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HomeMy WebLinkAbout178 19TH ST - Building Permits ' 4I CITY OF COSTA MESA • 4 t. BUILDING DIVISION Y • ; fl,;' � " DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER PERMIT t. B06-00700 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.g4MLDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 178 E 19TH ST Status: ISSUED Suite: Applied: 05/092006 Vicinity: GARAGE Issued: 05222006 Primary Occ: U1 Type of Construction: V-N Parcel Number: 42603107 Zoning: Applicant: DAVIS, CLINTON Address: 27111 ALISO CREEK ROAD /1, /-� STE 150 Phone: 949-588-8753 ISSUED BY: (/1'Y p ALISO VIEJO,CA Zip: 92656 Owner: BARKER, DORIS V TR • EXTENSION Address PO BOX 10642 Phone: AI,�,O WED COSTA MESA,CA Zip: 92627 A.I PER Contractor: AMERICAN TIMBER STRUCTURES INC EXPIRES d � p Address: , 23411 LAGUNA HILLS DR CX JiSa 11, STE K Phone: 949-588-8757 - y�`` ALISO VIEJO,CA r Zip: 92656 License: 838051 VS?I. D II�, Y ' Arch : Eng: "etc 1� Address: - Address: flA Phone: Phone: Zip: License: License: i SCOPE OF PERMIT DEMOLISH DETACHED GARAGE,APPROX 901SF. • OWNER TO CONTACT AQMD. FEE SUMMARY Plan Check: $45.01 Calc Valuation: $2,000.00 Permit: $69.25 Claim Valuation: $2,000.00 SMIP Res: $0.50 • SMIP Corn: $0.00 • Other: $0.00 Inspection: $0.00 Total: $114.76 PLANNING &ZONING SETBACKS , ��. MAIN STRUCTURt Front ,0-13',„ < , Rear " 0-0 Left 0-0 Right 0-0. , ACCESSORY Front 0 0 Rear 0-0 - Left 0-0 ,.. Right 0-0 PARKING ' -0, ' Required: 0 - - Proposed; 0 • • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days,or If work Is suspended or abandoned for a period of 180 days, INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2448.48 WOO) DECLARATIONS WORKERS'COMPENSATION DECLARATION: . I hereby affirm under penalty of perjury one of the following declarations: • , ' ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work tot which this permit is Issued. As I have andwill maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. —My wo)kers�'�^compensation Insurance carrier and polite umber are: I II 11 /��r— ^� p Carier:�Th•fTa-I'� Cc Me-cn Ste, Ito n � .n S v ra.n�G �n/ POIky.Number._ �-r C�Ili (This section need not be completeb it the permit Is valued at one hundred dollars(5100)or less.) tc I certify that in the performance of the work for which this permit is Issued,I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith complycomply_with,theseMpos. Ap`pl( Signature: SDa 5-72-0,6 WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TOONE HUNDRED THOUSAND DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licerysad under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Busigess and Professions Code,and my license is In full force end effect_LI s-. 6 3 S C-�( Class q I3 ( /M � Coors. ntractSignature: Date: S/2 Z/1)G CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is issued.(Sec.3097,Civil Code). Lender's Name: • Lenders Address: Signature: • :--T•- • Date: OWNER-BUILDER DECLARATIONS: • 4' - . . I hereby affirm that under penalty of perjury thatlamEXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Ls licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation.WILL DO THE WORK,and the structure Is not Intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or Improves thereon,and who does such work himself or herself orthrough his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of.the properly,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: • Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Drivels License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five(5)or more feet In depth Into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any ono time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ._ _.__.i_ing occupant ..._ _ _ ___...._....__ ___. 3 Does or will the applicant or present or future builtlinp occupant need to prepare an RM-PP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 8 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 —Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school'? 