HomeMy WebLinkAbout180 19TH ST - Building Permits ' CITY OF COSTA MESA
4BUILDING DIVISION
Y•#1 IE.rl ..1r DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
trill . PERMIT B06-00701
.
Promo.4.
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.BU$LDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
• Job Address: 180 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: 42603108 Zoning:
Applicant: DAVIS, CLINTON
Address: 27111ALISO CREEK RD
STETE150
150 Phone: 949-588-8753 ISSUED BY:
ALISO VIEJO,CA - Zip: 92656 EXTENSION
Address OO SURVIVORS
ALLGWED
COSTAA MESA,ESA,C CA Phone:
180 E 19TH ST - Zip: 92627
PER
Contractor: ,AMERICAN TIMBER STRUCTURES INC CVPIDCc a
Address: 23411 LAGUNA HILLS DR • C/� I1LJ
STE K Phone: 949-588-8757
ALISO VIEJO,CA
Zip: 92656 . License: 838051 . D
• it
Arch Eng: /
Address: Address: �7 i 1 "
all
Phone: - IA / Phone:
•
Zip: - ' License:. License:
SCOPE OF PERMIT
DEMOLISH APPROX 1,697SF SFD'-.--/
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 Com: $0.00 _ '
Other: $0.00
Inspection: $0.00
' : Total: $114.76 '
PLANNING &ZONING
SETBACKS L' - — _ -r i',
MAIN STRUCTURE Front '0-0', ''z:\c Rear 0-0' Left 0-0 _ Right / 0-0„
ACCESSORY Front 0-0 ' . -Rear, 0-0 . Left 0-0 -Right 0-0
PARKING Existing: - 0, , Required: 0 . Proposed: 0
•
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92.28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work:Is suspended or abandoned
for a period of 180 days. (/'
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain Inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-48(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.
have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued.
My workers'corn nation Insurance carrier and policy number are: —1 p q
Carrier:Sk+t CC ry 9x�ASc,'ItO vl J—th lti fwvl L C �n J Policy Number: I Y- G 4/ ` 9
(This section need not be corlpleted if the permit is valued at one hundred dollars(5100)or ess.)
lei 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 provisions.
Applicant Signature: L—C-✓ I2- Date: -572-2761
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(S100,000).IN AD011ON TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business77and Professions Code,and my license is in full
force and effect.Lic.a 7.37051 Class 0 /7
Contractors Signature: Cc, f .62 Date: sh Z/N.-
CONSTRUCTION.LENDING AGENCY: -
ID I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: t 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(3500).):
❑ 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 ofthe property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Lawdoes 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 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 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑Yes 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? ❑Yes 0 No
(Section 25533 of the Califomla Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials 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 0 N
(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 apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 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? ❑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 ❑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 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 property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Signature f Legal Owner(s) Date
��Jt r/2 2/D6And/Or Authorized Applicant Date
•
CODE. INSPECTION TYPE M),E INTIMLS CODE[ INSPECTION TYPE PAIS IN�E4,4
1616 Fixed System Final Fire Prevention 206 Final Mechanical'
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Well 212 Final Fire Prevention
202 Final Factory Fire Place - . 220 Final Planning Approval
203 Final Sign 222 Final Site
•
204 Final Demolition 250 Final Building/Occupancy
CITY OF COSTA MESA
• BUILDING DIVISION
}•4 i .b. i . e DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
-4• PERMIT B06-00702
484.0R,0061 '
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.®1NLDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 180 E 19TH ST Status: ISSUED
Suite: Applied: 05/09/2006
Vicinity: GARAGE Issued: 05/22/2006
Primary Occ: U1 Type of Construction: V-N
Parcel Number: 42603108 Zoning:
Applicant: DAVIS, CLINTON
Address: 27111 ALISO CREEK ROAD /�
STE 150 Phone: 949-588-8753 ISSUED BY: ��•��-�./
ALISO VIEJO,CA Zip: 92656
Owner: PETROCCHI, JANICE L TR , p L T N
Address FB0 SURVIVORS
COSTA MESA,CA Phone: EXTENSIO
• 180 E 19TH ST - Zip: 92627
ALLOWED
Contractor: AMERICAN TIMBER STRUCTURES INC
Address: 23411 LAGUNA HILLS DR PER
STE K i Phone: 949-588-8757
ALISO VIEJO,CA EXPIRES o
Zip:' 92656 License: 838051
Arch : - Eng:
'Address: Address: eea����1
Phone: _ •
�}'�tryppnLD
Zip: , License: EX n
ag
SCOPE OF PERMIT DL��'
DEMO DETACHED GARAGE,APPROX 790SF.
