 42.00 0.00 0.00
SMIP/NON—RE5
TOTAL PAID DUE
42.00 42,00 .00
REVENUE D2VISION TOTALS--> COLLECTED: 42.00 OVER/SHORT; .00
BLDG FMT PLOMBING ELECTRIC MECHANTC FIRE SMIP/TOT GRADING PLAN—CHECK
42,00
iklF ik if �k if if �F ik ik iF if iE fk iE iE ik iE iE if 1E ik iE if if if i! 1E if if !f dE 1f ik itlf if ik il� �E �f if if ik iE iE iE it 3F �h it iE i6 iE if ik ik ik'i iE il� ff if jE if df 1E ik if it if iF �f jE �k if �k 3f �E
I N D I V I D U A L F E E B R E A K D O W N
TYPE (jTY D E S C R I P T I O N UNIT COST TOTAL COST
INS 1 BUILDING RE—INSPECTION FEE 42.00 4'L.00
END OF FEES
87-11-1997/89:5g qM/fp2,88
PERMIT:TB837B6
', CONSTRUCTION AND PLANNING POOL 'A
-qPPAOVAIS Permit# Date Inspector 'APPROVAIS Pe.mit# Date Inspector
1. 7emporary Electrical Service or Pole 52. Pool & Equipment Location _
2, $oil Pipe�Undrgmd. . 53. S[eel Reinforcement '
3. Electrical Conduit Utility-Undrgrnd. 54. Forms
4. E�ectrical Conduit-Undrgrnd. 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. -
-B. Poundation 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P•Trap, O Undrgrnd.
10. Scructural Floor System 61. APPROVAL TO DECK
11, propertV �We� U�e & House Connec2ion 62. Backwash & Receptor•Final
12. Sewer Cap - 63. Heater & Vent-Final
13. Roof Drains 64. Plumbing System - Final '
14. Rough Plumbing � 65. E�eCtricabFinal - �
75. Rou9h Electrical�Conduit � � 66. Solar SYstem-Final
16. Rough Electric Wiring � 67. Fencing & Access ApProval �
17. Rough Wiring Sign +�68. APPROVED FOR PLASTERING
18. Rough Electriw6T Bar Ceiling , 69. POOL/SPA SYSTEMS FINAL �
19. Rough Heating & Afr Conditioning �� FIRE DEPT.-REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit #
21. Ducts, in $trutture 70. Underground HYdro
22. Ducts, Venti�ating 71. Product PiUing �Gaz ❑Oil
23. Gas Pipe•Rough & Test 72. Underground Flush
24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil
25. Roof Sheathing 74. Overhead Hyclro
26. T-Bar Ceiiing (Structuraq & Monocoat 75. Dry Chemical
27. Frame and Flashing 7G. Dry Standpipe
28. �athing & Siding 77. FIXED SYSTEM FINAL
29. Insu�ation 78. FIRE PREV. FINAL
30. DrY�vall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter•Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes:
34. Final Heating & Air Conditioning
35. Final Gas Pipe�Test
36. Haod or Canopy
37. Final Factory Fireplace
38. Final Plumbing
39. Water Service•Final -
40. Gas Service-Final
41. Solar pomestic-Final
42. Backflow Preventer
43. Backflow Irrigation
.44. Landscape Irrigation System
45. Sound Attenuation `
46. Handicap Regulations �� ; i
47. FINAL STRUCTURE & BUILDING � 1���9f ���� .; �•.
- c:
'48. FINAL PLANNING
: �.
49, Electric Release to Edison '' ''
50. Gaz Release to Southem Calitomia Gas Co� �.
51. CERTIFICATE OF OCCUPANCY
No. Date
�
��
PflUJECT AOOflE55: 7 z O W 1 9 TH ST
OWNEX'S NFME: UNO ENTREPRISES
aooness: SAME
RXCHIENGINEEfl:
RODRE55:
flEG.NO.:
UNIT:
UNIT:
PEflMITTEE: ROYD GAAPHICS ( 714 ) 546-4761
aooxess: P737 CRODDY WAY H
SANTA ANA CA 92704
LICENSED CONTBRCTOB DECLANATION: I nereDy allirm Ihat I am Iicense0 untler provisions ot Chdoier 9(commencinp witn Seclion
7000) of Drvipon J ol I�e Buvness aM ProfeSsqns CaOe, an0 my IKense ¢ in IW force anE efiecl.
c„ruc.:051804 sureuc.S53456 SS;61
Da�e: _.�. � 2--7 ' �3 SipnaWre: —������
WONNEflS' COMPENSATION DECLANATIONi I �er¢Gy a�lirm lhai I b�Ve d C¢riilitale 01 LOnSen� IO SeI6in5Ure Or d t¢tllll[dle o� WOfkerS'
Comoensation Insurance. or a cenifie0 mpy Inereol ($etYOn 3800. Lae. C�.
IPOLICY NO.: E%P. OATE:
COMPANY:
❑ Ceniliea covY n nem�y lumisnea. ❑ CetlitieG capy a liled with t�e ury BuilOing Division.
�I
Oate: AOD�icant
E%EMVfION FPOM WOPKEflS' fAMPENSA710X OECIAMTION: (Ih6 setlpn necd mi De com0letetl il Ne pemdt b lor one hu�re0 (5100) or less).
I ce�ify Iha� in I�e Oehorman[e ol Ihe work br w�icA t�is Derrtn� is issued. 1 shall no� employ any person in any manner sa as to 6ecome
suble�� io I�e Workers' (C/om0en5aiion Laws at Calilornia. !Y)/w�J �
Oa�e: � Z-� J/ 3 SiqnaNre: 7�!
NO710E: II, aiter makinp inis tleclaration. ywu shoule Gecom�Eje�a tne Workers' Comoensation pmvisions al tAe Labor
Code. yau mu5i torihwil� comDly wii� suc� O�ovisions ar I�fs p¢rmii shall Oe deemee revoketl.
CONSTflUCTION LENDING �GENCY: I �ereUy a��irm ihai I�ere is a ConS�mcti0n lenaing agency br lhe peAOrmante al lh¢ wOrk lOr
which Riis Oermit is issuee ISeciion 3097, Civ. CI.
LENOEfl: '
RODflE55:
CITY OF COSTA MESA — SIGN PERMIT PERM NO; SB 062370
PERMIT NO: SB 062370 PLAN CHECK NO: 01901-93 S GOVT; N SUPP: N
CONSTRUCTION TYPE; PERNIT TYPE: STR SIG PURPOSE: OTH
JOB DESCRIPTION : 56SF NONLUMINATED WALL SIGN S{J FT;
CLAIM VALUE; 504,00 CALC—VALUE; 509,00 GROUP OCC; B-2 /
COMMENTS: THE "OUR HOUSE COFFEE/BAKERY" WALL SIGN
r*****�r*�r****�r�e*�r�r�r�r*�r**�r**�r*�r***�r�**�r�r*�rr+r�r��e****��r***�e*�rx***�r****+���r�r��r*�*�e*
S I G N I N F O R M A T I O N
DISTRICT: 1 TYPE: WALL ILLUMINATION; E3(T CATEGORY; NEW
DIMENSIONS• 7FT OOIN X 8FT OOIN AREA; 56,OOSQFT LETTER HT; 14
STREET FROIJTAGE 1; 87,00 STREET 1; W 19TH ST
STREET FRONTAGE 2: 0,00 STREET 2:
PARCEL: 42226125 ZONE; C1 LOCATION > FRONT; X REAR;
BUSINESS NAME; OUR HOUSE > LEFT; RIGHT;
O T H E R T O T A L S G R O U N D S I G N
THIS ACTIVITY 56,005(jFT OVERALL HEIGHT; OFT OIN
THIS SITE 70,SOSSaFT GROUND CLEARANCE; OFT. OZN
ITEHS OF INFO : 1 PLANTER AREA: O;OOSQFT
ITEMS FOR ACTIVZTY: 1 BLDG SET BACR: 20FT�•
COPY VERBIAGE :"OUR HOIISE" "COFFEE HAR — BARERY"— EXTERIOR LIGHTING,EX,
70,5 SF SIGN AREA REFLECTS EX. GRND SIGN — C/C STZLL:•REQ.
PLANNING NOTES: �
It �F 1f k iF ik M 1F it iF k M if if it if 1f iF 1F iF k�t ilif iF iF if if iF 1f it i! if �f iFik if it k if �F k if iF it M M k if iF k 1f ff k M if 3f 1F M�f kiF iF iF 1F if 3f iF k k.lf iF iF k if ik 1F 3f 1t
D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T�;S
20NING APPROVED BY W Cc�L� DATE; S Z ?
HUILDING APPROVED BY ; DATE:
OWNEB 6UILDEB UEIXABRTION: I �er¢Oy allirm Ihai I am exempt �mm t�e Coniractors' State Li[ense Law lor t�e following reason APPL ICAT ION I SSt7ED BY ; DATE ; J 2% �
(Section703t.5BusinessanOProle55ionalCoae: Myciryolmumywhic�repuire5apermittoconstruct,alter,impr6ve,0emolish,or {E**{f{t�{**{F{f{t{F{E*{F{E{E{tiF*{t{t ��*{F{F{.****.*{f {F{f
re0air any slmcture, prior to ils issuance. als0 ROuireS i�e app6[ani lor suc� Oermit to hle a sipneA statemenl �hai he/she is I¢ensed LEGAL I ZATION : N F E�' $ U M M%� lZ Y STRUCTURAL SEGMENT : Y
pursuam to I�e pmvisions ol t�e Cantraciors' Siate Lirenu Law (Cliapter 9(commencing vnt� Section 7000) oi Division 3 0l I�e Business
an0 PmIe55ion5 CoCe) or Ilwl he/5�e i5 e�em0� Iher¢IrOm anG I�e hav5 lor lhe all¢p¢d e�emD�ion. Any dola�ion oI Settion 7031.5 �y
any apv�icam �or a pemnt suejects tne aov�iwnt ta a civii penauy ot not more tnan Irve nunerea aonars 1550U). BLDG PMT PLUNB ING ELECTRIC MECHANIC S IGN $MSp /RES ('iR%1� ING
i, as owner ai ine proDeny ar my em7royees wim waoes as tneir wle mmpensation, vrin ao me work, ana me pERM I i' 1%. 0 � S(, � �
O simcmre is noi �menEetl or oflered lor sale (Secuon 70aa, Busineu anG Professiwul Code: The Contraciors' Siate �icense Law SM I P/NON—RES
tloe5 noi a07�Y �0 an Owne� ol a propMy "�M EINOS or imprOv¢5 Illereon. an0 wh0 Oces Sut� "Nfk tlim5ell/her5ell or I�rOupA PL� 1 1. � 5
�i5 or �er own CmD�oYeeS. O�oviOeG Ilui Sut� im0«m¢n�5 ar¢ not inlenAetl Ot oil¢r¢0 �Or Sal2. Ii. �owever ��e OUiltlinp or • 5 Q
imo�ovement is 5dG wit�m one yeai ot cortroletion. the owner vtil tuve ��e GurUen of Orovinq �elshe Eid nat Uuild or imDwve I S S UE FEE
� ionneo��oosea�u�el. BUILDING—DIV—> PERMZT ISSUE PLAN—CHECK TOTAL PAID DUE
I, as awner ol ine propeny, am eeclusively comraciinp witn IicenseJ wmraclors lo conslmc� �he projecl (Seciion 70ad, Business TOTALS ---- > 7 3, 5 0 0, 0 0 1 1. 0 S 6 4, 5 5 8 9, 5 5 , 0 0
❑ an0 Pwfusions CoEu TAe Contractori S�ate Liceroe Law Gces not a0W lo an ovmer ol pmceM � OmlQs or imDroves tnereon
ana wno camnets tor sucn omlecls wim a caniracmqs� license pursuam to Ine Coniraciors' Sta�e License LawL � am aware REVENUE D I V I S ION TOTALS--> COLLECTED • 8 4, 5 5 OVER /SHORT • 00
tnaio�ooioimei�wo�kerscomce��ro�imWa�cesmmoeeo�wmea�ome. HLDG PMT PLUMHING ELECTRIC MECHANIC SIGN SMIP/TOT GRADZNG PLAN—CHECK
� I am e�empi unUer $ectian: B. 6 P. C.
br Inis reasan:
Oaie: Owner.
1 Go hereby cenny ilwt I am aware ot an0 unUerstantl t�e mpuirements ol Calilornu HealtA anU Safety Catle Seciions 25505, 25533. and
255k an0 inai I o� any INua OuilOmp acupant wiMvill not (dtde one) neeE ta comply wit� SaiG state co0es and itle reQuiremenls lor a
permil for con9mclion or modilicatian Irom I�e Air Ouali�y Management Oisiricl. flesi0en�ial constmction applicalions are eaemp� Irom
I�ese provisions.
Daie: poV��cant:
I �¢r¢by cerlily Ihal I have reatl I�is applicali0n an0 5�ale ��a� I�¢ aEove inl0rmaiion is cOrret�. I agree Ia tompty vn�h ail cily and counry
ordinances ana slate laws re�ating to buil0irg cOnsimclion ana nere0y autlror¢e reD�esentatives of Ih¢ ciry to enter upon Ihe ahove�mentioned
pmperly lor ins0eclion pur0ose5. /
�ate: SJ�7� /3 Signalwe:__���
orivers �icense ar Sociai Securii� a:
t6aba6 W���le—Builtling: Green—Cotle Enlorcemem: Canary—r10plicanC Pink—Revenue: Goltlenrotl—Assessor
17.00 56.00 .50 11.05
kititiF�FifftM�fiFifMkiFM�FMitkiFkikkikkikifiFkifkMMlflFiFifiFMkiFkltif�fllififkkifiFikkifiFikiFikiFiFifiFikiFiF�fiFiFifkikikiFititilifk
I N D I V I D U A L F E E B R E A K D O W N
TYPE {JTY D E S C R I P T I O N UNIT COST TOTAL COST
NO FEES WERE SELECTED FOR THIS PERMIT
01 00139951-00139934 TO T 84.55
�ATE: US/2�/93 TIME: 09:26
.
V
CONSTRUCTION AND PLANNING
APPROVALS Permit# Date tnspect
�, Temporary Electncai Sercic+or Po:e
2.. Soil Pipe-Undrgrnd, j
�'Electrical Concbnli-14t�!ity�Und�grnd,
� q. Electrical Conduk�Ur:drg�nd. �
� �. Steel ReinforteQte1i�
' 6. Electr�cal UF�i�md "
7. Footings ;,�, �
r g. Foundation T � '
9. Water Pipe•Undrgrcd. � �
10. Structural Floor Systen �
j,'
11, Property Se.ver Lin4 & House Connection
12. $ewer Cap . •-
13, Roof �rains ,�
,,. `.
14. Rough Plumbin,
15. Rough Electripl-Conyu�t
16. Rough EleMriG�jViring
17, Rough Wiring Bign
�$, Rough Electrical�T 8ar Ceilmg
19. Rouyh Heating & A�r CordiLorong
� :4'. '
20:;FioQgh FuctArY �QPlace>.,i : _ ' ` , s ' �
21, Duns, in Stwctars � - . �
22. DuGs, �ientiWtir7g'.; • �_ ., . ' r _ � ' � : `:
23. Gas Fipe-Ra[igh & dest t+_ ' . ' • ' _ • �
24..Roof Frami�g r• " ` ~ . .
. ;� t
25. Root Sheathing : � - + �:� � • a _
26, "��83i Ceihng (St�,c�[u•afl�& �i�ono�oat ' - �
27,�Frame and Plasn�++g - - � -
'B
28. lathin�'& 9idinq =� • ` • . ..
. � . . . . . -, ., • a
29. InsulatiEm .- . - • - .
3Q, prywall Naihng - � - _� �' '_
_ �r
' r: ri . �., -
31. P�aster 8io�vn Cca.. .- ,
�32.=Eiectncql Porverj�te �F'�: - '� i � �
_ .
'33..final Efectric • • . 1 �
----�-- c
�4�,firisl Heai�ng& A:r CondsioT�ir.g, "' `
I��i r ' �.
�35r�Final Ga3 Pipe-Tes4 ' � .:i � �c .� -
36. Nobd o� Canapy? �. •• :�
: 6 . . �
_37.-.��ria1 Fdctory Pireplacv .��;, : r S =,
�3$. Finai Plumbing � - � . � � - • :
:39.SVa�`erService:FirPaf � � _ , , � ��� � .r�
40.:GasService-Pinal . ' t �r- ' o r
. - . ' �.-, - , '
41.`5olar pomeAicFinal " ' � ' ' -'
T
42. Backflow Preventer •• .�. �. • ��
43. Backflow irr+gatioq ,_ ;�:. „_`
- i �.
�A4. Landscs�e Irriqation Systetn } � • • ' •� -
� 45:'So�nd Att¢auation S `.� ��' '� l
_46.•Handicap Ragulations . � �•
47.�FI�t�ALSTR�ICTUREFy�,EtUILDING .`(o °LL/�
` � j���� d.,Kl
48, fIhIAL PLANNING _
. , '
49.'�leciric Release to Edis$n
50::Ga�.Release to Southern California Gas Co
= 51. CERTIFtCATE OP OCCUPANCY
No. Date
C
POOL �A � '
�f APPROVALS Permit �� ` 6ata Inspector i
52. Pooi & E4u�pment Lowt�on �
53. Steel Reinforcement �
54. Forms _ � - �
55. ElOctrical Bondmg ' _ �
56. Rough Plumbinp & Pressure Test � � �'�
i .�
57. APPROVAL TO COVtR�GU\'iTE I '
58. Elactrical Condwt�Und�G�nd. � j �
-t- -,
59. Gas Pipe, r1 UnUrg�nd , Tctt ' �
_-_J
60. Backwash Lincs, RTrap, C� l:nd�m�id. �
61. APAROVA� TO DECK j • ;
62. Daekwash & Reeeptur�Fina� I '
_ �
63. Hcater & Vent•F;na. l
G4. Plumbing SYstem - F��al � �
65. Electrical•Final
66. Sola� SYstem�Finai � i
67. Fencing & Access AnProval � � �
68. APPROVED FOR PLASTERING ' �
69. POdL/SPA SYSTE67S FINAL � I _
!
FIRE D.�PT. REQUIREMENT � I �
4. " _ - -. ? I .
AP?R�1�'AlS � [Errnii � ��_
.. Y+__:i'_'..-� i
f 7G, Undergra,untl HyurOi_� _ � �,
�7L:P,f�y,ductPiping'.�C'i,��; '�'�fSJ . �
�-�---� --- �
sr
'72 UMer�ro�nJF�us�a �' `�_ _� I
,�� ` .
,73.,Wnclergrrd.Stnragqicnic,�;'..,z�as .�O�i � �
-74. �Overheail NyArb " � �
�-- - - ' - -- � -� I
' 7 �.�I�ry Ch�n�ita�� ;-�. . � �� '
y _ __ _ i
73: �Ory Standpipe �- z � �
' ' - �' - -
'�,77:'�IXED�,SYSTE6S F��1Al:j,? � I'
J8, �FIRE PREV. FItJAL ' ` - � _�_ _
' , �' �HEALTH:DEPT.AEQUfAE�b�ETvT:.