0 Yes 0 No (If yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which-Ts-the subject of thts application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No _...._..._. ....... 8 (If yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Leg ner(s) 57z Z/D�e AnnNOr.Autho•rirized'Applicant CODE! I1ISPECPON TYPE SAIF Ifal COPF( INSPECTIONTYPE DAIS INTEL$ • 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical • 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 , Final Demolition - 250 Final Bullding/Occupency - \ ' M CITY OF COSTA MESA < ►� BUILDING DIVISION >4l'.',,'' ''_t--`� DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER f t _7 PERMIT 806-00699 %Panano 4? (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.BMILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 178 E 19TH ST Status: ISSUED Suite: Applied: 05/09/2006 Vicinity: HOUSE Issued: 05/22/2006 Primary Occ: R3 Type of Construction: V-N Parcel Number: 42603107 Zoning: Applicant: DAVIS, CLINTON Address: 27111 ALISO CREEK ROAD STE 150 - Phone: 949--EXTLW f ALISO VIEJO,CA Zip: 926 i Owner: BARKER, DORIS V TR ALS. ED Address PO BOX 10642 - Phone: PER E COSTA MESA,CA Zip: 92627 '/ Contractor: AMERICAN TIMBER STRUCTURES INC EXPIRES 42/7/o Address: 23411 LAGUNA HILLS DR STE K Phone: 949-588-8757 r1 ALISO VIEJO,CA FjX+P ' iFJ_ ' Zip: 92656, License: 838051 it Is Arch : ' ' Eng: DATE ' Address: Address: Phone: Phone: Zip: - License: . License: SCOPE OF PERMIT DEMOLISH APPROX 1,246SF HOUSE AND DETACHED GARAGE. OWNER TO CONTACT AQMD. FEE SUMMARY Plan Check: $45.01 Calc Valuation: $2,000.00 Permit:, $69.25Claim Valuation: $2,000.00 SMTP Res: $0.50 SMIP Com: $0.00 • Other: $0.00 Inspection: $0.00 Total: $114.76 • • PLANNING &ZONING SETBACKS N, o - - i ' 2 MAIN STRUCTURE Front, 0-0 '' Rear 0-0 -- Left 0-0 Right 0-0- ACCESSORY Front 0-0 - Rear-' 0-'0 - Left 0-0 -Right .0-0 ' PARKING .Existing: 0. , - Required: 0 Proposed: 0 • • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days,or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and ell required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 /� 244846(WOO) J/ DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: . , • , 0 I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. J .1 have and vr0 maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this penNt Is issued: C —My wLork` r�I°mpen/sgtion Insurance HoIarder agdpQiicy number are: 1 r,` • C 1 q Cartier ,J7 LC- C-rrnee..lw t.on _.1—p.s.,rc,-..e. cur.. Policy.Number: O I (Thi section need not be completed It the permit/s valued of one hundred dollars($100)or less.) • I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply th these p a oris. 7 [ -2.A / Applicant Signature: 1 rDate:--Sr/2-2 b(, WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(SI D3.000),IN ADDmON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed,u�+der provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is In full force and'effect'Ltc70-�7-3 L�D5/ /Clays p L Contractor's SignatGre7- CC�A/,�.__.... VDaate:--�•S27./L76 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is Issued.(Sec.3097,Civil Code). Lender's Name: Lenders Address: Signature: ' t Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business end Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not Intended or offered for sale(Sec. 7044,Business and Professions Cale:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth Into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Wit the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous ' material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). __ __ _ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Flre Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare en RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aermit fm or such construction ormodification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ui Yes U No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 8 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No (If yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the Cash Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to ocatpy or allow occupancy of any building authorized by this permit until final