REF#:B06-00701 -, -
FEE SUMMARY
Plan Check: $45.01 Calc Valuation: $2,000.00
Permit: ' $69.25 - - Claim Valuation: $2,000.00
SMIP Res: $0.50
SMIP Com:' ' $0.00 - >
Other: $0.00 ,
Inspection: $0.00
Total: $114.76 , .
,,, PLANNING & ZONING
SETBACKS -:7-, .0� ' '
MAIN STRUCTURE Front' 0-0<' Rear 0-0 ' . "Left 0.0 Right 2 &0:, .,
. ... _ . , , ..
ACCESSORY Front 0-,0 - ,' Rear, 0-0' " Left 0-0 _ . Right X0-0
PARKING ' .Existinq: 0- , Required: 0 Proposed: 0 ,
i
-.-
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work Is suspended or abandoned
for a period of 180 days.
-7
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 end flnel approval must be obtained.Failure to obtain Inspections and final approval will result in the aeration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
1\ 2446-48(9/00)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION: - •
I hereby affirm under penalty of perjury one of the following declarations:- •
-
•
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. -
I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued.
My workers'compensation InsuranCQ7 carder anndp—olicy number are: p q
Carrier SLI (c M�QWSA1-10✓I l ilbt)rance Sn) Policy Number: I �' !` I
(This section need not be comp/ fed it the permit is valued at one hundred dollars(5100)or less.)
t 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 hat if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provisions.
Applicant Signature: "^ Date: -512 /D(4'
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARS(5100,00),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am Relapsedunder provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Busl ss and Professions Code,and my license is in full
force and effect.tic.I 7S 3Z_D ""I Class N IS
Contractors Signature: �zS.—_ Date: "c722._/C(r.
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 cMl 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 properly who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by drivers license. ❑Yes 0 No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e.-property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 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,wit be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑Yes 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).
._._._ r ._. ._
2 Does or will the applicant or presentt fu
or future building occupant need to file a registration form for acutely hazardous materials? ❑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 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? ❑Yes ❑No
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application epermit for such construction or modification
from the South Coast Air Duality Management District or from any other air pollution control district or agency? PI Yes U No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the fadlity 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 (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.
^. S nature Of L it g4a Ownerls) Date
5—/Z Z (>
And/Or Authorized Applicant Da e
CODE E INSPECTIONTYPE PATE Pius PPPE! INSPECTIONTYPE PATE Its
1616 Fixed System Final Fire Prevention - - 206 Final Mechanical
•
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Root 210 Final Electrical
. 201 Final 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
•SW kit CITY OF COSTA MESA .
4 ; BUILDING DIVISION
>:i ,,,,,' ; PERMIT NUMBER
,1 DEVELOPMENT SERVICES DEPARTMENT
PERMIT B06-00703
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.8L MLDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 180 E 19TH ST Status: ISSUED
Suite: • Applied: 05/09/2006
Vicinity: POOL Issued: 05/22/2006
Primary Occ: Type of Construction:
Parcel Number: 42603108 Zoning:
Applicant: DAVIS, CLINTON
Address: 27111 ALISO CREEK ROAD
STE 150 Phone: 949-588-8753 ISSUEDryrtBY:
ALISO VIEJO,CA
EXTENSI Zip: 92656 ll:JAIY N
Owner PETROCCHI,JANICE L TR ' �� ED
Address FBQSURVIVORS _ -
COSTA MESA,CA' " " - Phone:
180 E 19THST .. Zip: 92627 PER, {�
Contractor AMERICAN TIMBER STRUCTURES INC EXPIRES //1/n I
Address: 23411 LAGUNAHILLS DR
STE K - Phone: 949-588-8757
ALISO VIEJO,CA
Zip: 92656, . ' License: 838051 '
Arch : Eng: RED
Address: - , Address: �"'1 {l•(` a
Phone: ' _ Y.X�h•"ne: I /'`i
•
Zip: " . , License: - . - pg'pF. i.,
• SCOPE OF PERMIT
ABANDON(E)POOL FOR SFD. .- \
REF#:B06-00701'AND 702 - .. - ,
a FEE SUMMARY
•
Plan Check $0.00 Calc Valuation: " $1,000.00
Permit: $38.75 Claim Valuation: $1,000.00
SMIP Res: • ' $0.50
SMIP Com: ' $0.00 -
, Other: $0.00
Inspection: . $0.00 '
Total: ; $39.25
.