�__ _ _ -
79. IhtAL�INSPECTtUGS� T ' � ':
'_.�]'�-1 _. i • �-1.-_""
�o. �odo f�� r�riF;c;� E i5y�eo `�_ � y
- :r- - --- '-� i--
i �ob s: � � r, - .i
� -,-"G--`�'•�-�._ ' -----i
c. 5 � t
� � � f l ( _
,: ' .��_� ��r� _.�« F.'� 1
--15 ^ � =}- --- - - �
• ,`� �_ , �
t , ,.
- � ' -- - --�-' --- - - �
•�. :C
.i _-_ .
I S � �-�' �
L . �__�_ -
j "____:_ y-__-z t: ' ' , _ ,
. � , = r" =..-�
� ' ,-, -� ' � . .. �.
�� ��-. � . . - _ . .,; ,
,�7 -n�i �:..
- z . �." �: . . .
- --lu- - �---
• A � f t' ^ .
s �' � � s _ "�
- - -�f,L -:-�--
ty Y� . � . . � .
•_ -� - _ I
I
Applicant to /ill In all spaces exceo< <hosa witnin heavy boraer Iinas an0 sign a11 aporoo/�ate aeclaratlons.
CITY OF COSTA MESA CONSTRUCTION PERMIT P�j� "��33q O TRqCT NO. LOT NO. UNIT NO,
Proj@ci Address �� W' �Q � S� ��$T%� OlE+� C1� ��
Applicant's Mailing Address �4-�i �RW S 1 �. � C�Z�(�{ TVPE OF CONSTRUCTION NEW ADD ALTERATION REPAIR
Ownpr'SName C�'� KUIM�G L�LV� Phone � C�NVERSION ❑ DEMOLISH ❑ OTHER AP ,*, �
ll '^ DESCRIPTION OF WORK/USE OF BLDG. t'���T�%�T
Address 211"� A'�E�Sr N�CL�%� �%�1�'(l1� S MainBuilding:
Arch/Eng. �fjr�� C�= License Na. C�066e �' TVPE OF PERMIT GRaO�NG FOUNDATION STRUCTURAL T Fron[
Address �SZ M7,� �\�l�` �jT C1JSxjT►� y,r��k CR' �c-�Z� �TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL B Reer
CAntraCtof'S NamC � T'�"� \�\ L�•� V ohone6�9 Z�Z��S ❑ OTHER � 'L A
145� LPW ST 5'V C� q'L\Oq PROJECT DESCRIPTION 5�. FT. OCCUaArvCv T K Right
Address (mailing)
� w��/� CONSTRUCTIONTVPE VAWATIONS� $ Left
City License No. T Y ZONE GRADING CU. VDS. ACRES Ping. Ref. #
LIC@NSED CONTRACTOR OECLARATION (/'
I harCby affl�m tpal I am Iicensetl untler prOvislons of Charter 9(Commencing Remarks: 'PG 2�2� $ A � Planning Notes:^
with section 7000� o/ Division 3 of tho Businoss antl Prolesiions Cotle, antl
my ucense is in Iuu torca ana ettect. r ��
�Llce�s¢ la s � Lic �J
�ate,�.���8_ SignaWre �
� WORKERS'COMPENSATION DECIA TION
� I hereby aHirm that I have a certifiw[e of consent to selt-insure or a certifiwte
� Workers' Compen5ation. Insurance, or a certlf opY thareof (Secilon
/( Do, Lab. C.) �.�,�� /.
't�� rolf�v No. �E�i �"��`�a Comoanv T�r R/�� i
is hereby tu
Is filetl with
EXEtei,PT16N PqOM WORKERS' COMPENSATION DECLARJiY16N
(Tbip s¢t6on neetl not be completetl it the permit Is tor one hunamtl (5100) or
less), �
1 certity that in the periormance ot tho work tor which t s ver �t Is Bsuetl, I
Sildll p02 CTpIOy dfly person Ip dOY Tdllll ! SO d5 �O �UbICCi IO LIIB
Workers'�q{n� e�n5ation Lawi of Californi �
Dato �J�($.g_Signature
NOT�CE: If, �Ile� making thii tlecla�atio�, ou Shoultl becoma ubject [a tha
Workers' Comoensatlon provisions of tha I,.abor Cotlo, you muzt forthwitn
comblY with such provlsion5 Os this pormlt s�all ba Ceametl revoketl.
COrySTRUCTION LENDING HGENCV
I hC/pby aftirm thal [here Is a<Onit�ucHop IanGing ageOCy tOr tlm p¢riormance
01 Ine work fOr whith lhis p¢rmit is issuetl (SecHon 3097 Civ. C.)
l.enper's Name
Lenqer's Atltlle54
OWNER BUILOEN �ECLARATION
I hereby atflrm that I am exemp[ from tha Contracto�'s License I.,aw tor t�e
tollOwin9 reason (Section �031.5 Buiinass antl Professional Cotle: Any clty or
coubty which �NqWres a pe�rt�it to cOnitruct, alter, improve, tlem011zh or repal�
any sVucture, prior to its issuance, also requires the applicant for such permit
to /jl¢ a signetl slatement lhat ne/She Is Iicensetl pursUant to [be provlsions of
the Contrattar's License Law (Chapter 9(commencing with SeCtion ]000j ot
Division 3 ot [ne Business antl Professions Cotle) or that �e/ihe is exemo�
"'+erefrom antl the basiz for the alle9ed exemption. Any vbfatlan o! Section
31.5 by any applicant for a permlt subjects the applicant to a civil
,�81ty ot not mo�e than five huntl�etl tlolla�s ($500).
� 1, as owne� 01 the Property o� my employees with wa9es ds thei� sole
conlpenSatiOn, will tlo ltte wo�k, antl the Structure is not intentletl o�'o(t¢re0
for sale (Sec[ion 7044, Business antl Professlonal Cotle: The Cmtractor'S
Lic@nse Law tlo¢5 not apply to an owner p} a,property who bulltl5 0� imprOves
thareon, antl wno tloes zuc0 work himself/herself or through his or her own
emplOyees, provltletl lhdt such impfov¢TentS afe nOt Intentletl ol oHefetl tor
Shce, Ii, however, [M1e Dulltlin9 or Improvament I5 soltl wlthin one year ot com-
pletiaq the owner wlll have the burtlan ol provm9 he/she tlltl not builtl or im-
�roVG f0/ lh¢ P4rposa o1 sale).
I, as owner oi tne property, am excluslvoly contracting wilh Ilcensetl ton-
tlaCtO/s tU construc� lho project (5¢CtlOn 7044, Bu5ine55 antl Plot¢Ts1on5 COtle:
ThQ ConVa<to�'s Licertso Law tloes not apply to an owner o/ property who
builtls or ImO�o�eS lhereon, antl wh0 contraGts for sUCh prOloctS with a COn-
traCtor(5) ucense pursuanl t0 tne Contrac[or's license �aw). 1 am aware tnat
o�oof o( their WorkeYs Compensallon Insurance shoultl ba provitlea ro me.
❑ I am ezempt untlor Secllon 9. & P. C. tor this reason
Date Owner _
1 hBreby certity that � have reaG
InfOrma[ion iz CorleCt. I agr¢e to O
antl state laws relating to builtlin9
tentatives of this clty to e ter
InSp¢ction purpOses. �
Sighature � �
�rtyers' Ucense or 55 � ,—�]
above
Backtlow Preventer
Backflow Irrigation
ClariFi¢rs
Drinking Fountains
Floor Orains
Floor Sinks
GasService Outlets
I ntercepmrs
Kitchen Sink
Lavatories
P—Trap
Roof Drain
Reinspaction fee
FEES
Showers
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
Solar PiPing
Solar Ta
Swi ing Pool w/Spa i
rinal
Water Clout
Water Heater
Water Service
Auto�Wash
Laundry Trays
S15 .. Isue Fee $ 3
Boiler
Duct- UnderGround
Duci - Strucmral
Duct - Ven['rlatirtg
Exhaust System ❑ Multiple
Firepl/Fact. BIL ICBO #
Heating System & Ducting
❑4100,000 BTU 0100,�
Reinsyec[ion Fee � S75
CMF 0�65-46, rev. 30/84 White - Builtling; Canary - Appliwnt: Pink - Accounting; Goltlenrotl - Assessor
Hood or Type I ❑
Canopy Type I I ❑
7aio pbosTu Otoo,000
' tem Repair/Alteration
Fire Dampers
Registers
Issue Fee � $ 3
Automatic Washer
Construction Pole 5�
Cooking Unit
Dishwasher
Dryers ❑Gas ❑E6
Fan
F,A.U.
Fixtures
Device Boxes
Outlets
Switches �
Garbage Disposal
Generator �0-5 KW
0101 5/UG/di:
� � S 2one
Accessory Building:
Parking Req./Provided
� � Ii .
ECECTRICAL �
- � Transtormer ❑ 15�50 KW
❑ 50+KW
Meter ❑up to 100 amps
Meter �over100amps
S�b Panel
Motors �0-1 HP O1 %- 8
Inc.Solar �9-15 HP �16-15+
Microwave
Pole Ligh[
Sign
Standing Sections
5-15 KW Trash Compactor
I EOo,+
FEES
Z
O
N
I
N
G
R
E
�
M
T
S
Reinspection Fee �$15 Issue Fee ' $ 6
DEVELOPMENTSEAVICESREQUIREMENTS: - a/�
2oning Approved By �� Date� 6 6�i
BuildinB APProved By Dafe_F�y.
Applimtion Issued By Date Y�� �6
SUM V OF FEES
• BUILDING PERMIT $�QQ Sry��p $ I. � S
PLAN CHECIf $ ���-3 S PERMIT
PLUMBING $ ISSUANCE $
PLAN CHECK 25% $ � ENERGY P.C. $
ELECTRICAL $ ��• �'� GRADING S
PLANCHECK 50% $ � MICROFILM $ 'Q/)
MECHANICAL $ TOTAL FEE $ I �" •��
PLAN CHECK 25% $
CONSTRUCTION AND PLANNING POOL&SPA .
APPROVALS Permit # �� Date � Inspector AppROVALS Permit # Date Inspector
1. Temporary Electrical Service�,Pole 52. Pool & Equipment Location I
2. Soil Pipe-Undrgrnd. ��'ti� 53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms "
4. Electrical Conduit-Undrgrnd. 55. Electriwl Bonding -
5. Steel Reinforcement l; 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. .� � 57. APPROVAL TO COVER-GUNITE
7. Footings � 58. Electrical Conduit-Undrg�nd-'�
8. Foundation'• • 59. Gas Pipe, O Undrgrnd� Tesf "
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, D Undrgrnd. 'i �
10. Structural Floor System 61. APPROVAL TO DECK '�� �
11. Propertv Sewer Line & House Connection 62. Backwash & Receptor-Final ,
12. Sewer Cap 63. Heater & Vent-Final �. `�. ��
13. Roof Drains 64. Piumbing System - Final. �-��
14. Rough Plumbing 65. Electrical-Final �•�
15. Rough Electrical�Conduit 66. Solar SYstem-Final i.
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOUSPA SYSTEMS FINAL �
19. Rough Heating & Air Conditioning FIRE DEPT. REnUIREMENT '
n
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 �Gas ❑Oil � •�
25. Roof Sheathing ; 74 Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemiwl ' `
27. Frame and �ashing �� 76. Dry Standpipe
28. Lathing & Siding � 77. FIXED SYSTEM FINAL
r
29. Insulation ' 76. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT �
31. Plaster Brown Coat 79. FINAL INSPECTION �
32. Electrical Power Meter-Final 80. FOOD CERT�FICATE ISSUED �
33. Final Electric Notes: �
34. Final Heating & Air Conditioning � -•
35. Final Gas Pipe-Test
36. Hood or Canopy � , �
37. Final Factory Fireplace • .. , �
3$. Final Plumbing � � �
39. Water Service-Final ", _ � � � �. ' . '
40. Gas Service-Final � '"; + �
i �-
� 41. Solar pomestic-Final � � ' = � %' . . _
i 42. 6"ackflow Preventer . i- - i-' • . �
i
�43.�Backflow Irrigation } ` ' ! .
i 44. •iandscape Irripation System � ' �
� �
�45. Sound Attenuation ' � � I�, '
46. Handicap Regulations �' �. i
G '
47. FINAL STRUCTURE & BUILDING - - � . '
�0 3 �. $i U BC '
48. Special Requirements Completed : , . /
49. Electric Release to Edison '' ,- t
r.
50. Gas Release to Southern California Gas Co �' � •
51. CERTIFICATE OF OCCUPANCY - �' /
No. Date - � �
� � - - . . .. \."
Ciry of Costa Meu
Development Services Department
Building Safely Division
P.O.Box 1200
Costa Mesa, Califomia
The Building located
CERTIFICATE OF OCCUPANCY
720 4�'T 19TH STREE.T
No. OGU�70
has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto
for a Group A-3 Occupancy. '
Use of Building RES`i�`1LTRAI'PP
Legal Description 422-262-23
(See reverse side tor Metes end Bounds)
3uilding Permit No.R-12dN� Electrical Permit No.1�r1359H Plumbing Permit NoP13.i(k1.��A709
Mechanical Permit No. Gu�J 359R.Ai1402�'+I14294 Number of apartments and/or guest rooms
ISSUED T0: BuildingOfficial iu'. /C. C��
(�iE70DIG IQn�3G Id1P1 bY // . � �i�G�Liv�_
7l0 WEST 19th ST., �.S'iP+ b�SF+. CA• pate 2,7 ��� �/ �3 �/
J`
This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premis�es and SHALL NOT BE removed except by the
Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C.
CMF 3015-46 rev. 1/83 White - Owner; Canary - Numerical File: Pink - Bldg. Permit File
\
M
T ���
. . _ - ApP�icant'to'rni•w . >.-.,��urn nenvv bo.avr iin�c apd s19n all aPGroOriate tlec . � .1 __ _ " _ __
A MESA PEFMIT NO. ^`V VTRACT NO. LOT NO. BLD . . � '�
ION PERMIT B' 1�5l� 3 (p �'2, POQ��C� _ ,' • " �;� 7785 4/�2/d4 >2�va5 TI
Projecc Address ���« FL-_/�Zj/L_ >( _
ApplicanYsMailin ress. 2 - � _
Owner's Name - ' Phone
9
Addren %'s ��— i--�—�7 � ���� / e�"
Arch/Eng. � License No.
Address
Contrac[or's Nam hone
Addreu (mailing) L'�
City License No.
LICENSED CONTRACTOR DECLARATION
1 n¢�eby aifi�m [hat 1 am Iicensetl under prOVl5ion5 of Charter 9(commencln9
with sectlon 7000) of Dlvision 3 f the BuSiness antl Profe55ions Cotle, antl
my Iicense iz in full (orce a d e( ect. ,
LI<enu Clus itense No.�
Date � Signafura '
"�ORK 5 COMVENSATION DECLpRATION
•reby afflrm tnat I have a tertifiwte of mnsent to selt-Insure or a certlticate
Workers' Compensation Insurance, or a certifietl copY thereof (Snctlon
.,e00, Ldb. C.) p �y T �'� /
Policy No. �,�6� ��'�����Company�/"rD!h.!m /1120��
BCertifietl copy I5 hereby furnisheb
C rtifie py is flletl witn the city wltlin iv n, �
Date APPlicant�S��� C1���!-
EXEM O OM WORKERS' COMPENSA ON DECLARATION
(Thi55ecti n ee nOt be COmpletetl It the pBrmit i5 for One huntlretl (§100) or
less).
1 Certl/y [hat In [he p!/formance of the wOrk for wnlCh th15 p¢�m�t is i55uetl, I
shdll nOt e�nP�Oy any verson in dny mdnne� zo as to be[ome subjeCl IO the
Workers' Compensation Laws of California.
Oate 5�9nature
NOTICE: If.!after making [his tleclardHon, you shoultl becOme Subject t0 thB
Workers' Corrivensation proWzions ot the l.abor�Cotle, you must (orthwith.
compry with' such provisions.or this permtt shall be tleemetl revoketl.
CONSTRUCTION IENDING AGENCV
1 hereby afiirm that there is a constructlon lentlin9 agency tor tha pertormanca
of the work for wbich this permit is Izsuetl {Secllon 309� Giv. CJ
LEntler'S Name , �
lxntler's Atltlrezs
OWNER BUILDER DECIARATION '
I ha�eby afll�m Ihat I aT exampt trOm tha Cont�actor'S LIC¢ns¢ Law for tbe
as
�rova .<
LJ I. as
I,am
to
'a permii� zuo�ec[s.me appncan[ io a
�s not app�y ro an awner or a properry vmo.ow�as or �mproves
iO.tloes SUGh w0/k him5¢If/he�SeH o� through hls o� her own
Itletl tnat such improvements are not Intenrletl or offer¢tl for
, tha builtlin9 or improvement is soltl wi[hin ona Year ot com-
er wlll have tha burtlen ot proving he/sne tlitl not builtl or im-
'Dose of sale). . ' +
t[he property, am axclu5ively contractln9 with li<ensetl con-
'uct the prolect (Se<Hon 7044, Buslne55'antl Pro(ezsioni Cotle: •
s Ucanse Law does not apply to an owner of properly who �.
�es tnereon, antl who tontracts for sucn projects with a con-
pursuant to the Gontractor's Lic¢nse Lawl: �
untler Section 8. & P. C. for this reason .
1
Oate Owner
�/ I 9gnature
�� Drivers' LicenSe or 5 � _
CMF OB65-46 rev. 12/83 White
CanarY - APPlitant: Pink - ACCountin9:
TVPEOFCONSTRUCTION LJ NEW I�ADD �AI,TERATION LJ REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHER `
DESCRIPTION OF WORK �+ ���� M-' a %Z� .�X�SY-�A11
M
TVPEOFPERMIT GRAOING ❑ FOUNDATION TRUCTURAL
❑ TENANT d ELECTRICAL ❑ PLUMBING ❑ MECHANICAL
❑ OTHER
PROJECT DESCRIPTION 5ci. FT. oCCUPArvCV
CONSTRUCTIONTYPE � VALUATION$_.��
20NE GRADING CU. VDS � ACRE
Remarki: /� /% �� _Q'C�c�
Sink
kflow Preventer
<flow Irrigation
Drinking fountains
Floor Drains �
Floor Sinks
GasService �Outlets
Interceptors
Kitchen Sink '
Lavatories
P-Trap
Roof Drains
Reinspettion.Fee � $25
8oiler .