inspection. / SignatureO al Owner(s) Datz /`And/Or Authorized Applicant r--Dote- - - CON I -INSPECTION TYPE PATE ItiEULS $ODES INSPECTIONTYPE QAIE IMOLA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing • 200 Final Re-Roof - 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Flre Prevention 202 Final Factory Fire Place - • 220 Final Planning Approval - ' 203 Final Sign 222 Final Site • 204 Final Demolition, - 250 Final Building/Occupancy CITY OF COSTA MESA 4 t BUILDING DIVISION >/lDEVELOPMENT SERVICES DEPARTMENT v. 1 j % PERMIT ' n .4* • E06-00442 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa€tfTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 178 E 19TH ST Status: ISSUED Suite No Applied: 05/09/2006 Vicinity: HOUSE AND GARAGE Issued: 05/222006 Parcel Nunmber: 42603107 Applicant:ddressDAVIS, CLINTON Address: 27111 ALISO CREEK ROAD STE 150 Phone: 949-588-8753 ISSUED BY: ALISO VIEJO,CA Zip 92656 Owner: BARKER,-DORIS‘i TR Address PO BOX 10642 EXTENSION Phone: ED ,COSTA MESA,CA Zip: 92627 p Contractor. AMERICAN TIMBER STRUCTURES INC PER , Address: 23411 LAGUNA HILLS DR EXPIRES �/1 o8 . STE K Phone: 949-588-8757 ALISO VIEJO,CA Zip: 92656 License:838051 • at 1 SCOPE OF PERMIT SIC f ' a ELECTRIAL CAP FOR DEMO OF SFD AND DETACHED GARAGE. - / 1 1 / ' REF#:B06-00699 AND 806-00700 oar • FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 • Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $0.00 0 - - Misc Electrical Equipment $0.00 0 New Res(3+units) ' $0.00 '0 - Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 0, Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0 ' 'Switches $0.00 0 over 100 kva/kw $0.00 0 Non Res Appl ' $0.00 0 • Low Voltage Equipment $0.00 0 Res Appl - $0.00 . 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 - Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor _ $0.00 0 Service over 1000a $0.00; .i '- '0., - Circus(gen or ride), ' - $0.00 0- ' Motors to 1hp '' i' $0.00` 0 - , " - - Circus(meth ride or lights) ' '$0.00 0 Motors to 10hp ' % $0.00 c-,0 <-S Christmas Tree Stand - - '-$0.00 0 Motors to 50hp \ $0.00 0,,,;,o - Fireworks Stand - - $0.00 0 , Motors to 100hp $0.00. -0 -'S . - Other Electrical Fee " - " $18.20 Motors over 100hp $0.00 . 0 Communication drops ' N . $0,00• , 0 Investigation Fee Sub panel to 200a $0.00 0 Plan Check Fee $0.00 , Pole Light Pkg N,,,,$0.00 0' , ,- , 'Reinspection Fee, _ $0.00 Sign Circuits $0.00- 0"2. Temp Pwr Pole $0.00 , 0 - , TOTAL CALCULATED FEES $41.70 Intermed Pole $0.00 - 0 / COMMENTS/SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under'California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days,or If work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes,and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 244&46(8/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: - ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 1 have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. I pMy s compensation Insurance Carries and polio number are: 1 , q C reri r. C- ( nWi�e✓1Sa Tton 1�IA SII�eL CP- �,r/ Policy.Number. tT fl ' (This section need not be completed i the permit is valued at one hundred dollars($100)or less.) tif I certify that In the performance of the work for which this permit Is Issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with thoseoviilops. 4,2 Applicant Signat } Date: /ZZ�d� WARNING"FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby atfirm.that lam licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of1the.BusineM and Professions Code,and my license Is in full force and effect.,Lied F3 FOS--/ Class a •h Cant Signature: Date:----5"72_770C CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Cale). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: t, " ;'C','r 1 hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she Is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not Intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such Improvements are not intended or offered for sale.If,however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractors) • license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth Into which a person Is required to descend,will be made In connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title B,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions.that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or WOO-building-Occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constmcted under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescnbed by California Health and Safety Code Section 42303 been made? 0 Yes ❑No 8 (ll yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPUANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPUANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. cie _ Sign re Of Legal Owner(s) Date LAnd/Or Authorized Applicant • (Date��- LODE E tfSPED1lON TYPE QAIE 91Im8LS ODE INSPECTION TYPE Qd1E RMIIALE • 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final.Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 , Final Building/Occupancy . itt CITY OF COSTA MESA • 4 @ BUILDING DIVISION o r� �1 8 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER } i pr i 4 PERMIT E06-00503 (714)754-5273 • Fax(714)754-4856 • www.ci.costa•mesaELEsCTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 178 E 19TH ST Status: ISSUED Suite No Applied: 05/22/2006 Vicinity: Issued: 05/22/2006 Parcel Nunmber: 42603107 Applicant: DAVIS, CLINTON Address: 27111 ALISO CREEK ROAD - ISSUED BY: • SUITE 150 Phone: 949-588-8753 1 ALISO VIEJO,CA Zip 92656 Owner: BARKER,"DORIS VTR ; EXTENSION Address PO BOX 10642 Phone: ^T A _ D .COSTA MESA,CA' Zip: 92627 . PER i Contractor:- AMERICAN TIMBER STRUCTURES INC EXPIRES 44/o g Address: 23411,LACUNA HILLS DR . STEK r Phone:-949-588-8757 ALISO VIEJO,CA Zip: 92656lc wwrr,, - - License:838051 ��,Y SCOPE OF PERMIT . pATE TEMP POWER POLE. FEE SUMMARY Quantity Quantity • ISSUE FEE $23.50 : - - .' Temp Dist System/Lighting $0.00 0 Temp service test $0.00 - Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section - $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0" - Transformers up to 1 kva/kw $0.00 0 Pool/,Spa $0.00 - 0 ---_- - - -up to 10 kva/kw , $0.00 0 , •Lighting Fixts- $0.00 0 - - up to 50 kva/kw $0.00 0 - Recept Outlets $0.00 0 ,up to 100 kva/kw $0.00 0 Switches $0.00 0 ' over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl' , , $0.00 0 Low Volt Wiring System/Ckt $0.00 -0 Service to 200a $0.00 0 ,.• 'Misc.Conduit $0.00 ' 0 - Service to 1000a $0.00 ' 0 ' .. • Misc.Conductor $0.00 0 Service over 1000a ;$0.00 0 - . ' " Circus(gen'or ride) $0.00 ' 0 Motors to 1 hp •,$0.00 0 Circus(mech ride or lights) $0.00 0 . Motors to 10hp $0.00y,� 0;'r.'" ' : Christmas Tree Stand - $0.00' 0 . Motors to 50hp . �: $0.00 �,. 0 ' " Fireworks Stand --$0.00 ' 0 Motors to 100hp ' ' $0.00' -.‘.‘,.,‘:-.,,,,C1 ;- c Other Electrical Fee - $0.00 7- - Motors over 100hp ' ' $0,00 _ „ 0h ^" _ . - , Communication drops $0.00 - 0. Investigation Fee - $0.00 Sub panel to 200a - $0.00 -', 0 Plan Check Fee . $0.00 Pole Light Pkg �;_ $0.00 �0 - -Reinspection Fee ' ' , $0.00 , Sign Circuits - $0.00 ' 0 - Temp Pwr Pole "$23.50-, ' ' 1 TOTAL CALCULATED FEES $47.00 - " Intermed Pole $0.00 .. , 0 4 • . COMMENTS/SPECIAL CONDITIONS • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92.28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days,or if work is suspended or abandoned fora period of 180 days. • INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicagle codes, and all required Inspections and final approval must be obtained.Failure to obtain Inspections and final approval will result In the expiratio of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(WOO) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ' • 0 I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. • kr I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. My works(T�( compens,tion Insurance carier andpakcv number are:( i'� -�-Came �izc-E C O PJt.54LOn '_,nS tiravlce. i�+� Policyr Number:_- 1 �L L-+�`I ( (h/section need not be completed i/the permit is valued at one hundred dollars($700)or less.) 4 p I certify that in the performance of the work for which this permit is Issued,I shall not employ any person in any manner so as to become subject to the workers' • compensation laws of California,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these pr Isi ns AbplicantSigneiure: ,Date:— r/z Z/(E. WARMNG"FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOI ARE(S100,000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 370S OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Busineffis and Professions Code,and my license is In full force and effect.Lic.