PLANNING &ZONING
SETBACKS �w� J7.--. _�,' � �
MAIN STRUCTURE Fronts -0-0' Rear 0.0 . Left 0-0 Right.'/010/ ,
ACCESSORY Front; 0;0 v.., .-Rear,, 0-0 = Left 0-0 -,- Right ;0-0
PARKING \Existinq: 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 end 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
2446.48(6/00)
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penally of perjury one of the following declarations:
❑. I have end 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( 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 worIcel compensation Insure ca carder end policy number are: �y
Carrier: S (ttMOFASe- el I L\SUraalC PO n. Policy Number: (� 6199
(This section need not be corhpleted if the permit is valued at one hundred dollars($100)or less.)
IEr I certify that in the performance of the work for which this permit is Issued,I shell 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 shell forthwith
comply with these pr Bi / 2_ /
Applicant Signature: (- ons_
/1L.---� Date: z !! c,
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 DOLIARE(5100000),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 the Business and Professions Code,and my license is in full
force and effect.Lic.a g 25'7 Class ft 8
Contractor's Signature: �- AZ Date: •5/Z Z/D j
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:
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 end 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 then five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors 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 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(38)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file end certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes . 0 No
(Section 25505 of the Califomia Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure). _
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume 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 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 aermit 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 is the subject of this
application,have all of the disclosures prescribed by California Health end 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.
ature Ot L ner(s) / date
And/Or Authorized Applicant • Date
LODE I INSPECTION TYPE - PAM INTI11BL5 LODE# INSPECTION TYPE MALE RUAL$
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 - ,
4TU Mac CITY OF COSTA MESA
4 BUILDING DIVISION
, r� ..4 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
ZIse PERMIT
4;:b4Pearnso
E06-00443
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesagt us_ PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 180 E 19TH ST Status: ISSUED
Suite No Applied: 05/09/2006
Vicinity: HOUSE AND GARAGE Issued: 05/22/2006
Parcel Nunmber: 42603108
Applicant: DAVIS, CLINTON ^
Address: 27111 ALISO CREEK ROAD 6.ISSUED BY: �/
STE 150 Phone: 949-588-8753
ALISO VIEJO,CA • Zip 92656
Owner: PETROCCHl, JANICE L'TR
•
Address FBO SURVIVORS _ _ .
• COSTA MESA,CA - Phone: �p7
,180 E 19TH ST - H Zip: 92627 EXTENSION
'�g.�p,,I @,SI®N
Contractor: AMERICAN TIMBER STRUCTURES INC ALL® ED
Address: 23411 LAGUNA HILLS DR PER
. STE K-:'. Phone: 949-588-8757
ALISO VIEJO,CA Zip: 92656 EXPIRES ,4l4 a 8
License:838051
' . ' SCOPE OF PERMIT rX?I 9 ED
ELECTRICAL CAP FOR DEMO OF HOUSE AND GARAGE. 11 ,�
REF#:B06-00701AND 702. DATE ' ' /
/
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. s - - 0 , c, . Circus(gen or ride) '. -' ' $0.00" 0
Motors to 1hp ,, $0.00 0 Circus(mech ride or lights) $0.00- 0
Motors to 10hp i' $0.00 ;.0 ° Christmas Tree Stand - $0.00 ' 0
Motors to 50hp A ' ' ' $0.00., -, -`..,,0'.' = Fireworks Stand - ' ' $0.00 ` - 0
Motors to 100hp , $0.00 H -0-- ,`- Other Electrical Fee $18.20
Motors over 100hp $0.00 0 7
Communication drops ,, �� ,$0.00 ' / 10 - 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"i
Temp Pwr Pole $0.00 ' '-0. . ' TOTAL CALCULATED FEES $41.70
Intermed Pole $0.00 ...0
COMMENTS I 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
2446-46(6/00) •
DECLARATIONS
WORKERS'COMPENSATION DECLARATION: •
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
of work for which this permit is issued.
yl 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 wo ars;comp/snsation Insuranc@ carrier and policy number are: Q l
Cartier: S fE- l �^tv.atASs lrsq �il.au%�'a✓lTe T'(�-v%n� Policy Number: I71 1 9
(This section need not be completed if the permit is valued at one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California,and agree that if should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these provisio/ny�p ✓)
Applicant Signature: V!/ ,(L7C/�-�/ Date: 5 '�2- 24fp
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($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37C6 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am license der provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Busineva)and Professions Code,and my license is in full
force and effect.LM.# P T-IClass# .( /
Contractor's Signature: (' -f /2 Date: r/Z Z/D(o •
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 DMsion 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement Is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). '
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044.Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors 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 ❑No Driver's License No. Expires:
Verification of Ownership by(type of document,i.e.-properly 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 Ls 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,Tltie 8,California Administrative Code).
❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? ❑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 lime 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 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 a ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? DE Yes No
(Section 65850.2 of the California Government Code requires that the requested information be hlmished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If yea',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 eV 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 ❑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.
gnetur Of Legal Owner(s) / Date
c2/:2-7o
And/Or Authorized Applicant Date
CODE P INSPECTION TYPE PAIL IyJffiAL6 - CODE( INSPECTION TYPE PEE INII➢AU
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
601 M CITY OF COSTA MESA• -
t ► BUILDING DIVISION
>:� ;
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations: - '
O 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.
..hr 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 wo ers'compe rsation Insurance .rrlpr and policy number are: ` P�l ��
Carrier .z . - .. .v.• , • c •. c ' a Policy Number: !J
(This sect/on need not be comp'ted if the permit is valued at one hundred dollars($100)or less.)
'\/ I certify that in the performance of the work for which this permit is issued,I shall not employ any person In any manner so as to become subject to the workers'
,\ compensation laws of 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 prows s.- �
Applicant Signature: ��/� 42 _ - Date: $7'Z zl y
WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100.000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CCM,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 Busine;s and Professions Code,and my license Is in full
force and effect.Lic.4 S-32c(2-i Class*
j5
Contractor's Signature: r:�G—�" �.. Date: ti--C7-/O
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,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. 0 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:
O I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(38)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 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 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 a ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes 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 feel 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 (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.
Si nature f Legal Owners) -5--/Z
Date
z B/
And/Or Authorized Applicant "Date
;00E F tf1sPECT10NTYPE PETE D1TOIAL$ CODE( INSPECTION TYPE PATE MALI'
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
•
lam"'BNLDU 'J 80 E 19T Sit'
I
crokEWSNAMEIFaawR:HOFMANN
ADDREu:180 E 19TH ST UHT' St .r ' CITY OF COSTA MESA — BUILDING PERMIT_
f: r - PERM NO: B 082124
• PERMIT NO: B 082124 PLAN CHECK NO: N GOVT: N SUPP : N
dOSTA MESA, CA 92626 515-8822 '
ApPL.MuuNC ADDRESS: CONSTRUCTION TYPE: V—N PERMIT TYPE : STR PURPOSE: OTH
ARCHITECT 01)ENGINEER: UC.NO.: JOB DESCRIPTION : T/OFF WOOD SHINGLES INSTALL 25 YR COMP SQ FT; 4 , 500
ARCH.OR ENG.'S ADDRESS: HMT:
CLAIM VALUE: 4 , 500 . 00 CALC—VALUE: 4, 500 , 00 GROUP OCC: R-3 /
cONTRACTantusE:SKYLINE ROOF CO INC ( 562 ) 426-0848
CamtACTOR'SMNLDIC91538 P,O. BOX COMMENTS; INCLUDES PARTIAL RESHEATHING
ADDfES3:LONG BEACH CA ucNO.: 606954 *+t*ic-*Ht**at********N-*+T*at*it******it*atx-Htjt****at****it Ht*****HHiEitatit*********aa*N•*+t*aE*at**N-N-
90809 um: ZONING REQUIREMENTS
LICENSED CONTRACTORS DECLARATION:I hereby Slim under penalty Of perjury thin I am licensed under provisions of Chapter S SETBACKS
(commendng with Section 7000)Of Division 3 of the Business and Professions Code,and my license is in fug faux and effect.
\ CrrYLIC.No.057214 LIC.CLASS:C—3 9 1CC...NO,.:606^954 �� �P: 00/00 -- MAIN BUILDING •- ACCESSORY BUILDING
>r"' -LO'�'(� Contractor: /L �2R�"'- '1 � FRNT: FT IN REAR: FT IN FRNT: FT IN REAR : FT IN
Den: �+ 4 LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN
OWNER BUILDER DECLARATION:I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the
following reason(Section 7031.5 Business and Profession Code:Any city or county which requires a permit to construct,alter,improve, PARKING REQ: P RO V: PARCEL: 00000000 Z N E: REF NO:
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 O y
is licensed pursuant to the provisions d the Contractors License Law[Chapter 9(commencing with Section 7000)d Division 3 of the PLANNING NOTES>
Business and Professions Coded or that he or she is exempt therefrom and the basis for the alleged exemption.My violation of Section > '^
7031.5 by any applicant fore perrhil subjects the applicant to a cit penally of not more than five hundred ddWs POOP. *************W1E*******IE**********************************************.**********
❑ I.as OWner of the ProPerlY er my employees with wages as their sole compensehon.will do the work,and the strudure is not intended DEVELOPMENT SERVICES R E Q U I R E M E N'3T S
or offered for sale(Section 7We,Business and Professions Code:TheContractors License Law does not apply to an owner of property „".
who builds or inproves thereon,and who does such work Nmself or herself or through his or her own employees,provided that such
improvements mems intended ordferedfor Se'u,however.lhebaming«inpmamemu saki within Dn.yeara wnpleton,dw ZONING APPROVED'HY DATE:
ownerbuider will have the burden of proving he or she did not build or improve for the purpose of sale).