Duct- UnderGround
EzhaustSystem ❑ Multiple❑
Firepl/Fact.Blt,ICBO# �
Heating System & Ducting
❑0�100,000,8TU 0100,000BT
Reinspection Fee $25
enrotl - Assessor
Service 9ink
SewerCap� �
Sewer Connection � -
Solar Colleciors •
Solar Piping '
Solar Tank
Swimming Pool w/Spa
Urinal
Water Closet
Water Heater
Water Service
Issue Fee
Hoodor Typel ❑
Canopy Typell ❑ '
3efrigeration System
❑aioo,00067u OtOo,0006'
Sys[em Repair/Alteration �
�
laue Fee
A.P. •A`- y ' --
S� Main Buildin9: �
T, Fmnt �
ARear � �
C Right
K
g Left
PIn9. Ref. #z'F —
Parking Req./Providetl
Use of 6uilAing: n D�'
PlanningNotes: (lnin
- AutOmatit Washer
Construc[ion Pole Sub.
Cooking Unit
Dishwasher
Fan '
F.A,U.
Fixtures
Device Boxes � -
OuUets
Switches • �
Garhage Disposal
Generetor 00.5 KW �5-15 KW
$ 3
�Reinspection Fee
FEES
PUBLIC SERVICES REC
s
2oning Approved By �
Building�ApOroved By
$ 3
Zone ` �
Accessory Building: Z
� t O
N
� 1
N
� � G
/ R
E
Park.Fees $ —� �\ p
� U
I
�- . R
E
,. � M
: +�ctu�xErrtENTs N
� T
' S
ICTRICAL - \ FEES
Transformer ❑ 15-50 KW �
❑ 50+KW
Me[er �up to 100 amps
Meter ❑over 100 amps �
Sub Penel
Motors�0.1 HP�1'h-8
Inc. Solar �9-15 HP �1G75+
Microwave '
Pole light
Range
Sign
Stantling Sections
Trash Compactor
luue Fee
� � ' SUMMARV OF FEES ' '
BUILDINGPERMIT �$ J��3��. SMIP •$ � 'DO �
PLANCHECK- $ %' PERMIT . '
PLUMBING $ � ISSUANCE ,$
PLAN CHECK 25% $ ENERGY P.C. $
, ELECTRICAL , $ GRADING ;$ ' '
PLAN CHECK 50% $ MICROFILM $
MECHANICAL $ ' � � TOTAL FEE $ ���%• �
PLANCHECK 25% $ � . , .'
� ,�CONSTRUCTION AND PL NING
'APPROVALS Permit# � Z
�� �_�Temporary Electi�ic81 Service or Pole ,
2�'Soil Pipe-Undrgrnd.
• 3. Elec I �nduit Utility-Undrgrnd.
- �
4: Electrical Conduit-Undrgrnd.
5. Steel Reinforcenierit- �[��
I) 6. Electrical UFER�Grnd.
II 7. Footings � � {' U'
�y 8. Foundation •�; � T
I 9. Water Pipe-Undrgrnd. ^ �
10. S[ructural Floor System
11. Property Sewer Line & House Connection
12. Sewer Cap
d
13. Roof Drains
14. Rough Plumbing �
15. Rough Electrical-Conduit �
' 16:' Rough Electric Wiring � ,
17�. Rough Wiring Sign
1�. Rough Electrical-T Bar Ceiling '
�. 19. Rough Heating & Air Conditioning
20.�Rough Factory Fireplace
21. Ducts, in Structure
J22; Ducts,�Ventilating :
23. Gas Pipe-Rough & Test
24. Roof Framing
(
25. Roof Sheathing �
I
26. T-Bar Ceiling (Structural) & Monocoat
� 27. Frame and Flashing
28.��Lathing &� iding ,�y( L�r/(�
29. Insulation
('I 30. Drywall Nailing ' -�'� 7 �„�,,,y-�
37. PlasteP Brown Coat �
`
32. Electrical Power Meter-Final
. .
_�
33. Final Electric �
I34. Final Heating & Air Conditioning
' 35. Final Gas Pipe-Test
36. Hood or Ganopy �
37. Final Factory Fireplace - -
38. Final Plumhing
39. Water Service-Final
40. Gas Service-Final
419 Solar pomestic-Final �
42. Backflow Preventer
q3. Backflow Irrigation
4a. .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 Callfornia Gas Co
� 5�. CERTIFICATEOFOCCUPANCY
Date
Date
� w / �
POOL PA
Inspector � AppROVALS Permit #
52. Pool & Equipment Location �
- 53. Steel Reinforcement � .
- 54. Forms - � �-
55. Electrical Bonding
��i 56. Rough Plumbing & Pressure Test
- 57. APPROVAL TO COVER-GUNITE
58. Electrical Conduit-Undrgrnd. �
59. Gas Pipe, O Undrgrnd., Test �
60. Backwash Lines, P,Trap, � Undrgrnd.
61. APPROVAL TO DECK - '
" � 62. Backwash�& Receptor-Final -
� 63: �Heater & Vent-Final
64. Plumbing System�- Final ` .
65. Electrical-Final ��
� 66. Solar System-Final ' �" �
67. Fencing & Access Approval -
68. APPROVED FOR PLASTERING
� 69. POOL/SPASYSTEMSFINAL � .
FIRE DEPT. REQUIREMENT
APPROVALS Permit #
�
�
70. Underground Hydro
71. Product Piping � Gas ❑ Oil
72. Underground Flush
73. Undergmd. Storage Tank O Gas ❑ Oil
�„�: 74. Overhead Hydro
75. Dry Chemical
i 76. Dry Standpipe
C 77. FIXED SYSTEM FINAL
78. FIRE PREV. FINAL
HEALTH DEPT. REQUIRER
�° 79. FINAL INSPECTION
' 80. FOOD CERTIFICATE ISSUED
ni...,..._ l. _.r �: � � _/ . i
:Oate ' Inspecior '.
r� �
_.
- �-, r
I
� •
�
' � . %
C _
ADp��cant to till in all spaces except tnose within heavy boraer Ilnes antl sign all apo�opriate tleclarations.
CITV OF COSTA MnESA C�\ONSTRU�TION PERMIT
PrOject Address , \� � �'V \ � �
�
Applicant's Mailing Address �
Owner's Name ,�l � �"`�r P one _ � Z
Adtlreu �ti�J�-�Ceq�,�l�'-Qt �S
Arch/Eng. License No.
Adryress � �/
Contractor'sNama ��I Phone
Adtlress (mailing)
City Licenu No.
LICENSED CONTRACTOR DECLARATION
I hpreby'aflirm tha[ I am Ilc¢nsetl untle� provisions ot Cltarter 9(commencing
with section 7000) of Division 3 of lhe Business anq Protessions Cotle, antl
my Iicense iz In full force antl etiect.
Llcense Class �icensa No.
pate Signa(ure
WORKERS'COMPENSATION DECLARATION �
',,?�yh9reby aftirm thal I have a certificate of consent ro saH-insure or a tertHlcate
��, Worke�s' Compensafion Insurance, oY a c¢rtlfletl copy Ihe�eot (Soctlon
' B00, Lab. C:) . �
Policy No. ComOany
8 Certifietl mpy i5 he�eby lutnishetl. ,
Certlfl tl copy is (IIeO with the city Builtling Division.
Date OPlicant i�= '"�`Pa-� =y��
EXEMPT ON�FROM WORKERS' COMPENSATION �ECLARATION
(Thissection neetl not be completetl It the permit Is tor one�huntlretl (5300) or
lesg) •
I tertity.that In the OeRo�mdnce of the wo�k (or which Ihli perm�t is BSuetl, I
zha�� not employ any person in any manner so as to become subject to the '
Workers' Compensalion,�aws of California. i .
Date Signature -
MQTICE: If, at[er making this tletlaration, you shoultl become subjec[ to the
Wo�k¢rs' COmpenwtiOn provisions of the Labor Cotle, you must forthwith
cohiply with Such p�oviSiOns o� titis permit�shall b¢�tleemCtl revoketl.
CONSTFUCTION LENDING AGENCV " _
I hpreby atfl�m [hat l�e�e i5 a const�uCtio� lentling agency for the pe�(Ormance
of the work for which this Oermit ii ISsueUi (Saction 309] Civ. CJ
Lentler's Name
LCptl¢�'S Atltlf¢SS
OWNER BUILDER DECLARATION '
I hereby affirm that I am exempt trom the Contractor's License Law tor the
fo�lowing reason (Sectlon-�031.5 Business antl Professlonal Cotle: AnY city or
county whlcn r<quires a permit to con5truct, alt¢r, Improve, CemOlish o� repair
any sVucture, prior to its IiSuance, also requires the dppllcant tor5u<h permit
to {j�¢ a signatl statement that he/Sbe i5 Ilcensetl pu�suant lo the provisions o1
� th¢ Contractor's License Ww (Chapter 9(commencing wi[h Sectlon 7000) of
�i�ision 3 ot the Business antl Pro(essions Cotle) or that ne/she is ezempt
erefrom'dn0 the ba5i5 fOr the alle9etl exemption. Any viola[ion.of Section .
J31.5 by any appliCanl (Or a pe�mit. Subjects [M1e applicant t0 a civil
��Bhdlty of not mo�e than five huntl�etl t1011ars ($500).
I, a5 owner o} the p�Op¢�ty o/ my employe¢5 with wage5 as theVr sole
I COmpensalion, will Go the wo�k, antl thE sVuttu/e is not IntenO@tl or oiteretl
br sale ($ection 7044, BUsiness and P�O�CSSIOOdI COtle: The Conl�actor'S �
L�cens¢ Law �oes not ap01y to an own¢r of a prope�ty who builtls or imp�oves
ttlereon, antl who tloes sucn work nimselt/herself or'through his or her own
ernplaYees, O/avitleQ Ihat SUch improveR�¢nts are nOt IntentlCtl o� o�teretl fo� .
sale. It, howaver, the bulltlinq cr imProvement is soltl within one year of com- '
P�etion, the owner will have lhe burtlen of proving,he/she ditl nol Uulltl o� im- �
��ova 10� the purpose of sale).
I, as�owner ot the property, am exclusively contracting witn Ilcensetl con- '
tractorsto construct the project (Section 7044, Businezs antl Protessions Cotle:
The ConVacto�'z License L.aw tloes no� aPO�Y to an owne� of Property who
bUiltls or Improves tnereon, antl who contracts for such projects wieh a con-.
t�actor(51 IlcenS¢ pursuant to the Cont�dctor'S LlcenSe Law). I dm aware that
P�oof ol th¢Ir Wo�keY.S Compensatlon inw�anc0 snowa be provlaetl to me.,
❑ I am ezempt unCer SectiyuX . �_ g<& P. 0. ror this reason �
•'tf
� Dbte _
I h¢reb:
��forma
dqtl SLdi
sentatla
Inspetti�
Slqnatm
x�rivers'
_ �a.+��r�
that I have reatl this application antl s[ate that tne above
rec[. I agree to comO�Y �+'�th all city antl counly ortlinances
atin9 to Duiltling construction, anC hereby authorize repre-
�, city to enter upon the above-menllonetl propqrty for
or55�
TVPE OFCONSTRUCTION L\U NEW LIADD LIqLTERATION IJ REPAIR'
❑ CONVE0.510N ❑ DEMOLISH ❑ OTHER q p. #
DESCRIPTIONOFWORK/USEOFBLDG. �R , �ti
. . S Main Buildi
E
TVPE OF PERMIT GRAo1NG FouNDAT1oN ❑ S7RVC7URAL T Front
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL , A Rear
❑ OTHER
PROJECT DESCRIPTION 5�. F7. oCCUPANCv ' C Right
K
CONSTRUCTIONTVPE - VALUATION$ ���� g Left
ZONE GRADINGCU.VDS. ,ACRES p��g,Ref.#
Remark:: , � 2(,�q 3� Planning,Notes:
Bar Sink
Backflow Preventer- --
Clarifiers
Dishwasher
Drinking Fountains
Floor Drains
Floor_Sinks
Gas Service
Interceptors
Kitchen Sink _
La'vatories , - .
°—Trap'
Roof�Drains '
�Reinspection_Fee , $15
8oiler •
Uuct - Under Ground �
Duct- Ventilating
Ezhaust System ❑ Multiple ❑
Firepl/Fact. Blt. ICBO # �
Heating System & Ducting
❑ a i oo,000 sru O i oo,000 ar
Reinspection Fee � $75
CMF 0865-46, rev. 4/84 White - Builtling; Canary - ApplicanQ Pink - Accounting; Goltlenrotl - Assessor
Showers
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors �
Solar Piping �
Solar Tank �
Swimming Pool w/Spa
Urinal
Water Closet • -
Water Heater
Issue Fee=
Hood or Typel, ❑
Canopy� Typell ❑ ,
Refrigeration System ,
❑0.700,OOOBTU ❑100,000
System Repair/A�t¢retion
laue Fee
ES
3844 7/II/�4 17.
' Zone
Accessory Building:
Z
' O
• . N
I
. N
G
R
Parking Req./Provided E
Q
M
T
$.
ELEC7RICAL �
Auromatic Washer - - Transformer ❑ 15�50.KW .
Construction Pole Sub. ❑ 50 + KW
Cooking Unit i Meter ❑up to 100 amps
Dishwasher , . I Meter �over100amps
Oryers ❑Gas' DElectric
Fan
F.A,U.
Fixtures
Device Boxes
Outlets
Switches '
Garbage Disposal �
Generator �65 KW 05•15 KW
Sub Panel
Motors �0.1 HP � 1 h- 8
Inc.Solar �9-15 HP �16�15+
Pole Light
Range
Sign
Standing Sections
Trash Compactor
FEES
$ 3 I
�—L Reinspection Fea $15 luue Fee $ 3
FEES
DEVELOPMENT SERVICES REQUIREMENTS:
Zoning Approved By Date
Building Approved By Date
Appli�stion laued By Dat �
SUMMARV OF FEES
BUILDINGPERMIT $ ID�C�� SMIP $ •SO
PLAN CHECK $ �� �y� PERMIT
PLUMBING $ ISSUANCE $
PLAN CHECK 25% $ ENERGV P.C. $
ELECTRICAL $ ' GRADING $
� PLANCHECK 50% $ MICROFILM $
MECHANICAL $ TOTALFEE $ � (%��
$ 3 PLAN CHECK 25% $
CONSTRUCTION AND PL NING
APPROVALS Permit #
� Q �
1. Temporary Electrical Service or Pole
2. Soil Pipe=Undrgrnd. ' .
3. Electri,cal Conduit Utility-Undrgrnd.
4. Electricaf Conduit-Undrgrnd.
.5. Steel Reinforcement
6. Electrical UFER Grnd. �-
7. Footings
" 8. Foundation "
9. Water Pipe-Undrgrnd.
� 10. Structural Floor System
11. Property Sewer Line & House Connection
, '12. Sewer'Cap
13. Roof Drains
14. Rough Plumbing
, 15. Rough Electrical-Conduit
� 16. Rough Electric Wiring
17..� Rough Wiring Sign �
18. Rough Electrical-T Bar Ceiling
19. Rough Heating & Air Conditioning
20. Rough Factory Fireplace
21. Ducts, in Structure
22. Ducts, Ventilating
23. Gas Pipe-Rough & Test
24�,Roof Framing �
25.,Roof Sheathing
e)
26. T-Bar Ceiling (Structural) & Monocoat
27. Frame,and Flashing
28. Lathing & Siding
29. Insulation
30. Drywall Nailing '
31. Plaster Brown Coat
32. Electriral Power Meter-Final
33. Final Electric '
34. Final Heating & Air Conditioning .
35. Final Gas Pipe-Test '
36. Hood or Canopy
37. Final Factor.y F.ireplace
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 Sou[hern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. � D'ate ,
Date
a
, POC SPA
Inspector qppROVALS Permit#
52. Pool & Equipment Location
53. Steel Reinforcement �
54. Forms
_ 55. Electrical Bonding �
56. Rough Plumbing & Pressure Test
57. APPROVAL TO COVER�GUNITE "
58. Electrical Conduit-Undrgind.
� 59. Gas Pipe, O Undrgrnd., Test
� 60. Backwash Lines, P-Trap, O Undrgrnd.
61. APPROVAL TO DECK
62. Backwash & Receptor=Final
63. Heater & Vent-Final
� 64. Plumbing System_- Final .
65. Electrical-Final � ,
} 66. Solar System-Final - ' '
� 67. Fencing & Access Approval �
�68. APPROVED FOR PLASTERING
� � 69. POOL/SPASYSTEMSFINAL -
- FIRE DEPT. REQUIREMENT
APPROVALS Permit #
70. Underground Hydro
71. Product Piping � Gas ❑ Oil
72. Underground Flush
73. Undergrnd. Storage Tank O Gas ❑ Oil
74. Overhead Hydro , '
75. Dry Chemical .
76. Dry Standpipe .
77. FIXED SYSTEM FINAL
78. FIRE PREV. FINAL
HEALTH DEPT. REQUIREMENT
79. FINAL INSPECTION
80. FOOD CERTIFICATE ISSUED
Notes: '
0
Date � Inspector
�
�
I X
AVP���ant to fill in aIl soaces excev< those within heavY ooraer lines ana sign all avvrao��ate eaclarations.
CITY OF COSTA M�CONS\�U�TION PERMIT PERMIT NO. . � TRACT NO. LOT NO. UNIT Nn �
Project Addr�s w
Applicant'sMailinaAddr ec 1�0 N,�„ "`
avner's Name T � hone ' L-
Address � � � � -
Arch/Eng. ' , License No.
Atldress �
Contractor's Nam _ , Phone
Atldress (mailing)
City �icense No. � �
IICENSED CONTRACTOR DECLqRAT10N � '
� hereby aHirT [hat 1 am licensetl uotler provisioo5 ot Charter 9(commendng '
w�thtsection ]000) ol Division 3 ot tne Business antl Professlons Cotle, antl
my license is in full force antl effe<t.
L�cense Class � License No.
�dte'' Slgnature
N'ORKERS' COMPENSATION DECLARATION �
leieby aiflrm that I bave a certi(icate o( �onsent to self-insure or a certificate
WO/ke�5' CompensatiOn Insurdrlte, o� a ce�tifietl,copy thereof (SectiOn .
.400, Lab. C.)
POlicy No. ComOany
Cer[ifietl Copy i5 M1ereby fumiSM1etl.
Certit�i �c�o�py is tlletl with the tlty Suiltling Dlvislon.
Date_J./_�1— APPlicanFj � ^a- -M"�{.t��✓`$�
EXEMPTIC/N'FROM WORKERS' COMPENSATION DECLARATION
(This Settion neetl not be completetl if Ihe pe�Tlt is (or one huntlr¢C ($100) Or
Ie;sl.
I certify that in tne pertormance of the work tor which this perm�t is issuetl, I
Shall�n0t employ any pBiSon in any manner so as to become SuOject to th0
Workers',Comoensatlon Laws of California. �
Date Si9nature -
NOTICE: IY, after making this tleclaraUon, you shoultl become subject to the
Workers' Compensation provisions ot Ihe Labor Cotle, you must forthwith
cqmply wil� such ptoviiions or tnis permil shall b¢ GeemeO �evoketl.