# [Cleat*, Contractor's Signature:k -v,� / - Dete: 1/4-7.c z2. t, CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I Nim EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a,permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement Is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of properly who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: . 4 Date: Owner ID verified by drivers license. - 0 Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person Is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,Califomia Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: • Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or presenter fdture building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 Iran RMPP is presently required,has Section 25534 of the California Health and Safely Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes I]No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ,..Si%elutefegD to c azo t. ArdOr Authorized Applicant ( Date.-,_ CODE I INSPECTION TYPE PATE INTRIALS ' CODES INSPECTION TYPE PATE PERM - 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Fidel Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place . 220 Final Planning Approval 203 Final Sign 222 Final Site 204,,,- Final Demolition - _ 250 Final Building/Occupancy ' M ' CITY OF COSTA MESA o ►� BUILDING DIVISION > y ___ DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER �t !s PERMIT • I, 1 P06-00340 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa�IUMBING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 178 E 19TH ST Status: ISSUED Suite No Applied: 05/09/2006 • Issued: 05/22/2006 Vicinity: HOUSE AND GARAGE Parcel Nunmber: 42603107 Applicant: DAVIS, CLINTON Address: 27111 ALISO CREEK ROAD - ISSUED BY: STE 150 - Phone: 949-588-8753 ALISO VIEJO,CA _ - Zip: 92656 Owner: BARKER, DORIS V TR EXTENSION Address PO BOX 10642 ALL Phone: ra o iL �{ Y./ COSTA MESA,CA Zip: 92627 PER j• Contractor:-, AMERICAN TIMBER STRUCTURES INC EXPIRES 0114/Oct Address: ' 23411 LAGUNA HILLS DR STE r K Phone: 949-588-8757 ALISO VIEJO,CA • ; Zip: 92656 • .License: 838051 • ' • • SCOPE OF PERMITiltr: r�a- SEWER CAP FOR DEMO OF SFD AND DETACHED GARAGE. , REF#:606-00699 AND B06-00700 - - - Dia 6 ' - ',- FEE SUMMARY - ' - AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 . Sump Pump $0.00 0 . Backflow irrigation - ' $0.00 0 -, Landscape Irrigatioh- $0.00` '0 Swimming Pool $0.00 0 Backflow Preventer , $0.00 0 L.,. - -P-Trap --- d H.$0.00 0 Trap Primer $0.00 0 Bathtub ` - $0.00 0 - Pressure Regulator .$0.00. 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank _ -$0.00 0 Wash Basin $0.00 0 Dishwasher', $0.00 0' Sewer Cap for Demo $9.80 1' Wash Basin Set $0.00 0 Drain,Floor `$0.00 0 Sewer Connect.,. , $0.00 0 Waste and Vent System- $0.00 0 Drain,Rainwater , ' $0.00 0 ; - Sewer Private Line . $0.00 0 Water Closet(Toilet) $0.00 0 Drain,Roof., $0.00 0 - Shower i $0.00 0 Water Heater/vent $0.00 0 Drinking Fountain $0.00,,,,, 0Sink,bar $0.00 -0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tanks -- $0.00 '- 0 3-." Sink,commercial $0.00 0 - - Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 '\O .c - "-Sink,Floor - -$0.00 0 -Water Service $0.00 0 • Gas(1-4 outlets) 7$0.00 0�-,�...,, (Sink,kitchen - - $0.00 0 Water Softener ' ' $0.00 0 Gas(Over 4 outlets)• - $0.000 0 '...,...-„,,i,....‘„:,Sink,service/mop $0.00 0 OTHER" - $0.00 Gas Repipe $0.00 0. '-Spa(private) - $0.00 0 .VIOLATION $0.00 Gas Service '- . $0.00' ' 0 • _ -Spa(public) , - -- . -$0.00 -0 ' PLAN CHECK $0.00 Interceptors(Grease,Oil),''$0.00 .,. , 0( - - REINSPECTION $0.00 0 Interceptors(Sand Auto) N,$0:00 0' , 1 '�-, - , ' TOTAL CALCULATED FEES: $33.30 ='COMMENTS/SPECIAL CONDITIONS ' " • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) r EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days,or if work is suspended o abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-+8(WOO) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declaiatioiis: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. ( —Mwo?reri'compensation Insurance carrier and policy number are: - l -7-Ft I q 1 • carder: Policy Number 2 - (This-section need not be completed it the permit is valued at one hundred dollars($100)or less.) 'air I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these pywis' s _Appllcent Signature: CTOate:- S/2 Vo& ` A< ING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYEIi TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS(S100O00),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST.AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of.lhe.Busineps and Professions Code,and my license Is in full anLic..il force d effect., g OSl f Classy » t'S (.. /2 Contractor's � Date_ — CONSTRUCTION LENDING AGENCY: • ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: • I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or Improves thereon,end who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). • ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Driver's License No. Expires: Verification of Ownership by(type o1 document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person Is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. T 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work Which Is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes 0 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (II"yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. §160 Of LI Owner(s) / 2/©ate rAnd/Or Authorized Applicant .. �22/ r—Date.. CODE 1 INSPECTION TYPE PATE 1111MI ' ODE INSPECTION TYPF PATE MALE 1616 • Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Costa Mesa Building Department207 PLICATION FOR PERMIT 111 EAST 20th STREET BUILDING 1 z• COSTA MESA, CALIFORNIA FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY Receipt No. Permit No. Building/ y� �,9tt� _ .�6 h` Address Costa Mesa, California Re ei by Date Rec'. I Date Issued Nearest /7-57'53 In-/e-S S Cross St.�„iQ//nie®i ezete� . Building �7 �j / ty.. Owner se -I-elf C, A3czA. �PiC� Address /z? h , �7 or a Mail Costa Mesa, California Address/9, g 64/2, Nearest i _ r Tel Cross St. '/City . j_ de? i1 . . No, / , — Zone / i/f No.of Pas I Type /V Group--y" Architect or Lic. `/Y- �-> Engineer No. Approved ��i by C'•' , Date%�/1:" Address ORR CATIONS ty ue. Address Cei1 it �Ln S.S..-.) LegalLot I Description I No. IA Block 1 Tract \� (Attach Metes and Bounds) AP ng-0.57-7 reAM I lV o:A1 No.of Bldgs. n 1 Size of Lot 56_ /,3�/•3 I Now on Lot `�, 4 � 0 Use of // No.of No.of u. 195° xi Existing Bldg.�Y�..,0I Families I Rooms cj Setback Line from Rear Yard "/G \V Z Center of Street Side Yard er o f..I 5( 1- `��, �( DESC6yiIPTION OF WORK �` New I V Alteration I I Addition 1 16 Cj Repair I I Moving I I Demolish I `C...%' Buildi ii �JVo.of Size/7' _4 /.s ,„,,,,No. Rooms / Stories 7 4 , wafi 4„e„ ' I Roof Ing � vvrin -- APPROVALS Use of New (1 • Building //L{ 4.4,,..;(2-,,,„. /��/��-1...-- Foundation Location Inspector Date Forms,Materials, 4 i _..te . / Under-Pinning Li— Frame: Fire Stops, Bracing,Bolts I hereby acknowledge that I have read this Application and state that the above is correct and agree to comply Lath.Int. with all City Ordinances and State Laws regulating building construction. Lath.Ext. Signature of • / / Permittee ♦!- _ _, G!. �i Plaster, Int. 'Et.Authorized Agt. Plaster,Ext. Valuation Permit Fee $ 6-°-15. Masonry Reinforced G : . Plan Check $ /` e--G \� $ O Total Bond Beam Fee $ 9' 6 tI FINAL � 1M 204 5-BP 2M R-RS I l . d - C d , - G o 0 0 a a . 1 ta cos , =) ' ' O'J '9'55PQmesn 3442 "'" *"--::9.00 . . :\ i — - - . , Street ....o •• - • PLT p�N - -- r — - - -. - Show location and distances from '� , property line and between buildings. , i 0.- - a. . . _ . G I l , -_ . _ _ . _ _ . 4