CONSTFUCTION LENOING AGENCV �
� hereby aflirm that there IS a conslruction Ieniling a9¢ncy tor the performance'
of tha wOrk for whi�h this pCrmit is Issued (Section 3097 Civ. CJ
Lentler's Name
Lentler's Atltlress
OWNER BUILDER DECLARATIOfJ �� �
I hereby dffltm Ihat I am exempt }rOm the Contractor'z License Law (Or Itte
�nllowing reason (Section ]031.5 Business antl Professional Cotle: Any city or
tounty whlch requires a permit to construct, alteq improve, tlemolish or repair �
any structure, prior to lts issuance, also requires the applicant for such p¢rmlt .
10 tile a 5i90etl stalement that he/She IS licensetl Oursuani to th0 O�ovisions ot
the ContractorY Ucense Law (Chapter 9(commencing with Section 7000) of
�ivision 3 of [he Business antl Professions Cotle) or that he/she is exemp[
�tef�om antl the ba5i5 10� the allegetl ex¢mption. AnY violalion of Sectlon
�31.5 by any applicant for.a permit subjec[z Ihe �appllcan[ to a civll
enalty o1 not more tnan tive huntlretl tlollars (5500). � '
� 1, a5 owne� ot the p�operty O�.my employee5 with wage5 as thei� SOIe
ComOensation, will Co tlte work, antl the structure is not Intentletl or offeretl
�or sale (Sec[ion ��044, Business anE Professional Cotle: The ConVactor's
Ucense Law Ooes not apply to an owner of a property wAo bu(Itls or improves
thereon, antl w�o,tloes such work himsel(/hersalf or through his or her own
Cmployees, provitletl Ihat such imOrovemen[s ara nOt int¢ntlOC o� otferetl for '
Sale. H, howeveq lhe bulltlin9 cr improvement is Soltl within one y¢dr oi com- �
oletion, the owner will bave tne burtlen of provin9 he/she tlitl not builtl or im-
�Ove to� the�purpose ot sale). . , � '
i, as owner of the pro0erry, am exclusively conVacting with Ilcensetl con-
tractors to consV uct the project (Section 7044, Business antl Professions Cotle:
Yhe ConVactor's License Law doe5 no[ apO�Y to an own¢r O� p�operty who
builtls or IeYiDroveS the�eon, antl who cont�aClS fo� Such p�p�eGtS with a con-
tractor�s Ocense pursuant�to tne Contractor's License Law). I am aware (hat
proot o� tqeir Worker's Compen5ation inzurance shoultl be provltletl fo me.
❑ 1 am exempt untler $ection B. & P. C. for this reason
bate y Owner � � -H`p9' "�''
I hereby certlty that I have reatl this aoP!��atlon antl state tnat the above -
�nformation is mrrecL I a9ree to compty with all tltY aptl countY ortlinances
dntl state laws relating to buil0in9 construction, antl hereby authorize repre-
Yentafives of; fhis <ity to enter upon the abova-mentloneC p�operty for
�n5pectian �poses.
Si9nature 1 - ��— �""`�� Date -
TVPE Of CONSTRUCTION LVJ NEW LJ ADD LJ ALTERATION LJ REPAIR
❑ CONVEFS�ON ❑ DEMOLISH ❑ OTH�ER�j q.p, q(6
DESCRIPTION OF WORK/USE OF BLDG. l`�.b� —�-�� S Main Buildi
E
TYPE OF PERMIT cRqDInG FOUNDa.riOrv STRUCrURaL T Front
❑� TENANT ❑ ELEGTRICAL ❑ PLVMBING ❑ MECHANICAL ' 8 qeaf
, �❑ �OTHER � . A` ,
PROJECT DESCRIPTION Sp. FT. OCCUaArv v � C Right
K
� CONS'1'RUCTION TVPE VALUATION $ CV � g left
20NE ' GRADING CU. VDS. 'ACRES Ping. Ref. #
nemarks: � � '� �,Gj � � . Planning Notes:
Sink
Preventer
Irrigation
Drinking Fountairis .
Floor D�ains �
Floor Sinks .
Gas Service Outlets
I nterceprors
Kitchen Sink ' �-
Lavamries
P—Trap •
Roof Drains.
Reinspection Fea +; i � $15
Boiler '
Duct - Under Ground
Dutt - Structural
Duct - Ventilating � _
Exhaust System ❑ MWtiple ❑
Firepl/Fact. Blt. 7CB0.#
Heating System & Dutting
❑ ai oo,000 sTu o, oo.000 sr�
Drivers' License or 55 � � I I Aeinspection Fee
CMF 0865-46, rev. 4/84 White - Builtling: Canary - Appliwnt; Pink - Accounting; Goltlenrotl - Assessor
$15
Showers
Service Sink —
Sewer Cap
Sewer Connection
Solar Collectors
Solar Pipin9
Solar Tank
Swimming Pool w/Spa
Urinal
WdtCf CI052S
Water Heater -
Water Service
Isue Fea
Hood or Typel ❑
Canopy Typell ❑
c
7efrigeration System '
�0�100,OOOBTU ❑100,000
System Repair/Alteration
laue Fee
$ 3
$ 3
Automatic Washer
Construction Pole Sub.
Cooking Unit '
Dishwasher
Oryers ❑Gas ❑Electric
Fan '
F.A.U.
Fixtures • �-
Device Boxes
OuUets
Switches
Garbage Dispoul
Generator �0-5 KW C
3B4? 7/II/84
2one
Accessory Building:
Parking Feq./Provided
ELECTRICAI ,
Transformer ❑ 15-50 KW
❑ 50+KW
Meter ❑up to 100 amps .
Meter ❑over 100 amps
Sub Panel
Motors � 0.1 HP O i%' - 8
InaSolar�O9�75 HP 016-15+
Microwave
Pole Light '
Standing.Sections
5-15 KW Trash Compactor
73.92 7L
FEES
Z
O
N
I
N
G
R
E
Q
M
T
S.
�Reinspection Fee �$15 I I luue Fee I $ 3 I
DEVELOPMENTSERVICESREQUIqEMENTS: •
2oning Approved By Date
Building Approved By Date
Appliration Issued By � Date � �
SUMMARV OF FEES
' BUILDING PERMIT $ �:'y'� SZ% $MIp $ •s�
PLAN CHECK s 2$.q 2— PERMIT
PLUMBING $ � ISSUANCE $
PLAN CHECK 25% $ ENERGV P.C. $
ELECTRICAL S GRADING $
PLAN CHECK 50% $ � MICROFILM $ '
' MECHANICAL -$ TOTAL FEE s.� 3-q Z—
PLAN�CHECK 25% $
CONSTRUCTION AND PL NIL� . POO SPA . .
APPROVALS Permit # � Date Inspector qppROVALS Permit # Date Inspector
7. Temporary Electrical Service or Pole 52. Pool & Equipment Location �
' 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement '
3. Electrical_Conduit Utility-Undrgrnd, - 54. Forms �
4. Electri1cal�ConduibUndrgrnd. - 55. Electrical Bonding . �
5. Steel Reinforcement ., �- ��K,9.Y 56. Rough Plumbing & Pressure Test
6. Electrical UFEF Grnd. � . 57. APPROVAL TO COVER-GUNITE � _
.�7. Footings -. 7�8c� � 7„� 58. -Electrical Conduit-Undrgrnd. .
� 8. Foundation - 59. Gas Pipe, O Undrgmd.,-Test �
_9. Water Pipe-Undrgmd. - 60. Backwash Lines, P-Trap, � Undrgmd. -
70. 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 Etectrical-Conduit ' ' ' 66. Solar System-Final
16. Rough Electric W�ring 67. Fencing & Access Approval � -
77. Rough Wiring Sign . � 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling . 69: POOL/SPA SYSTEMS FINAL -
19. Rough Heating & Air Conditionin9 . 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. Undergrountl Flush '
24"Roof Framing 73. Undergrnd.StorageTank OGas �Oil
25.� Roof Sheathing 74. Overhead Hydro �
26.�i-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical ,,
, 27. Frame and Flashing - 76. Dry Standpipe
28.,. Lathing & Siding �� � 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE 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-T¢st
36. Hood or Canopy � �
37. Final Factory Fi�ePlace
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 Requirements Completed , - .
49. Electric Release to Edison � � � � - � . �
50. Gas Release to Southern California Gas Co �
51. CERTIFICATE OF OCCUPANCY ,
No. Date '
AOD���ant t0 flll in all spaces except thosa within heavy Do�tler Iines antl Si9n ]II appro0riate Eeclarations.
CI7Y oF COS7A nnEsn" CONSTRUCTION PERMIT PERMIT NO. TRACT NO. LOT NO. UNIT NO.
Prolect Address �Zo i rs� sT�e
Applicnnt's Mailing Adtlress 9�s� �O/Q(�/Y G��S.,S
/f4N�r�JfOW '
Owner's Name �hOne
Atldress
Arch/Eng. _ License No.
Atldress p ��//� �j�,y
CAntractor's Name� p��IU�� r� Phone
P.tldresslmailing) ,f_/-��r �D'ef�N 'd.�
City License No. �J� � �
LICENSED CONTRACTOR DECLARATION '
I hereDy aili�m thal I am lic¢nsatl untler p�avi5iOn5 0� Cha�te��9 (cOmmencin9
wit� saction ]000) of Divislon 3' o( the Buiiness antl Professions Cotle, and
my Iicanso is in full torte ana etiect. ���i��
Licenso C�l�e�s`s� �- �cense No.
Dete�.a�..�� Si9natura
�'�'00.KER5' COMPENSATION DEC RAl ION `
� hereby affirm that I nave a certlBcate ot consent to self-insure or a certlficate
pf.�Worke�s' Compan5ation InSurence, Or a certifietl COpy the�eot (Section
3800, Lab. CJ � - - � - ,
�P liry No. Company � '
LCerli(iGtl copy is hereby furni5hl0. \ � �L ;
J C¢r tle mpy is f' iN the ci[y Builtlip�.
Date Applicant
EXEMPTION FiiOM ORKERS' COMPENS T N �HCLFRATION
(This section neetl no be complatetl if the parmit is for one huntlretl (E100) or
�ezs).
� cer[i1y that in the performance ot the work }or whic� thiz perm�l Is i55ueQ I
s�all not employ any person In any manner so as to become su0je<t to the
H'orkers' Compensadon �aws of �alifornia.
Date Si9nalure -
NOTICE: 1�, aiter making tnis tloclaration, You snoultl become subject [o tha
Workerz' COTPensatiOn proWsions of the LaGor Cotla, you must /orthwit�
tbmpty �+��h suGh O�oviSions or Inis permit shall be tl¢emetl revoketl.
CONSTRUCTION LENDING AGENCV -
� he�eby aftl�m thdt there I5 a co0itruction le0tlin9 dgenCy fOr tha pe�fO�manCC
o( (ho wark fOt whlcn th15 permit is issu¢tl (SaCtiOn 3097 Civ. C.)
L,entler's Name
I.entler's Atltlress _
OWNER BUILDER DECLARATIplJ�
i 1 herGby af�IrT t�al I am axempt fmm tho COnttaclOr'S Lic¢nse Law ior [he
following reason (Sactlon �031.5 Businezs antl Prateisional Cotle: Any <ity or
COunty wnith requires a permit to conStrutt, alter, ITProve, DemOlish Or repdir
any structure, prior to its issuance, also requlres Ne applicanl tor sucn permlt
�o file a Si9netl s[atemCnt that ne/She IS Ilcen58tl pur5uanl to [he provlsions Of
I-the Contractor's License Law (Cnapter 9(commenUn9 witn Sectlon 7000) 01
Dlvisfon 3 ot t119 Busln<Ss antl Pfofe55lon5 Cotl¢) of thdt he/Sh0 IS Oxempt
herelrom antl the baiis for the alle9etl exempcion. Any violation ol Section
l031.5 by any applicant 1or a permit subjncts tho aDP���ant to a civil
eenalty o1 mt mora tban tive huntlretl tlollan (ESOOj. '
U I, as owner ot lhe O�aPerty or my amployees with wages as t�eir sole
Compon5a[lon, wlll tlo tne work, antl [he str�cture is not Intentl¢C or oiferetl
for sale (Soction 7044, Business anA Professional COCe: The Contractor's .
Llcense Ldw tloes not apply to bn owner ot a property who bulltls or impmvas
thareon, antl wno Oo85 such wO�k hlmseli/he�self o� thrOugh his or her Own
9mpl0yae5, ptoWGotl lhat such ImOrOvemGnts are not Intentletl or Oltered fOr
Sale. If, howaver, the CWltling cr improvemant issola wlthin one year of com-
blation, th0 Ownar will have tho burtlen 01 proving he/tha altl not builtl or IT-
�rOve lor the purpose Of sale).
I, as owner ot the property, am excluslvory contracting with Ilcensetl con- '
tractors to construct Ihe orojacf (Section ]Oab, ousiness antl Profnsslons Cotla:
7he ConVactor's License Law doe5 nat dPply [o an Owner oi O�operty who
builtls D/ �mp�oves N¢reon, antl who conVacts-for such Drojects witn.a wb-
tractor(z lirense vursuant to tha Contractoi'i Litense Law). I am aware that
proot o� thelr Worker•s Compen5ation insuranee shoultl oe provitlea to me.
❑ I am exempt un0er 5ection B. d P. C. tor this reason
bate
I hereby, certif�
intormabon is c
antl state laws i
S¢OfdIIV¢5 Ot tl
in5pection Ourpt
-5i9�ature _
Orivers' License
_ Owner
have r¢atl thiz apoliwtion and slate [hat tne above
a9ree to comply with all city antl couniy ortlinances
o bu Itling constructlon, antl hereby aut�orize reora-
j ter upon the above-mentlonetl Groperty (Or
Datel_�/N,�_8�
�/,3SO
TVPE OF CONSTRUCTION NEW ADD ALTERATION REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHER p� p,:�(6
DESCRIPTION OF WOFK/USE OF BLDG.
. S Ma(n Buildi
E
TVPE OF PERMIT GRADING FOUNDATION STRUCTURAL T Front
❑ TENANT ❑ ELECTRICAL ❑ PLVMBING ❑ MECHANICAL B Rear
❑ OTHER %�
PROJECT OESCRIPTION SQ. FT.� oCCUPArvcV C Right
K Leit
CONSTRUCTIONTVPE VALUATION$ $
�ONE GRADING CU.YDS. ACRES pl�g, Ref. #
Remarks: I {(� �ay� Planning Notes:
Irrigation
rinking Fountains
loor Drains
loor Sinks
asService Outlets ��
Kimhen Sink
Lavatories
P—Trap
Roof Drains
Reinspection�Fee � ' $15
Boiler r ' '
Duct - Under Ground
Duct - Structural
Duct - Ventilating
Exhaust System � Multiple
Firepl/Fact. Blt. ICBO #
Heating System & Ducting
❑6100,000 BTU 0100,000
`�����-- I f Reinspectian Fee
I
CMF 0865-46, rev. 4/84 White - Builtlinq;
Applicant; Pink - Atcounting; Goldenrotl -ASsessor
$15
ShoWers
Servite Sink
Sewer Csp �
Sewer Connection
Solar Collectors
$olar Pipin9
Solar Tank
Swimming Pool w/Spe
Urinal
Water Closet
Wa[er Heacer
Water Service �
Isue Fee
Hood or Typel ❑
CanoPV TYPe 11 ❑
Refrigeration System
OP100,OOOBTU ❑100,0008T
System Repair/Alteretion
laue Fee
FEES
$ 3
$ 3
Automatic Washer '
Consmuc[ion Pple.Su
Cooking Unit
Oishwasher r-
Oryers ❑Gas' DEIi
Fan
F.A.U.
Ffz[ures
Device 8oxes
Out18L5
Switches
Garbage Disposal
Generator �0.5 K W
Ib67 6/01/84
ELECTRICAL
75.50 TI.
zone
FEES
ormer ❑ 15-50 KW ' '
❑ 50+KW
Meter Uup to 100 amps
' ' Meter ❑over100amps
:tric � Sub Panel �
Momrs O0.1 HP � 1 X� 8
Inc. Solar �9-15 HP 016�15+
Microwave
Pole Light
Range
' Standing Sections
5�15 KW Trash Compactor
$15 Issua Fee ,
JDEVELOPMENTSEHVICESREUUIREMENTS:
Zoning APProved By
Building APProved BY � — �� �
$ 3
� . . SUMMARV OF FEES
BUILDING PERMIT $ SMIP $
' PLAN CHECK �R $ PERMIT
+ PLUMBING �%"S � DU ISSUANCE $
PLAN CHECK 25% $ SO ENERGY P.C. $
. @LECTRICAL $ GRADING S
PLAN CHECK 50% $ MICROFI�M $
MECHANICAL $ . TOTA�FEE $ ,5•SD
PLqN CHECK 25% $
Z
O
N
I
N
G
R
E
Q
M
T
S.
CONSTRUCTION AND PL If�G � - POG_ .. SPA - � . _
APPROVALS Permit #_`��s Date Inspector AppROVALS Permit # Date Inspector
1.,Temporary Electrical Service or Pole 52. Pool & Equipment Location
� 2. Soil Pipe-Undrgrnd. ' � 53. Steel Reinforcement
3:.Elecfrical Conduit�Utility-Undrgrrtt7: .. �� 54. �Forms - �'�
4. Elecfiical Conduif-Undrgrnd. .:, � 55. Electrical Bonding -
5:;Steel,ReinforcertiEnt 56. Rough Plumbing & Pressure Test
.'
6.•�lectrical UFER G�,nd. 57. APPfiOVALTO COVER-GUNITE
7,�, Footings ;,�� ;� 58. Electrical Conduit-Undrgrnd.
8.'�Foundation �, �G � .� 59. Gas Pipe, � Undrgmd., Test ' `��
1:
��9. Water Pipe-Undrgrnd. r� . 60. Backwash Lines, P-Trap, � Undrgmd.
tO:.Structural Floor System 61. APPROVAL TO DECK
11', �Property Sewer Line & House CQnnection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final
13. Roof Drains �'y 64. Plumbing System - Final `
14. RoughPlumbing ' -'��.!L,y� �,E.� 65. Electrical�Final � ,
15. Rough Electrical�Conduit � � . � 66. Solar System-Final
16. Rough Elec[ric 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 �
i
22. Ducts, Ventilating � � 71. Product Piping O Gas ❑ Oil
23. Gas Pipe-Rough & Test �. ���l p,/�y ;.f:� • 7Y. Flnderground Flush .
� 24. Roof Framing � 73. Underg�nd.StorageTank OGas ❑Oil
25. Roof Sheathing � � 74. Overh�ad Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing ' 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE 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: �y( �
� 34. Final Heating & Air Conditioning � � �
35. Final Gas Pipe-Test '
._
36. Hood or Canopy
37. Final Factory Fireplace �� ,� -t,f
38. Final Plumbing � � j.l�I � �
39. Water Service-Final . � ���
40. Gas Service-Finai . . , '
41 . Solar pomestic-Final
42. Backflow Preventer J -
43. Backflow Irrigation . ' ,
44. ,Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations - '
47. FINAL STRUCTURE & BUILDING
46. Special Requirements Completed
49. Electric Release to Edison .
50. Gas Felease to Southern California Gas Co �
51. CERTIFICATE OF OCCUPANCY �
No. Date
Applitant to tlll in all spacas exceot those witnln neavy eortler lines antl sign al1 approo��ate Oe<larations.
Ci7Y OF COSTa'MESA � CONSTRUCTION PERMIT ' """" "�'' "'"'�"' "�"' -" '�-' """ '""'
Projec� Address � ��q �/J�� S� ����
AppliCant'S M2iling `Addr SS �C��1t'YORF�/y OR. TVPE OF CONSTRUCTION NEW ADD ALTERATION REPAIR
/�'�(�6� ,r Phone � CONVERSION ❑ DEMOLISH ❑ OTHER p,p, qM,
Owner's Name DESCRIPTION OF WORK/USE OF BIDG.
Addreu
ArchlEng. _-i '' _ Licenu No.
Address � �' '
� "�.�.rector's Nam — L n•� hone � Z' (6 E
1 Atldrezs (m: �`��1' �s� �iQ�E Ml G, ��QF.i '2�
�(�' Ciry License No. 3�� ��
W LICENSED CONTRACTOR DECLARATION
� I bere�y aftirm thal I am IlcenSetl un0er prpyi5ions o/ Cbart<r 9(commen<in9
r wiih section 7000) of Division 3 ot the 6usinei5 antl Professionz Cotle, antl '
� my II<ense�is in tull tor<e a ftect.
t Llcense Cla �' License No.�9/�
O Date � � Si9nature _
� WORKER ' C01 GENSATION DECLARA710N .
hereby aHirm tnat I have a certifitate o/ cbnsent to selt-insure or a certiticate
of WOrke�s' CompenSatiOn Insu�ance, Or a ce�tl(ieC copy thereof (Section
3800, Lab. C.) /�_� ,
PolicY No.i�lil��,Zl4� ComRanY�St. 7Tf11 .
Certitietl mpy i5 her¢by (umizhea.
C It' co Bletl witn the city Builtli on.
Ddt /a�Plicant_
� EXEM ON F OM WORKERS' COMPENS ION OECLARATION
(Tnis se<tion neetl not be com0letetl if tne permit is for one huntlretl�(5300) or
less);
j 1 certlty that In the oerformance ot Ihe work for which thts oerm�t Is Issuetl, I
, shdl�•nOt employ any person in any manqe� So as to became Subj¢Ct lo Ihe
' Workers' Compensation laws of CalHornia.' . . �
Date Signature
NOTICE: 11, alter making thiz tleclaration, you snoultl become subject to tne
r'Workers' Compensation provlsions of the �bor Cotle, you must tortbwilh
1 � comply wit� suCh provhlons o� thi5 pe�mil shall b< Ceemetl �¢vOketl.
CONSTRUCTION LENDING AGENCV_ ' •
I hereby aftlrm that t�ere is a connruction lentltng agency tor t�e performance
of the work tor wNch tbis permit ix issuetl (Sectlon 309] Civ. CJ
LpnEer's Namc
lAntleYs AGtlrMs _
OWNER BUILDER DECI.ARATION��
I here�y aiflrm that I am nxempt from tha Contractor's Litenso �aw for the
following reazon (Saction 7031.5 Buzlness �ntl Protes51ona1 Cotle: Any clty or
Counly which requiros a perml[ to con5tru�t, alle�, ImprOvo, dem011Sh ot �epair
any structure, prlor to Ils issuance, also requlres the appllcant 1or such permit
' to file a si9netl SWtement [hat be/5h0 is IlConsotl pursuanl to lhe O�ovi5ion5 af
the Contractor'S LlCanze law (Chapt¢r 9(commencing wilh Section 7000) of
�IviSion 3 of [ho Bu5ine55 antl Pro/e55ioq5 COtlO) or lhat h0/Sha i5 ex¢mpt
.herafrom antl tne basis br the allegetl akomption. Any violation at Section
7031.5 by any applicant 10r a permit subfecls th¢ appllcant t0 a civil
�enalty of not more lnan /ive nuntlretl tlollars (5500).
I, as owner of the property or my employoes wlth wagos as lh¢ir sole
compensaHon, will Co the work, antl tne =�ructure Is not IntenCetl or otteretl
for sale (Se<tlon 7044, Business antl Prolessional Cotle: Tha Contractor'S
Litense Law tloes not appty to an owner ot a properry who bullCs or Improves
Ih¢r00n, antl who tloet Such work himi¢lY/ha�sell or through hI5 or he� own
employees, provldetl that such improvemonts are not intendetl or oHeretl for
Sale. H, hOweveq the builtlln9 cr improvory�ant Is sold within one Year ol COm-
pletlon, the ownor wlll hava the burOen ot provin9 he/sha tlItl nol builtl or im-
�av! f0� Ihe purpOse ai Shc¢).
1, as�owner ot tha properry, am excluslvery con[ra<tlng with Ilcensetl con-
t�d<to�ilo conitrucl IhC projecl ($eclian 7044, Buziness antl PrOteisions Cotla:
Tne Con[ractor's Licenie Law tloes not dpPry to an ownar ol property who
buHtls or improves tnereon, antl wno contracts for sucn pro7ects with a con-
tractor(s1 Ilcense pursuant�to the�ConVac�oi'i Llcense Law�. I am aware that
proOf Of [heir Worker'S Compensation insuranca shoultl ba provldetl to me.
❑ I am exempt untler Sectlon B. 6 P. C. �a� tnis reason
Date Owner .
I��ereby certity that I have reatl
information is mrrect. I aaree to t
insoection purposes.
$Igndture
Drivers' License or 55 �
n antl state tnat tne�above
clty antl county ortlinances
anG hereby authorize repre-
S Main Bwldin9.
E
TVPE OF PERMIT GRADING. FOVN�ATION STRVCTVRAL T Ffont
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING. O MEGHANICAL B Reaf
❑ OTHER A
PROJECT DESCRIPTION 5Q. FT. OccUVArvcv C Right
K Left
CONSTRUCTIONTVPE VALUATION$ S
ZONE - GRADING CU. VDS. ACRES Ping. R¢f. �I'
Remarks: � [i� I iL14I 3 �" P I S Planning'Notes:
Bar Sink
Backflow Preventer. ..-.
Backflow Irrigation
Bathtubs
Clarifiers
Dishwasher
Floor Drains
Floor Sinks �
Gas Service ' Outlets �
Interceptors
Kitchen Sink -
Lavatories
P—Trap
Roof Drains
Reinspection Fae • I $15
loiler
luct - Under Ground
Duct - Structural
Duct � Ventilating
Exhaust System ❑ Multiple ❑
FirepVFact. Blt. ICBO #
Heating System & Ducting
❑0.700,000 BTU O100,000BTi
Reinspaction Fee � $15
CMF 0865-46, rev. 4/84 White - Builtlin9; �anary - APPlicant; Pink - Accounting; Goltlenrotl - qssessor
ShOw¢rs
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
$olar Pipin9
Solar TSnk '
Swimming Pool w/Spa
Urinal
Water Closet� �
Wa[er Heater
Water Service
Isue Feo
Hoodor. Typel ❑
Canopy Type I I ❑
�
Refrigeration System '
❑a�oo,000eru ❑ioo,000
System Repair/Alteration
laue Fee
FEES
Automatic Washer � - �
Construction Pole Sub.
Cookin9 Unit " , .
Dishwasher �
i
Dryers ❑Gas ❑Electric
Fan ; ��
F.A.U. �
Fixturez . _ . _ �
Device Boxes .
Outlets
Switche5
Garbage Disposal
Generetor �0.5 KW
5950 8/09/94
2on8
Parking Req.IProvided
ELECTRICAL
Transformer ❑ 15-50 KW
❑ 50+KW
5�15 KW
Meter lJup ro 100�amps
Meter �over 100 amps
Sub Panel
Motors �0�1 HP �1:4-8
Inc.Solar 09;15 HP 016-15+
Microwave
Pole Light
Range
Sign
Standing Sections
Trash Compactor
5 3
Rainspection Fee $15 Issue Fea
$ 3
BDOt? Tl.
Z
O
N
I
N
G
R
E
�
M
T
S.
FEES
$ 3
DEVEIOPMENT SERVICES REQUIREMENTS:
Zoning Approved By �ata
Building ApProved By Date
Appliwtion lauad By �j � nate�
SUMMARV OP FEES -
BUILDING PERMIT $ SMIP $
. PLAN CHECK $ —� PERMIT
� PLUMBING $ 1 • �� �SSUANCE $
PLAN CHECK 25% $ I.DO ENERGV P.C. 5
ELECTRICAL $ GRADING S
PLANCHECK 50% $ MICROFILM 5
MECHANICAL $ TOTALFEE $ g•��
. PLAN CHECK 25% $ '
,' � _ ,
�
� Ot7. r OS'� n POI._&SPA
CONSTRUCTIO��'AND PL N1NG �;; � � �.,p.
�r � % Dateq^' ;faspecior Date Inspecmr
APPROVALS ; 2ermit # ,� t � APPROVALS Permit #
1. Temporary El�ctrical Service or�Pple• r 4 52. Pool & Equipment Location
.
2. Soil Pipe-Undrgrnd. �'-' 53. Steel Reinforcement �
� f.
� 3. Electrical l.onduit Utility;Undrgrnd. -� 54. Forms
' 4. Electrica� ConduirUndrgrnd. , . 55. � Electrical Bonding
5. Steel ReinforcemenY � � 56. Rough Plumbing & Pressure Test
6• •Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE �
7..Footings � �:� , 58. Electrical Conduit-Undrgmd. %�
�•
8. Foundation ' ;�:i 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. Plumbing System - Final �' •
14. Rough Plumbing � � ' 65. Electrical-Final .•
15. Rough Electrical-Conduit � 66. Solar System-Final
16� Rough Electric Wiring � 67. Fencing & Access Approval
1�7. 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 Hydra
22. Ducts, Ventilating 77. Product Piping OGas ❑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 IStructural� &�Monocoat 75. Dry Chemical �
27. Frame and Flashing ' � 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation � 78. FIRE PREV. FINAL �
30. Drywall Nailing � HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat ,79, FINAL INSPECTION
32. Eiectrical 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 ' '
3S. Final Plumbi,ng . t
39. Water Service-Final
40. Gas Service-Final , ' � �
41. Solar pomestic-Final . _
42. Backflow Preventer . '
43. Backflow I�rigation . � �
44. .Landscape Irrigation System �
45. Sound Attenuation � � ' .
46. Handicap Regulations �
47. FINALSTRUCTURE&BUILDING ' �
48. Special flequirements Completed �
49. Electrie Release to Edison - '
50. Gas Release to Southern California Gas Co � -
51. CERTIFICATEOF OCCUPANCY
No. Date
CITY OF COSTA'''M)�ES/A�
Projecl Add�ess �tt
Applicant's Mailing Addres
Owner's Name
Address
Arch/Eng. r� � '�
Adqress �-`%�L7�—k
N PERMIT
No.
Applican� lo fill in all s0aces ekeepl those wi���� neavy Doraer lines ana sign all approo��ate aeclaratlons.
Xddreulmailin9) v � r I/ ' c��'�
Ciry License No. IL�+.t /Ylnr�r rL`I,� G1 t I S� �
LICENSED CON7RACTOR �ECIARATION
I hq�eby at(irm that I am licensetl untler O�ovislons of Charter 9(commencing
with�section �000� o/ Divition 3 ot Ihe Businesi and Professions Cotle, antl
my Iicense is in (ull fof e a e1 ecL � c
IJcense Clas3 `�' Li e�se � Z�-�\5
Date �" �� 5'9 �U ���
WORKERS' COMPENSATION DECLARATION
hareby affirm lhat I have a certificate of consent to sel�-inzure or a tertificate
ot Wo�kerz' COTpensSlion Insutanca, o� a certltietl copy thereot (SeCfiOn
I FqO�101SKERS' COMPENSATION OECLARATION �
neetl not bo completetl if the permlt Is ior One Ituntl�etl (5100) o�
in (ha pertorman<e o1 the workj� i t �t is Issuetl, I
�loy� dny Pe�son in any ��o o fnDjacF-to lhe
MLnsai/on Lawz of Calif / ..w .
Date �Q/ Signature " ��
NOTI 1f. fter makln9 Ihis tleclar n, you zhoul ec me suE7ett p ne
Work 5' C mpensation provisions the I,.abor tle, you must f+F� witM1
Cohip y w lh sucn provision5 Or tnis p¢rmlt shall be tleemOtl yy:oketl.
CONSTRUCTION LENDING AGENCV
1 hareby af(trm that thera fs a construction lentlfng agency for the per(ormance
01 the wOrk for wnich t�h permit Is Issuetl (Seclion 3097 Clv. CJ
LenOer's Name
L.antler's aatlress
OWNER BUILDER DECLARllT10N�-
I hereby afflrm that I am exempt (rom t�e Contractor's License Law for tha
followin9 reason (5ec[lon 1031.5 BusineSS antl Professlonal COUe: Any ci[y or
coUnty whiCh reqWras a pe�mJt [O con5truct, aller, Improv0, tlemolizh o� r¢pab
any 5[�uctur¢, Pvb� lo Its isSUdnce, also �CquirCs [he applicant tOr such pe�mll
lo tile a signaC Statemont that he/she is Iicensaa pursuant to the orovlsions o(
tne r..o�.a�r�.•a i icnnax 1 aw rGnaoter 9 fcommenclna with Sectfon 70001.of
�nCrefrom antl lha ba515 fOr the allegetl OzemptiOn. Any vlolaUOn o( Sectlon
7031.5 by any applicant tor a permlt subjeCls I�e applitanl to a Civll
�enalry of not more ihan five huntlretl tlollars (5500).
�, a5 Owner ot thC prop¢fly Or my amployCGs with wd9e5 as theif sola
compensation, wlll tlo the work, antl the SVUCIu/e is no[ IntenOctl Or oHeretl
for sale (Section 7044, Business antl Prolossional Coda: The Contractor's
Li�Bnse 12w tlOes not apO�Y to an own¢r Of a p/ope�ty wh0 bulltls or imp�ov¢5
ehoreon, antl who tloes such work himselt/hcrself or througM1 h�s or ber own
oTploycas, provldutl Ibal SUCh improvOmOnts dle nOt Intentletl or ottefetl 10r
sale. II, however, tne bulltlin9 ur improvement is soltl wlthin ona year ot <om-
P�etton, tne owner wlll nave tne burtlen o( proving he/she tlitl not builtl or lm-
�rove torthe purposa ot zale).
I, az owner oi the proDer(y, am exclusively tontracting witn Iicenzetl con-
trdctors to cons[ruct lho Project (Section >044, Buzinesz antl P�olession5 Cotle:
The Contractor's LicenS¢ Ldw doe5 not appry lo an Owner of prOperty who
b411tls or improv¢s lh0reon, antl who cO�Vactz tor such prOjeGts witM1 a con-
trdctor(5j license pursuant to the Con[ractor's Licenze �.aw), I am aware tnac
P�oof oi ineir Wo�ker's Compensation insurance snoultl be provi0etl to me.
!❑ I am exempt untler Section B. & P. Q tor this reason
Date Owner
I hGreby certi(y tnat I have reaa thi5 appliWtion antl stata [hdt the abOv¢
informatlon is cortect. 1 aoree ro comoLxwith all Nty antl county ortlinances
antl ttate laws
sentatives of I
��Ypection Pu
9qnature �
Dq�ers' Licy�
���� ���
TVPE OFCONSTRUCTION LJ NEW IJ ADD LJ ALTERATION LJ REPAIR
❑ CONVERSION ❑ DEMOLISN ❑ OTHER p� p�6
DESCRIPTION OF WORK/USE OF BLDG.
S Main Buildi
7VPE OF PERMIT GRADING FOUNDATION 57RUCTURAL T F�Ont
❑�}.TENANT ❑ �E�j ECTRIGAL ❑ P} VMBING ❑ MECHANICAL A Reat
L'v �OTFIER .�Cnn.L'1_<!_AP� /R.t�ifil�Ti(-/+L) � Right
PROJECT DESCRIPTION Sp.FT. OCCUPANCV K.
COI`15THVCTION TYPE VALUATION $ S Left
ZONE � GRADING CV. VDS. ACRES p�ng. Ref. �
Remarks: Pldflfling NOt¢5:
9ar Sink
Backflow Preventer
Backflow Irrigation
Bathtu6s
Clari(iers
Dishwather
Drinking Fountains
Floor Drains
Floor Sinks
Gas Service OuUets '
Interceptors
Kimhen Sink
Lavatories
P—Trep
Roof Drains
Rainspection Fee $15
Boiler
Ducc - Under Ground
Duct - Structural
Duct � Ventilating
Exhaust System ❑ Multiple
Firepl/Fact BIL ICBO #
Heating System & Ducting
❑ ai oo,000 eru O i oo,000
CMF 0865-46, rev, 4/84 White - Builtling; Canary -APplicant; Pink -Accoun[ing; Goltlenrotl • Assessor
S15
Showers
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
Solar Pipin9,
Solar Tank
Swimming Pool w/Spa
Urinal
Water Closet
Water Hearer �
Weter Service
laue Foe
Hood or Typel O
Canopy Typell ❑
Refrigeration System
❑aioo,000sru dioo,000
System Repair/Alteration
Issua Fee
FEES
$ 3
5 3
6425 8/16/84 7o0i1
Zane
ACcessory Building:
Z
O
N
1
N
G
R
Parking Req./Provided E
�
M
T
S.
ELEC7RICAL
Automatic Washer " Trensformer ❑ 15-50 KW
ConstructiorPoleSub. � 50+KW
Cooking Unit
Dishwasher
Dryers ❑Gas ❑Electric
Fan
F.A.U.
Fixtures
Device Boxes
Outlets
Switches
Garbage Disposal
Generator O0.5 KW �5�15 KW
Meter �up to 100amps
Meter ❑over t00amps
Sub Panel
Motors � 0-1 HP � 1 X-�8
InaSolar �9-15 HP �76-15+
Microwave
Pole Light
fiange
Sign
Standing Sections
Trash Compacror
FEES
• �'Reinspection Fee �$15 I ' laue Fae I $ 3'
DEVELOPMENT SERVICES RE�UIREMENTS:
Zoning Approved By Data
BuildinB APP�oved By Date
Applintion laued ey �Uf(5 Date___—�
SUMMARV OF FEES
BUI�DING PERMIT $ SMIP $
PLAN CHECK $ PERMIT
PLUMBING � $ O �SSUANCE $
PLAN CHECK 25% $ ENEflGV P.C., $
� ELECTRICAL $ GRADING $
PLAN CkECK 50% $ MICROFILM 5
MECHANICAL S TOTALFEE 5 7.bU
PLAN CHECK 25% $
. . �,. ; ' � .`. . . f .
� PO(. _ ,,� SPA
CONSTRUCTION�AND P NI G " � �
APPROVALS Permit #� �Date Inspector APPROVALS Permit # Date Inspector
�
7. Temporary Electrical Service or Pole 52. Pool & Equipment Location
• 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit�Utility-Undrgrnd. 54. Forms � ,
� 4. Electrical Conduit�Undrgrnd. 55. Electrical Bonding
i
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test .
�
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE '
7. Footings � , 58. Electrical Conduit-Undrgrnd. •�
' S. Foundation '� 59. Gas Pipe, � Undrgrnd., Test , f�
••i
9. Water Pipe-Undrgrnd. . 60. Backwash Lines, P-Trap, � Undrgrnd.
10. Structural Floor System 67. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap . 63. Heater & Vent-Fina� -
13.'Roof Drains . 64. Plumbing System - Final ,•
14. Rough Plumbing _ 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
1�6. Rough Electiic 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 Structuie 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping OGas � OOiI
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. 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 Irrigation . . . �//7�� ��
44. .Landscape Irrigation SYstem
45. Sound Attenua[ion ' '
46. Handicap Regulations '
47. FINALSTRUCTURE&,BUILDING • .
46. Special Requirements Completed ,
49. Electrie Release to Edison ' �
50. Gas Release to Southern California Gas Co
51. CERTIFICATEOFOCCUPANCY
No. Date
��
AOV���ant to fill in all soaces excepl tnose within heavy Eoreer lines ana si9n all aoGroD��ate aeclarations.
CiTv oF COS7A MESA CONSTR UCTION PER ITy
Project Addresg �20 (`_
��Applicant's Mailing Address � '� �
Owner'sName .a7.1�• GEG- Phone
Address Tf7/Y1'F�
Arch/Eng. � License No.
Address �/�a./ —7� ,,��p
Contracmr's Name�/��� 7a � ���Phone �{,LC11¢
Address (mailing�� �i-� �_�— �i�"�ffi'�{
City LicenSe Nq. � � %2 �
LICENSED CONTRACTOR DECLARATION
I hereby affirm [hat I am II<Cnzetl untler provision5 01 C�arter 9(�ommencing
with'sec[ion ]000) of Division 3 of [he Business antl Protessions Cotle, anU
my Iicense is in lull force antl etfect. �L��
IJE¢IlSC CId55 `C � 2 P _LIC¢OS¢ N d f'
Date Signature
WOHK RS' COMP NSATION DECLARA ION �
�'s hereby aHirm [hat I nave a certiticate ot consenl_ selt-insure or a certiticale
' �( Wo�ke�5' COmpensation InSu�ance, or d certl(ietl copy the�eof (Sectlon.
3800, Lab. C.)
Policy No. Company
eCertifietl copy is hereby turniShGtl. �
Cercifietl copy is filetl with the city Builaln9 Division.
Date � APplicant
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(This section need not be complete0 i7 tbe permit is fos one hunC�ea (5100) or
I¢5T).
1 certity that iq tne pertormance ot Ihe wo�k for which this OerT�t Is Issuetl, 1
shall not employ any person in any manner so as to ecome subject to the
Workers'C=� er�p�oc l.aws ot Califor�ia. ��
Date � � Si9nature
NOTI[E: If, a1[¢r making tnis tleclaration, u snoul bew sub�ect to [he
Workers' Comp¢nsatlon provisions o( the labor-Co , you must forNwitn
COmply wil� 6uch prod570ns or this Oe�mil Sh31 be tleem¢tl revoketl.
CONSTRUCTIbN LENDING AGENCV
I hereby atBrm [bat there is a conslruction lentling a9ency for lhe performance
of lhe work lor whitn lnis permit is issue0 (Section 3097 Civ. C.)
L.entler's NamO"
�entler's Ailtlresi .
OWNER BUILDER DECLAfiATIOfJ�
1 hereby afBrm lhat 1 am oxempt (rom the ConVactor'z Licenso Law tor the
following r¢asqn ($ection 7031.5 Bu51nfl55 antl P�of¢Tsional CotlC: Any <ity o�
mun[v which reauirez a oe�mi[ to con5truct. alteq imp�ove, Eemoli5h Or repab
7lvizlOn 3 01 th0 6usin855 antl PrOfesEloni COOe) or that ba/Sho Is ¢xemp[
,hcretrom anG �he basiz for the allegetl ezomptlon. Any vlolatlon of Section
7033i by any applicant (or a permit subjocts tbe aOP���ant to a civll
�enalty of not more than five huntlretl tlollars (5500).
I, as owner of t�e property or my ¢mployees with wages as their sola
tompenwtion, wlll tlo tha work, and [�e Structura i5 not inlentlotl or olteretl
for sale (Sectlon 7044, Busin855 antl Pmtes510na1 Gatle: The ConVattor'S
Llcenie Law does not apply to an owner ol a property who bWIOs or lmprovas
lhereOn, antl Wryo tloes SUCh work M1imsclf/M1crsell or [hrOugh hIs or h¢� own
omployeas, p�Ovltl¢O tllat SUCM1 Improvemenls afe nOt Intentletl Or Oftefetl tOr
sale. Ii, howaver, tna bullaln9 cr improvemanl Is soltl within one year ot com-
pletlon, lno oWnor will have the burtletl oi proving hC/s�e �IO nOt builtl O� Im-
�rove�for Ihe purposn of sale).
I, az owner of the O�operty, aT exclu5ively ContracUng with IICGnzetl con-
tractors to conslruct the project (Section 7044, Buslnass antl Pro�esslons Cotla:
The Contractqr's License Law do¢s nOt apPIY to an owner o1 prOp¢rty who
builtls or improves theraon, antl who contratts for such pro�ects with a con-
traccor(s Iic¢qse pursuant to tbo Contractor's Licenze Law). I am aware that
prooi O� tneir Wp�ker'S Compansatlon insuranCO shoultl DB provltlatl [o me.
❑ I am exemp� untlet $ecUon B. 8 P. C. �or thii reazon
Date Owner
$i9nature _'/^
Drivers' LicenS�
CMF 0865-46, �av. 4/84
a
upon
] ztate that Ne above
antl countv ortlinances
/71 /�D.�j
TYPEOFCONSTRUCTION NEW ADO ALTERATION REPAIR
❑ CONVEfiSION ❑ DEMOLISH ❑ OTHER q,p, qp,
DESCRIPTION OF WORK/USE OF BLDG. 5 Main Buildi
TVPE OF PERMIT GRADING FOUNOATION STRVCTURAL T FrOnt
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING � MECHANICAL A Rear
❑ �OTHER . ' �
PROJECT DESCRIPTION 50. F'r. OCCUaArvCV C Right
K Left
CONSTRVCTION TVPE VALUATION 3 $
ZONE GRADING CLL VDS. ACRES p��y, Ref. #
Remarks: � � y �3 � Planning Notes:
Sink
Preventer
Irrigation
Drinking Fountains
Floor Orains'
Floor Sinks �
Gas Service Outlets
Interceptors -'
Kitchen Sink
P—Trap
Roof Drains
Reinspection Fee $15
Boiler
Duct - Under Ground
Duct - Struc[ural
Duct - Ventilating
Exhaust System � Multiple ❑
Firepl/FacL Bit. ICBO #
Heating System & Ducting
�10.100.000 BTU � 700,000 BTI
Reinspection Fee � $15
White - Builtling; Canary - AOPliwnt; Pink - Accounting; Golaenrotl - Assessor
P
Showers
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
Solar Pipin9
Solar Tank '
Swimming Pool w/Spa'
Urinal
wacer Closet
Water Heater
Water Service
laue Foe
Hood ar Typel �
Canapy Type I I �
Refrigeration System
�100,OOOBTU ❑100,000
System Repair/Alteration
Issue Fee
FEES
S 3
FEES
$ 3
3�6i �ii.a�ea
Zone
Acceuory Building:
Parking Req.lProvided
ELECTRICAL
Automatic Waiher — Transtormer ❑ 15-50 KW -
ConstructionPoleSub. � �50+KW
Cooking Unit Merer ❑up to l0pamps
Dishwasher Meter ❑over 100 amps
Dryers ❑Gas� ❑Electric ' �SubPanel � �
Fan � Motors �0.1 HP 01:4-8
F.A.U. Inc. Solar �9-15 HP �76�15+
Fixtures Mittowdve
Device 8oxes Pole Light .
Outlets Range
Switches Sign
Garbage Disposal � Standing Sections �
Generator �P5 KW �5-15 KW , Trash Compactor
Fee I 515 � I �ssue Fee
DEVELOPMENT SENVICES REQUIREMENTS:
ZoriinB APProved By
Building Approved By -_y_
13.Oi TI
FEES
0
$ 3
SUMMARV OF FEES
BUILDING PERMIT $ SMIP 5
PLAN CHECK $ . PERMIT
PLUMBING $ ISSUANCE $
PI.AN CHECK 25% $ ENERGV P.C. $
ELECTRICAL $ GRADING S .
PLANCHECK 50% $ MICROFILM 5
MECHANICAL . $ ��� � � TOTAL FEE $ ��`d �
P�AN CHECK 25% $ oili�
2
O
N
I
N
G
R
E
�
M
T
$.
"' CONSTRUCTION AND PLANNING � POI._ 6� SPA .
APPROVALS Permit # M�y�3 Date Inspector � APPROVALS Permit # Date Inspector
�. Temporary Electrica� 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 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-Trep, 0 Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11. �Property Sewer Line & House Connection .62. Backwash & Receptor�Final
12�. Sewer Cap ' 63. Heater & Vent-Final
13. Roof Drains , 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final -
15. Rough Electrical-Conduit 66. Solar,SYste'm-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 ❑ 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. Insulation � 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electriral Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes: .
34. Final Heating & Air Conditioning �f�3��Y � .
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 pomesticFinal , • _
42. Backflow Preventer . � � �
43. Backflow Irrigation �
44. .Landscape Irrigation System
45. Sound Attenuation � � '
46. Handicap Regulations' ,
47. FINAL STRUCTURE & BUILDING .
48. Special Requirements Completed
49. Electrie Release to Edison �
50. Gas Release to Southern California Gas Co
51. CERTIFICATEOFOCCUPANCY
No. Date
AOG���ant to fiil in all spaces except those witnin neavy boraer Iines ana sign a11 aoG�ovriate aeclaratlonf.
CiTv OF COSTa raESA CO1N-S,TRUCTION PERMIT
IProject Address w �
Applicant's Mailing Address
Owner's Name Phone
Addreu
Arch�Eng. License No.
Addresr ' T-ym�N—/IL�'
Contractor's Nam�—TI�Y` ����� � �6'���hone e -B�� �
Address (mailing) �=-?. $ � • �*�%�1%�Y N6A/7'bL'� Rll�
Ciry License No. �7 � �
LICENSED CONTRACTOR �ECLAR TION
1 herCby affirm that I am IicenseU untler provislons of Charter 9(commencing
� with,section 7000) of Divislon 3 of the Business antl Professions Cotle, antl
' my license Is In full force antl eitect. /
License qass � � Lic nsa N�,�h ��
Date � - Signature � '
W00.KER5'COMPENSATION OEC ATION,
I hereDy afBrm tnat I nave a certifiwte of conun t elLinsura or a cerUtiwto
, of Workers' Comp¢nsa[ion Insurance, or a certilietl copy thereof (SecUon '
3800, l.ab. C.) � r , - -
PoliGy No. ' COmpany ,
8 C¢rtifietl copy is heieby'furniShGtl.
Certitietl copy is filetl`with tne city Builtlin9 Division.
Date !? �FPPlicant
EXEMPTION FROM WORKERS' COMPENSATION OECLARATION
(This section neeC not be complatetl i( the permit is for one huntlretl (y100) or
lezs). -
I ce�tify that in the pet(o�mance of the wOrk fOr whic0 t�Is plrT�t is isiu¢U, 1
shall not employ any person in any manner so as t become subject to the
Work¢rs' C m en t n Lawi O/ California.
Date ��Si9nature _.
NOTICE: H, after m king this tleclaratio�.�fGu-� 1 come subject to lha
Workets' Comp¢n5dtlon prov(5ions o�The Labot otle you mu5t fOrthwilh
comply with such provislons or this permit s all De aeemotl revoketl.
CONSTRUCTION LENDING AGENCV
I hereby atflrm that t�ere is a construtlion lentlin9 agency lor t�e performance
of lhe work for wnich this Oermit is I5sue0 (Section 3097 Civ. C.) .
LEntler'S Name
Lenaer's Ailtlress
OWNER BUILDER DECI.ARATION��
I hereby dHirm that 1 am ex¢mPt irom tha COn[ractor's Llcea50 Law fOr lno
tollowin9 reason (Sectlon 7031.5 Businass antl Prolai5ional CoOn: Any city or
' county which requires a oermit ro<onttruct, alter, improve, tlemolish or ropalr
dny it�uclure, prlo� lo iti i55uanca, alm repulreSlhe aDP���ant 1or SUGh pntmil
to tile a Signetl statement lhat he/ihe Is Iicansetl pursuant to lhe prOvislons o!
the Contractor'S License Law (Chapter 9(commencing with Section 7000) of
Dlvlsion 3, oi the BuSinoss antl Prol¢SSions Cotle) or thdt hC/Sna Is axempt
lherefrom antl the basis forche allege0 exemption. Any violation of Se<tion
7031.5 by any applicant for a pnrmit subjects the appllcanl to a civil
�e0dlty of not more lhan live hUntlretl tlollar5 (E500�.
I, a5 Owne� o( tha prOp¢rtY or my OmplOyeas with wago5 a5 Ihol� solo
compensation, will tl0 tho work, antl the itructure Is not intentlatl or otleretl
tor sale (Section 7044, Busineis antl Professional Cotle: The Contra<tor's
License Law tloes no[ appty lo un owner o/ a proPerty who builOz or improvas
lhereon, antl who tloes such work himseil/horsalt or throu9h his or her own
employoe5, provitletl tnat such imprOvoments ara nOt Intentlatl or ofioretl for
sale. If, however, the bulltlin9 �r improvement iz soltl withln one year of com-
Dletlon, Ihe own¢r will have Ihe burtlen ol p�oving ho/ShC tlitl not bulltl or Im•
�rova forthe purpose of sale). ,
LJ I, as owner oi the property, am uxclusivoly convacting with ilcansua con-
tractorsto conSVuct the Oro�ect (Sectlon 7044, Business antl Professlons CoGo:
The Contrattor's License Law do¢5 nOl apply lo an Ownar of Oroparty who
builtls or ImOroves Ihereon, antl who conVattz br such projec[5 wlth a Con-
tractor(s1 Ilcense pursuant�to the Contractor's �iconse Law). I am aware that
proot ol their Work¢r'S CompeOSatlon Insutance ShOultl be ptovitlBtl to me.
❑ I am exempt untler 5ettion B. 3 P. 0.(or thls reason
Date Owner
tnis aOPliWtlon antl state Ihat tha above
omply with all city antl countY ortlinances
constructlon, antl nereby authorize repra•
upon tne above-menHonetl property for
.� s� � .,...., ,..,. _.,. ,..,. ���� � ���.
E'
TYPE OF CONSTRUCTION NEW ADD ALTERATION REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHE A p.*
DESCFiIPTIONOFWORK/USEOFBLDG. �r6'UQ�'� .
S Main Building:
E
TVPEOFPERMIT GRA�ING FOVNDATI� STRUCTVRAL T Ffont
❑ TENANT �ELECTRICAL ❑ PLUMBING MECHANICAL 8 Reer
�, � �OTHER C Rlght
PROJECT DESCRIPTION 5a. F7. � OCCUPANCv K
CONSTRUCTIONTVPE VALVATION$ g Left
ZONE GRADING CU. VOS. ACRES p�ng. Ref. 5W
Remarks: �,�% - �� Planning Notes:
Sink
Preventer
Floor Drains
Floor Sinks
Gas Service
Interceptors
Kitchen Sink •
Lavotories
Roof Drains
Reinspection Fee
Showers
Servite Sink
Sewer Cap
Sewer Connection
Solar Collectors
Solar Piping �
Solar Tank
Swimming Pool w/Spa
Urinal
ts �Wacer Closet �
� Water Heater
Water Service
$15
Boiler
Duct�- Under Ground �
Duct - Structural
Duct - Ventilating
Ezhaust SyStem ❑ Multiple ❑
Firepl/Fact. BIt. ICBO # �
Heating System & Ducting
❑0-100,000 BTU O 100,000 BT
Drivers' License � I I Reinspet[ion Fee I $75
CMF 0865-46, rev.4/84 White - Builtling: Canary - Applicant; Pink -Accounting; Goltlenrotl -Assessor '
Isue Fee
Hood or Typel ❑
Canopy Typell ❑
Refrigeration System -
06100,OOOBTU ❑t00,0008TU
System Repair/Alt¢ration
Issue Fee
ES
$ 3
FE
$ 3"
Automatic Washer .
Construction Pole Si
Cooking Unit
Dishwasher
Dryers ❑Gas ❑EI
Fan .
F.A.U.
Fixtures _
Device Boxes '
Switches
Garbage Disposal
Generator 00.5 KW
Fee
1966 6/II/84
Zone
Accessory Building:
Pnrkin9 Req./Provided -
ELECTRICAL ,
.Trensformer ❑ 15-50 KW _
❑ 50+ KW
Meter ❑up to 100,amps
Meter ❑over 100 amps
Z Sub Panel
Mowrs�0�1 HP�1X-8
�Inc.Solar �9-15 HP 016�7
Microwave
Pole Light �
Range
' Standing Sections
5 KW Trash Compactor
$15 Issue Fee
120�15 TL
FEES
$ 3
DEVELOPMENTSERVICESREQUIREMENTS:
2oninB APP�oved By Date
Building Approved By � Date / /'
llpplimtian luued By Date___y�(J �
' SUMMARV OF FEES
'� BUILDINGPERMIT $ SMIP $
PLAN CHECK � $ PERMIT
PLUMBING $ ISSUANCE $
�� PLAN CHECK 25% $ ENERGV P.C. $
ELECTRICAL $ G�-i�. �O GRADING $
E, PLANCHECK 50% $ ? .5.� MICROFI�M $
� MECHANICAL $ Z� �� �TOTAL FEE $ ��• � S
PLAN CHECK 25% $ �I'-��
G
Z
O
N
I
N
G
R
E
Q
M
T
S.
�
CONSTRUCTION AND PLANNING � POO� a SPA
APPROVALS Permit Date Inspector qppROVALS 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. �j 54. Forms �
4. Electrical Conduit-Undrgrnd. �� g 55. Electrical Bonding
.5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
. 6. Electrical UFER Grnd. � ��o � 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 ' 67. 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. fiough Electrical�Conduit 66. Solar System-Final �
16.; Rough Electric Wiring 7 1 V C 67. .Fencing & Access Approval
17. Rough Wiring Sign.� 68. APPROVED FOR PLASTERING
18. Rough Electrical�T Bar Ceiling 7�� C 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit #
21. Ducts, in Structure _•5 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. Ory Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrica� Power Meter-Final ' 80. FOOD CERTIFICATE ISSUED � f � r
, ,.
- 33. Final Electric Notes: �
34. Final Heating & Air Conditioning � C
8/c3�inJ c.r�.n '7 �b g' �au c� �2��c � �°
35. Final Gas Pipe-Test � �
36. Hood or Canopy �
37. Final Fac[ory Fireplace , '
38. Final Plumbing -
39. Water Service-Final + '
40. Gas Service-Final �
41. Solar pomestic-Final
42. Backflow Preventer � •
43. Backflow Irrigation , - _
44. ,Landscape Irriqation SYstem '
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING
48. Special Requirements Completed - ��
Ay
49. Electric Release to Edison • -
50. Gas Release to Southern California Gas Co �
. n-
51. CERTIFICATE OF OCCUPANCY �" ' '' r' .'
/t . i ,
No. Date ��n ' � j�� � o
�
e
• ADO�Icanl lo /Iil in all spaces axcepl those witnin neavY bo�Eer Iines antl sign all apDrop�iate Eeclarations.
CiTV OF cos7a —M-E1SA CONSTqR �T PE M T
Prolect Address { � O � • � • �' � �
Applicant's Mailin Address
Owner's Name � 0 hone
Address
Arch/Eng. Licenu No.
Address �L
Convactor's Nam�y � �" hone 7
Addresslmailingl�-J.�%�p V '�
GtyLicenseNo. ��.�pb�
tICENSED CONTRACTOR DECLARATION
1 heroby affirm that I am Ilcensetl untlor provisions of Charter 9(commencing
wltn section ]000) of Dlvislon 3 01 ne Buslne55 antl Pro/essions Cotle, antl
my Ilcenta is In tull orc an ettect. �� gt'
Uce�^�ps � �Ucense No. �
Dalc.�1.r��__ 99nature
WORKERS' COMVENSATION DECL FTION
I nereby atfirm tnat 1 have a cer[ititate of consen[ to selt-Inzure or a certificate
�f Wo�kers' Compensation InSu�anco, o� a certitie0 copy Ihe�eOIt ,(Sectlon
3800, Lab.L�r (�O12 �OZCompan ��� �- �`�"��
�+olitY No, -�i b �
C¢rti(ietl <opY �s hereby furnishetl.
Ce Yf Y' lea wrth the ciry eui iny �i sio�
-Oate � APplicdnt .� �� ��N�^
'�XEM TION FROM WORKERS' COMPENSATION DECLARATION
(This SactiOn neetl nat ba COmpletCtl it th¢ Pe�mit IS tor One buntlretl (5100) o�
iess).
,I certlfy [hat in the performance of [he work for wM1ich this oerm�t is Issuetl I
Shall nOt ¢mPloy dny person in any mdnn¢r so d5 So becoine subj¢<t to t�¢
Workers' Compensation Laws ot Calitornia.
Data � Sl9naturo
NOTICE: 1f, aft¢r making this Ceclaration, you shoultl become subject to tho
Workors' Componsation provlsions of the Labor Cotle, you musl forthwitn
Comply with suGh p�ovlsions or IhiS pe�ml[ shall be tleemetl revoketl.
CONSTRUCTION LENDING AGENCV
1 hereby atfirm tbal there is a conslruction lentlln9 agency4or the performanca
Ot th0 Work tOr whlth tni5 Permit is iisuetl (Sectlon 309] Civ. C.)
lantlor's Nama
Lentler's A�tlraSs _
OWNER BUILDER DECLARATION� �
I hereby afflrm Ihat I am exempl lrom tho ContraclorY Licenu L.aw tor tho
followin9 reason (Section 7031.5 Buslnass antl Professional [otle: AnY citY or
countY whiclt raquir¢5 a petTit [O coMt�uGt, all¢r, ImprOve, tlemolish Or repalr
any structure, prlor�to its Issuance, also requlres the applicant for such permlt
f0 �II¢ a Sign<4 StatNm¢nt tha[ M1e/S�e IS IicensaC pursuant t0 [he Provisionz ot
the Contractor'S Li<ense I�w (Cbapter 9(comm¢nNn9 with Section 7000) ot
OlviSion 3 ot Ne Buzineis antl ProfeiSions Cotle) or that h¢/Sha is exempt
therefrom anC the Dasis for the alle9etl ezemptlon. AnY violation oi Section
7031.5 by any applicant f0� a Permlt Subject5 the dppllcant [o a civll -
Q�enalty oi not more than (ive nuntlretl tlollars (E500).
U I, as owner ot the prop¢rty or my employ¢es witn wages as thei� SOIe
mmpensation, wlll do the work, antl the structure (s not (ntenCetl or ofteretl
for wle (Section 7044, Buslness antl Professional Catle: The Cantractor's
LicenSe Ldw tloes not apP�Y lo an owner ot a property who builAs or Improves
thereon, antl who tloes such work hlmself/nerselt or tnrough his or �er own
employ oes, provitlecl tnat such Improvements are not InlentleC or otferetl tor
ule. If, �owavGr, t�e bulltling cr ImprOvem¢nt IS soltl wlthin One year ot Com-
pletiOn, the owner will hdve (he burtlen Of provfng h¢/The tlttl nat �ufltl or IT-
�rove �orthe purpose of sale). .
I, ai owner ol the proPerty, am axcwsiveiy conhacting wun ucensee con-
[ractors [o construCt tna p/o�ect ISeclion 7044, BU51ne55 antl Prole55io�s COtlO:
Tha ConVactor's License 12w doos not apply to an ownev Of proporty wno
bu0tls or improvus theroon, antl who contracts for such pro�ects wilh a con-
tractor(5 Iicensn Pursuanl�to�the Contrac[or's Licensa Law). I am aware that
prooi O� th¢ir Worke�'s COTPenSdtlon insurance ShOultl be providetl t0 me.
❑ I am Bx¢mpt untl¢r Section B. & P, C. fOr thii reaion
Date
i nereoy cerufy tnat i
informa[ion Is mrrect. I
antl state laws relating t
sentatives of this city
inspection purpozes.
Signature
Drivers' Ucense or 55 �
the
a
abovo
TVPE OF CONSTRUCTION lJ NEW LJ ADD �ALTERATION LJ REPAIR
❑ CONVERSION ❑ DEMOlISH ❑ OTHER qp.,�
DESCRIPTION OF WORK/USE OF BLDG. S Main Builtli
E
TVPEOFPERMIT GRADING FOUNDATION STRUCTVRAL T Ffont
❑ TENANT ❑ ELECTRICAL ❑ PLVMBING I�v1ECHANICAL B Reel
� OTHER A
PROJECT DESCRIPTION 5a. FT. oCCUPArvCv C Right
K
CONSTRUCTIONTVPE VALUATION$ g Left
ZONE GRADING CU.Y�S. ACftES Ping. Fef. #
Remerks: , �'� �"� ' Planning Notes:
Sink
Irrigation
king Fountains
rt Drains
ir Sinks
Service OuHets
KitChen Sink
Lavatories
P-7rap
Roof Drains
, �.Reinspection'Fee -� $15
Boiler
DuCt- UnderGround
Duct - Structural
Duct - Ventilating
Exhaust System ❑ Multiple
Firepl/Fact. Blt. ICBO 5�k
Heeting System & Ducting
❑4100,000 BTU 0100,000
Rainzpection Fee � $15
tMF 0865-46, rev. 4/84 - White - Builtling; Canary - Appliwnh, Pink - Accountlng; GolOenrotl - Assessor
ShOwerS
Service Sink
Sewer Cap
Sewer Cannection
Solar Collectors
Solar Piping '
Solar Tank
Swimming Ppol w/Spa
Urinal ,
Wet¢r C105¢t
Water Heater
Water Service -
laue Fee
Hood or Typel ❑
Cunopy Type I I ❑ ,
Retrigeration $ystem
[�O�t00,000B7u ❑t00,000
System Repair/Alteretion -
Issue Fee
FEES
$ 3
F
S 3
Automatic Washer
Construction Pole Su
Cookin9 Unit
Dishwasher
Dryers ❑Gas ❑E6
Fan
F.A.U.
Fixtures
Device Boxes
Outlets
Switches
Garbage Disposal
Generator �65 KW
Fee
5324 8/01/84
Zone
Parking Req./Provided
ELECTRICAL
Transiormer ❑ 15-50 KW
❑ 50+ KW
Meter lJup ro 100 amps
Meter ❑over 100 amps
Sub Panel
Motors�04 HPO1'h-8
Inc.Solar �9-15 HP �16�15+
Miaowave
Pole Light
Range
Standing Sections
15 KW 7rash Compacmr
$75 Issue Fee
I BoO� TL.
FEES
$ 3
Z
O
N
I
N
G
R
E
�
M
T
$.
DEVELOPMENT SERVICES REQUIREMENTS:
Zoning Approved By Date
Building Approved By Date
Appliotion Issuad By— �+-b DatB_.�_
SUMMARV OF FEES '
BUILDING PERMIT $ SMIP $
PLAN CHECK $ PERMIT
PLUMBING $ ISSUANCE $
PLAN CHECK 25%� $ ENERG� P.C. $
ELECTRICAL 5 GRADING $
PLANCHECK 50% $ MICROFILM $
MECHANICAL $ �S•�O TOTALFEE $ I�
PLAN CHECK 25% $ 3 .e,O
�
CONSTRUCTION AND PLA�IIN � �I POV� & SPA . ,
APPROVALS Permit #�Y� Date Inspector qppROVALS Permit # Date Inspector
1. Temporary Electrical Service or Pole �., 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. � ' 53. Steel Reinforcement
3. Electrical Conduit Utility-Undigrnd. -� 54. Forms .
4:� Elect�ical Conduit-Undigrnd. . 55. Electrical Bonding - -�
� 5. Steel Reinforcement . , - 56. Rough Plumbing & Pressure Test . •
6� Electrical UFER Grnd. ' 57. APPROVAL TO COVER�GUNITE '
� 7. Footings ' ' • 58. Electrical ConduirUndrgrnd. �
.'$. Foundation �. . � 59. Gas Pipe, O Undrgrnd., Test �
9. Water Pipe-Undrgrnd. . � 60. Backwash Lines, P-Trap, O Undrgrnd.
id. Structural Floor Syitem 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 SYsrem - Final
14. Rough Plumbing •, � 65. Electrical-Final
15. Rough Elec[rical-Conduit � 66. Solar System�Final
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
78. 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 0 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. Fiame and Flashing 76. Dry Standpipe
28. Lathing & Siding 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 �f� f)tl �� ,
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 Irrigation
44. .Landscape Irripation System �
45. Sound � Attenuation
46. Handicap Regulations
47. FINALSTRUCTURE&BUILDING �
48. Special Requirements Completed
49. Electric Release to Edison �
50. Gas Release to Southem Califomia Gas Co � '
51. CERTIFICATE OF OCCUPANCY • '
No, Date
1
` �%1DD��cant to fill In all spaces except lhase wlt�in heavy borEer Ilnas antl sign all aoo�opriate aeelantions. ..
CiTv OF COS7A naESA COCNSTR CTION PERMIT
Project Address �� � �/ � �
Appliwnt's Mailin9 Addreu
Owner's Name NG hone
Address
Arch/Eng. License No.
Addreu
Contractor's Nam L� /h-o_ne ��
Addreulmailingb��Yy/1/• /�/L�IA�tN.+G /D�.Cl� �.iabLC�
Ciry License No. 9�-'�'
LICENSED CONTRACTOR DECLARATION '
I Ileleby'aftirT Nat I am IiCensetl untle! provi5I005Of ChdrtGr 9(commentin9
with.—section 7000) of Divislon 3 of tne 8usiness antl Professions Cotle, antl
my 1lcense is in tull rce eitect.
License Class �� - icense No..����
Date J� �� c'onar vn ���A»3o.PM _ __ __
WORKERS' COMVENSATION DECLARATION •
I hereby aftirm that I have a certificate of consent to zeli-insure or a certlficate
ot Workerz' Compensation Inwrance, or a certi(ietl copY thereof (Settion
3800, Lab. C.) � - -
Policy No. Company
Gertitietl copy is hereby fumisnetl.
rtifietl co '=tj�d wiih the city B' �ng Diviyo�Q '
Date ��'� APPlicant � /
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(Thissection neetl no[ Oe completetl"if the permit'i5 (or One hunGreG (E100) or-
lesz).
1 certity tbat in Ih¢ P<rformance ot [he wo�k for whlch [his permR Is issuetl I
shall not employ any pe�son in any mann¢r 50 as to Decome subjecl to t�e
Workers' Compensation�Laws o( Calitornia. �
Date Si9nature �
NOTICE: It, after making this tleclaration, yov shoultl becoma subjecl to the
Workers' Compensation provi5ion5 0( tne Labo� Cotle, you mu5t fOrt�with
compry .with, mch provisions o} this permil ihall De tleemed revokeC.
CONSTRUCTION�LEN�ING AGENCV '
1 hereby aftirm that there is a construction lentlin9 a9ency for tha performance
of the work /or wnich this permit iz Isiuetl (Section 309] Clv. C.)
LenEer's Name
LenUer's Atltlress
OWNER BUILDER DECI.ARATIOfi �- �
I hereby aHirm that I am exempt trom tne ContractorY Ucense Law for the
followin9 reason (Sectlon 7031.5 Buziness antl Professional Catle: Any city or
county whlcM1 reqWres a permlt IO con5l�utt, dllGr, improve, tlGTOlish o� �epair
any structure, pNar to itz-issuance, also requires the applicant tor such permit .
to tile a signetl statement [hat ne/she ts Ilcensetl pursuant to the oroviLons of
tne Contractor's License L.aw (Chapter 9(commencin9 witn SecHon ]000) of
Dlvision 3 oi tM1e BuSiness and PrOfessions Cotle) Or that he/she IS exempt
thera(rom antl the Casis for Ihe allegetl exemption. Any violaUon of Saclion
-7031.5 by any applicant to� a permit subjects the applitanl to d Clvil
�enalty of not more lhan live huntlree tlollars (E500). -
LJ 1, as owner o/ Ihe property or my employaei with wages as tneir sole
'compensation, will tlo the work, antl the structure Is not IntenOetl or ot(eretl
tor sale (Section i7044, BuSiness antl Professlonal Cotle: The Con[ractor's
License law tloes not apply to en owner o1 a property who builas or Improves
cnereo�, ana wno aoez s�cn wo.k nlms¢It/M1orsalf or [hrou9h his Or ner own
e.mployaes, provitletl lna[ such improvements are not intentlatl or oiferetl for
SdIG. I1, however, the builtlin9 G/ ImprOvemenl IS SOItl wlthin one yBar of com-
pletlon, the owner will have the burtlen ot provin9 he/she eltl not Duiltl or im-
�fOve tor the pufpo5e Ot sale). "
I, a5'own¢� of the pro0erty, am exclusively contracting with Ilcen58tl COn-
t�actorsto mnsVuct the pwject ($ection 7044, BUSin¢55 antl Protez5ion5 CoAe:
The Contractor's License Law tloes not app1Y to an owner of pro0erty who
bulltls or improves thereon, antl who contracts tor such pro7ects with a mn-
[rac[or(sl license pursuanl�to�[he�GonVactoYi License Law). I am aware tnat
O�oof o( lhei� Worker's COmpenSaliOn insu�ance ShOultl be ProvlUetl t0 me.
❑ I am exem0� untler Section B. & P. C. �o� this �eason
Date Owner
I hereby c¢�tity thdt I havG reatl lhi5 application antl State that tha above
information is correct. I agree to comply with all city antl county ortlinances
dntl�state laws relating to builtling conSVUC[ion, antl hereby autho�Iie repre-
sentatives of this' city to enter upon the above-ment{one0 prooerty for
Inspection pu�9� jo e5ti � ' ���
$i9nature lZ'XX'3 /R�/.`�'�"�DO Dat
Drivers' License or 55 �
►!� � �S .�
TYPE OFCONSTHUCTION NEW� ADD ALTERATION REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHER q.p..�s
DESCRIPTION OF WORK/USE OF BLDG.
S Main Building:
E
TVPE OF PEHMIT GRADING FOUNDATIOTN� STRVCTURAI T Front �
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING l(GMECHANICAL � 8 Rear
❑ OTHER %�
PROJECT DESCRIPTION Sci. FT. OCWPANCY C Right
K Left
CON STRUCTION TVPE .VALUATION S S
ZONE GRAOING CU.YDS. 'ACqES p�ng. Ref. #
Remarks: A���J���� �� � /�������L PlanningNotes:
Bar Sink ,
Backflow Preventer
Backflow Irrigation
Bathtubs
Clarifiers
Dishwasher '
Drinking Fountains
Floor Drains �
Floor Sinks
Gas Service Outlets
Interceptors
Kitchen Sink
Lavatories � .
P—Trap -
Roof Drains "
qeinspectian Fee � $15
Boiler
Duct-UnderGround
Duct - Structural
Duct - Ventilating
Exhaust System ❑ Multiple
Fiiepl/Fact. Blt. ICBO #
Heating System & Ducting .
❑aiao,000 eTu Diao.000
Reinspection Fee � $15
CMF 0865-46, rev. 4/84 Wnite - Builtling: Canary - APplicant; Pink - Accountin9; Goltlenrotl - AssaSsor
ShOwers
Service Sink
Sewer Cap
Sewer Connection
Solar Collecrors
Solar Piping
Solar Tank
Swimming Pool w�Spa
Urinal
Water Closet
Water Hearer
Water Service
Isue Fae
/Hood or Type I Q'
Canopy Typell ❑
Refrigeration System
❑0.100,OOOBTU ❑100,000
System Repair/Alteration
laue Fee
Automatic Washer
Construction Pole
Cooking Unit
Dishwasher
Dryers ❑Gas ❑
Fan
F.A.U.
Fixtures
Device Boxes
Outlets
1583 6/04/B4
Buildi
Parking Req./Provided
I8.00 TI
Zone
ELECTRICAL
Transformer ❑ 15�50 KW
❑ 50+KW
Meter LJup to 100amps
Meter �over700amps
lectric Sub Panel �
Motors O0.1 HP �1'/, - 6
Inc.Solar �9�75 HP �16
Mivowave
Pole Light
Runge
Garbage Disposal �Standing Sectians
Generator 00.5 KW 05-75 KW � Trash Compactor
$ 7 f
� Reinspection Fae $15 luue Fee
FEES
DEVELOPMENT SERVICES REQUIREMENTS:
j Zo�in9 APProved By
�� Building Approved By
Aoolifation Isssued Bv �� _ _ .
$ 3 � •
2
O
N
I
N
G
R
E
�
M
T
S.
FEES
5 3
SUMMARV OF FEES
BUILDING PERMIT $ SMIP $
PLAN CHECK $ PERMIT �
PLUMBING $ ISSUANCE $
PLAN CHECK 25% $ ENERGY P.C. $
ELECTRICAL $ GRADING $
PLAN CHECK 50% $ MICROFILM $ T�
/,Q o �_�
MECHANICAL - $ � TOTAL FEE $ 11�_
PLAN CHECK 25% $ 3 �
CONSTRUCTION AND PLANyN�ING •! � POOL & SPA .
APPROVALS Permit #�L4�r.��s� Date Inspector AppROVALS Permit # Date �Inspector
1. Temporary Electrical Service or Pole ,, 52. Pool & Equipment Location
' 2,Soil Pipe-Undrgrnd.; � �,;� 53. Steel Fieinforcement
. 3 jElecttical Conduit Utility-Undrgrnd. 54. Forms . �
4.-CElectrical Conduii-Undrgrnd. ' , 55. Electrical Bonding
5/Steel�Reinforcemen[ 56. Rough Plumbing & Pressure Test '
6. .Electrical UFER"Gmd. 57. APPROVAL TO COVER-GUNITE
� . ,-
7. Footings j:' � ' S8. Electrical Conduit-Undrgrnd.
�i � �. •
6" Fouritlation �,<j _ � ; 59. Gas Pipe, O Undrgrnd., Test
,9. Water�Pipe-Undrgrn{l. . � 60. BackwashLines,P�Trap,OUndrgrnd.
� �i
10. Structural Floor System , 61. APPROVAL TO DECK
i t. Property Sewer Line & House Corirrection : 62. Backwash & ReceptorFinal �
� 12. Sewer Cap �.• ` 63. Heater & Vent-Final '
n. ..
13. Roof Drains ,% ,�i .; ''� 64. Plumbing System • Final
�
14. Rough Plumbing - � 65. Electrical-Final .
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 �,� APPROVALS Permit #
21. DuCts, in Struc[ure ;� 70. Underground Hydro
22. Ducts, Ventilating � . 71. Product Piping � Gas ❑ Oil
3. Gas Pipe-Rough & Test ' 72. Underground Flush ,' �,'
. rhoof Framing • 73. Undergrnd. Storage Tank O Gas ❑ Oil .•�
�
: Roof Sheathing � • 74. Overhead Hydro : �'
�
26. T-Bar Ceiling (Structural) & Monocoat 75. D.ry Chemical �, I
27. Frame and F.lashing " 76. Dry Standpipe ' �
, .
28. Lathing & Siding - 77. FIXED SYSTEM FINAL y ' ,.
29: Insulation � 78. FIRE PREV. FINAL
30. Drywall Nailing " , HEALTH DEPT. REQUIREMENT ,-
31. Plaster Brown Coat � • � 79. FINAL INSPECTION
32. Electriral Power Meter-Final 80. FOOD CERTIFICATE ISSUED � -�
33. Final Electric Notes. � r ' � � : � - �
34. Final Heating & Air Conditioning � _
tS��3�d"t �--� � ./
35. Final Gas Pipe-Test � � � . � �P
36. Hood or Canopy �j �,� (, EO
37. Final Factor,y Fireplace � � �
38. Final Plumbing �
39. Water Service-Final
40. Gas Service-Final
41. Solar pomesticFinal _ y ` c.� �
�
42. Backflow Preventer ' �� � �,
.�
43. Backflow Irrigation •
44. Landscape Irrigation Sysiem �
45. Sound Attenuation
46. Handicap Regulations ' � �
47. FINAL STRUCTURE & BUILDING �
48. Special Requirements Completed
49. Electric Release to Edison '
. r
50. Gas Release to Southem California Gas Co � . , .� �
57. CERTIFICATEOFOCCUPANCY �!
No. ' Date � � �
��
�
1
� =
CITY OF COSTA MESA
CONSTRUCTION PERMIT
AOP��cant to fiil in a11 svaces excev< <hose within heavy eortler lines ana si9n ali aoo�aorlate Oeclarations.
ProjectAddress� �a-C1 ��� �"�� �"r
Applicant's Mailing Address �� � 1—Uv1H8
Owner's.Name hone
Address ,a� ��' • � �q�' S
Arch/Eng. License No.�
Address, '
Contractor's Name ��� " — � ���� �C�]-=�-{"��-� Phone y90-3413
Addresslmailing) � ��`� �����ir l..�fP�i� '`' �`�-F'a 1
atv �fen�se No. O t�i �-193
LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am Ilcensetl unEer provi5ions ot Charter 9(commencin9
with seclion 7000) of Dlvision 3 of the Bu5ine55 antl ProfeSsions Cotle, antl
my license is in full Porce antl elfect. ^ a
Ucense Class ' � � licqqse No. �
Date �^ �^�_k '�_ Si9nature '�
WORKERS' COMPENSATION DECLARATION �
`1 hereby afiirm that I have a certificate o� tonsenc to selftinsure or a certlficate •
�bf Workers' Compensatlon Insurance, or a certifietl-copy therea! (Section
f 3800, Lab. C.) � 1 ,. p�-f�. '
Policy No.lilC�.fa�73SD company L�`��"�` �`1�-��Iv
�Certltietl copy is hereby fumishetl.
certit�ea co�ty�s tiietl witn tne'tlty B iitlln� r.fti,v�-i-si
Date (�+--�r-� APPlicant �n ^�^ � ���'�1� ,
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION- �'�
(Thismction neetl not be completetl if the permlt�is for one huntl'retl (E300) or
lezs)
I certify that in the performance ot the work for whlch this oerm�t is issuetl 1
shall not employ any person in any manner so as to becoma subject to t�e
Workers' Compensatlon Laws of Califomia. '
Date Si9nature
NOTICE: It, after making this tleclaration, You shoultl become subject to the
Workers' Gompen5ation Provisions ot tne Labor Cotle, �you must (orthwith -
comply wlth� such provi5ions or. this;,permi[ shail be tleematl revoketl. �
CONSTRUCTION LENDING AGEIVCV' �
�, 1 h¢reby aftirm that fher0 i5 a constructlon IenCing agency tor the p¢rformanc¢
i of the work for which tnis permlt is issuetl (SecHon 3097 Civ. �C.)
Lentler's Name . . .
Lentler•s Atltlress
OWNER BUILDER �ECLARATION �
I hereby a(tirm thal I am exempt irom lhe Contractor•s License l.aw tor the
following reason (Section 7031.5 Business antl Professional Cotle: Any ciry or
county w�icn requi�es 2 pe�mlt to <on5t�uct, alte�, Improve, tlemOliSn o� �epai�
�any structure, prior to Its issuance, also requires the applicant for such Oermit
to file a signetl statement that he/zhe is litensetl pursuant to lhe provisions of
the Contractor's�License Law (Chapt¢r 9(commencln9 with Section 7000).ot '
71vl5ion-3 of the BuSiness anA Prof¢SSions Cotle) or that h¢/Sh¢ is e%empt
ierefrom antl the basis (o(the alle9etl axemption. Any violation ot Section
J33.5 by any applicant Tor a permk subjeccs the_applicant to a civil.
�enalty of not more lhan five huntlretl tlollars (5500).
1;' a5 owne� ot the� O�operty or �my em0�oyee5 with wages as thei� So10
compenzatlon, will ao the work, antl the structure is not Intentletl or otferea
tor sale (Section 7044, Business anG Professional Cotle: The Contractor•s
License Law tloes not apply fo an owner ot a proper[y who builtls o� ImOroveS
thereon, and who Uoes such work himself/hersel! or tnrough nis or har own
employ ees, provitletl thaf such Improvemen[s are not intenUetl or ofteretl for �
sale. I1, howev¢r, tne builtling or improvement is-Soltl within One year of com-
pletlon, the owner will have'tha burtlen o( provin9 he/she tlla not builtl or im-
�rove fortne purpose ot sale). '
I, as owner of [he property, a�m excluslvely contractlng with Iicensetl con-
t�att0/s to <onst�uct the p�ofect (Section J044, Business antl Pro/essions Cotle:
Tne Contractor's License Law tloes not apply to an owner of property wno
builds or improves thereon, antl who contracts for such pro7ecls with a con-
tractor(s) license pursuant to roe Contractor'S License Law).
❑ I am exempt untler $ectlon B. & P. C. 1or fhis reason
Dafe Owner
I hereby certify that I have reai
information is COIfecL I agree to
antl state laws relating to builtlin
sentaiives of this ci to ter
inSPettlon PS1W 5M.
fate that the above
a county ortlfnanres
•by aulhorize repre-
lonetl 'property ,tJor
�at -,�[(_�4_
TVPE OF CONSTRUCTION LI NEW I� ADD LI ALTERATION LI REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHER_
DESCRIPTIQN OF WOi�K �_'^' , �", -K �DUF N L�Ia- �iO
TVPE OF PERMIT L� GRADING � LI FOUNDATION LI'STRVGTURAL
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL
❑ OTHER
PROJECT DESCRIPTION SQ. FT. ' OCCVPANCV_{��
CONSTRUCTIONTVGE � VALUATION$�5j
20NE GF3ADINGCV.VDS. ACRES_
Remarks:
Bar Sink
Backflow Preventer
Backflow Irrigation
Bathtubs '
Clarifiers .
Dishwasher ' -
Drinking Fountains �
Floor Orains
Floor Sinks '
Gas Service "Outlets
Kitchen Sink
lavatories �
P-Trap
Roof Drains �
Reinspection Fee $25,
Boiler
Duct - Under Ground .
Duct - Structural
Duct - Ventilating '
Exhaust System ❑ Multiple
Firepl/FacL Blt. ICBO #
Heating System & Ductin9
❑ ai oo,000 sru O i oo,aoo
S�gnature � � e I I
D I e 5 LI 55 � Reinspection Fea
CMF 0865-4fi rev. ]/83 W��te - Builtling: Canary - ApO���nh Pink - Accountin9: Goltlenrotl -Assessor
�
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
Solar Piping . '
Solar Tank
Swimming Pool w/Spa
Urinal
Water Closet .
Water Heater
�WaterService �
Iwue Fee
Hoodar Typel ❑
Canopy Type I I ❑
Refrigeration System .
❑ai oo,000 eTu ❑ i oo,000 aTu
System Repair/Alteration
laue Fee I $ 3
�
A.P.SW .— ej
S Main Building:
E
T Front
A Rear
C Right
SLeft
P�ng. Ref. #
Parking Req./Provided
UseOfBuilding: �
Planning Notes: �
Automatic Washer
Cooking Unit
Dishwasher
Dryers ❑Ga
Fan
F.A.U.
Fixtures
Device Boxes
3560 7/p6/84 _ qy,,, ,
a Zone `� �
Accessory Building: 2
_ O
N
1
N
G .
� R
E
Park.Fees $ ' n
U
I
R
E -
M
• . N :
� T .
ELECTRICAL
7ransformer ❑ 15�50 KW
❑ 50+KW
-' Meter �up to 100 amps •' -
Meter pover100amps �,
Switches
Garbage Disposal
Generator �65 KW 05-15 KW
Sub Panel
Motors D O-7 HP � 1 X- 8
Inc.Solar �9-15 HP �16-15+
Microwave �
Pole Light '
Range
Sign
Standing Sections �
Trash Compactor
� Reinspeaion Fee �$25 � Issue Fee
PUBLIC`SERVICES REQUIREMENTS:
Zoning Appraved By
Application Approved By
Application Issued By
BUILDING PERMIT
PLAN CHECK
PLUMBING
PIAN CHECK
ELECTRICAL
P�AN CHECK
MECHANICAL
PLAN CHECK
FEES
$ 3
SUMMARV OF FEESg��qGvnc.G �Y:/- •J�
$ �q� • 1� SMIP $
$ � l • � % PERMIT
$ ISSUANCE $
$ ENERGV P.C. $
$ GRADING $
$ MICROFILM $ '
5 TOTAL FEE $ y9 • 17
$
1.1.c�OreS
CONSTRUCTION AND PLANNING , -� - PO01. JPA
APPROVALS Permit# Date .Inspector� APpROVALS Permit# Date Inspector
1. Temporary Electrical Service or Pole � � 52. Pool & Equipment Location
2. Soit�Pipe-Undrgrnd. � 53. Steel Feinforcement � �
_ 3.`Elecfrical Conduit Utility-Undrgmd. - � 54. Forms . � � ' '
4. Electrical.Conduit-Undrgrnd. - ,, • 55. Electrical Bonding
5. Steel Reinfarcement � ' , � � 56. Rough Plumbing & Pressure Test
6. Electr.ical UFER Gmd. 57. APPROVAL TO COVER-GUNITE ,'
7. •Footings ' 58. Electrical Conduit-Undrgrnd. �
8. Foundation � ` . . � 59. Gas Pipe, � Undrgrnd., Test � ,
9. Water. Pipe�Undrgrnd. - 60. Backwash Lines, P-Trap, O Undrgrnd.
10. Structural Floor System 61. APPROVA'L TO DECK
� 11. Property Spwer 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 '
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 Facto�y Fireplace � APPROVALS Permit #
21. Ducts, in Struaure 70. Underground Hydro �
22. Duas, Ventilating � 71. Product Piping OGas 'OOiI
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�(Structuraq & Monocoat 75. Dry Chemical- ,
27. Frame and Flashing ' � 76. Dry Standpipe �
28. Lathing & Siding . , 77. FIXED SYSTEM FINAL -3` "
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 •
estic-Final , . �
sreventer � � '
rrigation . � � - -�
�� Irrigation System ' � �
[enuation .
iegulations � �
RUCTURE&BUILDING -
quirements Campleted , �
�lease to Edison . ' - � i_
i
��e to Southern California Gas Co �
:ATE OF OCCUPANCY .
Date � �
'� � J � . �� ._� \.
�� � ' 4`��� FEE �RECEIVED
, ,y , .
COSTA MFr$A BUILDING DEPARTMENT •� ��� C�_s� ��J
� P. o. eoX 3,� � fINANCE DEPL �
� COSTA MESA. CALIFORNIA � �
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
COSTA MESA. CA�IFORNIA
CITV L.4`�
ARCHITECT
OR ENGINEEF
ADD�
1�43Y, T
covi �..croR
ADDRE55 �
LEGwL LOT
DESCRIPtION NO. i
A.P. NO.
5�=E g� �
OF LOT
USE OF
E%ISTING BLDG.
c.�. �y'� �f
,� TEL. �_ � � �
� �/ NO.
d �-�^--Cr � i c.
�o. R 240
�
�o'
iTv uc.
�o. a c� o
.i�C L. �' .�
� �
JCK TRACT
No.oF e�ocs. 0
MOW ON LOT
SETBiCN LINE FROM �1 1 �
CErviER OF SinEEi � i- REAR VARD { O
SIDE YARD RIGHT i 3'L ,� LEFT ZS , T 'I
DESCRIPTION OF WORK
NEW ALTERATION ADDITION
REP!' MOVING ' DEMOLISN
BUIi .G � q � NO.OF I
SIZE �1�iOO ROOMS 7 STORIES �
EXTERIOR WALL ROOF C����
COVERING �.�GD COVERING ,1 I
USE OF NEW G� t I A 1... T !/. I
9U1
A P P L��FC�IQS�P�� E R M I T
BUILDING
FOR OFFICE USE ONLY
RECEIPT NO. PERMIT NO.
�,CSD '
NECEIVfD BY DnTE RECErvEO OATE ISSUEI
- -� �__�_,- �_ � �
COSTA MESA. CALIFORNIA
APPROVED
BY
SUBJEC�
OATE y � �
IONS
-�p(AN T GN.
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1 MEREBV /�CKNOWLE�GE TM4T I MPVE REFO THIS FPPlICP1iVrv nrvY
$TATE iMRT THE iBOVE I$ CORRECT ANO 4GREE TO COMPLV WITM RLL
CITY OROINRNCE$ PND ATE 1A1N5 REG(1LATING BVILDING CONSTRl1C�
iiorv. I ^ � VALUATION
SIGNATURE OF �l � 2/ p3O PERMiT FEE S
PERMITTEE "� � �
� PLAN CHECK S
AUTHORI2ED AGENT TOTAL FEE $
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CC3TA MESA BUILDING-SAFETY DEPARTMENT
,� BOX 1200 COSTA MESA,CALIFORNIA 92626
For Applicant to Fill in Completely — Use Ink Only
BUILDING i%/� � w 1 '�{ fi H St
ADDRESS I�v �/ V V �
OWNER �. K• �AM
ADDFESS �n M� �) S R Q�o ��
CITY INS�R 1_' C.S � NO�. V�'�'1
CANSTRU�ION �
IFNnFR NONfL.
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ADDqESS
AODRESS S '�V`Q F(j rS�'j.O�JlL
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CITY NO.
F STATE CITY
� LIC. NO. LIC. NO.
a O'F LOT J. (� ZOO NOW ON LO S'1
a USE OF '
.�. EXISTING BLDG. C � C..0 S
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FSeparate permits are required for
� electric, plumbing and heating work.
F VSE OF BUILDING AND WORK TO BE PERFORMED
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BUILDING
ADDRESS
OWNER
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1046 il�/26/78
FORSTRUCTURALPERMIT
DATE RECEfVED nnTr �cc�i�
_ 1 �� _ ��JPERMIT NO. �
J �I
o 1,.� . I 9'1 S'f'
f 1
J� 2� �OT � j 2 BLOCK
E P M
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� VALU$
^ /VPE 1i0UP '
/ l ..__�� 7— /�
ZONEG I NO.OF
PLANS S
V AROS APPRO V ED
MAIN BUIIDING
IFROM C/L STREET)
BET.
VAR. �
C.U.P.�
APPROVED � W
USE OF NEW
BUILDING
VAflDS Af
ACCESSOR'
/
T .
I hereby dcknowled8e that I heve reatl this appllcatlon end stata '
that the 8bove info�metlon is correct and apree to comply with
ell laws r¢9uleting buildine constructlon, entl I shall not employ
any oerson In vlolation of the workmen's eompensetion Iaws of
the State of Californle.
I hereby Certify [hat I am properly Iicansetl as a contractor untle� SQ. FT.
ihe Stace of Californie eusiness antl Professions Code, Dlvision 3, -THE AMOUNT SHOWN UNDER VALU
Chapter 9, antl thet sueh Iicenses nre in full forca an6'effect, or I THE PURPOSE OF ESTABLISHING A PERP
am axempt from Ne provistons of t�e Srote of Cellfornia Buslness VALUAYION PERMIT FEE $
antl Professions Cotle, Division , Chapter 9. /p
Signaiare of `� / /� //��)� PLAN CHECK $
Permittae I 5�`1 (/ U ' TAX $
Auihorizatl Agent � / � `/ TOTAI PAI D S
23.00 TL'
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