❑ Profof
Professions of the
TheContractors License Lacliarively wvrith does not apply licensed
an toner of property who lconstruct the wS or pmovesthh;reeon aanndewhohn BUILDING APPROVED BY DATE: .%il
contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law). ..
❑ I am exempt under Section: B.&P.C..form®reason: APPLICATION ISSUED BY : DATE: 3•�zo—
Date: Owner: LEGALIZATION:N F E E SUMMARY STRUCTURAL' SEGMENT:Y
I do hereby certify that I am aware of and understand the requirements of California Health end Safely Code Sections 25505,25533,and •7
25534,and that I or any future building occupant will/will not(oircb one)need to comply with said state codes and the requirements for BLDG PMT PLUMBING ELECTRIC✓'MECHANIC FIRE SMIP/RES GRADING
a construction 'r Man
n or modification from the AtueTiy agemen Dimconstructionda.Residentialconstruction applications ere exempt from theta PERMIT 99 . 75
. 50
Dale; Applicant: ' s*".- SMIP/NON—RES
WORKER'S COMPENSATION DECLARATION:I hereby affirm under penalty d perjury one d the following decimations: I S S U .��
SUE FEE
o Ihave and wD=nen acertificate of consent to seR;mure f«workers wnpemaon,as provided f«by Section 3700 d the LaborBUILDING—DIV—> PERMIT ISSUE PLANCHECK TOTAL PAID DUE
cedar«the pedamm.mhceathe work f«which mis garcon is issued.
TOTALS----> 100 . 25 . 0 . 00 0, 00 100 , 25 _ 100 . 25 . 00
X❑ have and will maintain waken'wnpeneaton insurance,as required by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.My workers compensation insurance CAR*and polio/number are:
Carrie,: STATE FUND EXPIRES REVENUE DIVISION TOTALS--> COLLECTED,: 100 , 25 OVER/SHORT; 00
Policy Number: )801-4700001718 01 /01 /98 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK
(This section nand nal Da comdafad t the perm/is for one hundred dollars WOO/or lest./ 99 . 75 . 50
\ ❑ I certify that in the performance of the work for which this perm is issued,I shell w employ any person n any manner iso es to /1.-
become
�
become subject to the waken'wnpensation laws of Calfamle,and agree Ma H l shoed becammee!tabled I°IM w0Nan' *************************************,***"3F****************************W*********
compensation provisions of Section 3700 of the Labor Code.[shell/Mit mm tMse,//- 7 f
p M/ )6,' ��r� IND I V I D U A L. �F E E BREAKDOWN
J Data: esu-9, APPfcent: N c
Warning:Fauns ro secure workers'compensation coverage Is unlawful,and shall sublact an employer to criminal penalties and TYPE QTY DESCR IP T I O N -,• 1. UNIT COST TOTAL COST
civil fines up to one hundred thousand dollars($100,000), th
M addldon to e Coat of companeatbn,damages as Provided for In
seegon3706oftheLaborCods,lm«esbandaftoreytyees. SFR 4500 REROOF BY VALUE RESIDENTIAL NOZONE 1 , 00 4 , 500 . 00
• CONSTRUCTION LENDING AGENCY: I hereby aim under penalty of perjury that there is a construction lending agency for the END .'OF• ,FEES
performance of the work for which this permit is issued(Section 3097.Cit.C).
LENDER'S NAME: I '
LENDER'S ADDRESS: '
I certify that I have read this application and state that the above information is COMP.I agree to comply with all city and
county ordinances 'SMOKE DETECTOR ,7 .
and stale laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned propertyf /�
MARK MILLER
«inspedion
purposes.
_ REQUIRED 03-20-1997/12:53 Pn/5188.25
x. /n////�// �/Q" n Dale: 3-itF 7 t '.'f PERM IT:082124
36•
Signature of Oxmragent/Appkmnt/Contreaor i
r` (5151-48 WP) White-Building A Solely;Green-File:Canary-Applicant;Pink-Revenue;Godenrod-Alaessor -. -
1
•
ries CONSTRUCTION AND PLANNING ,• POOL ,PA
APPROVALS Permit# Date Inspector APPROVALS Permit # Date Inspector
- 1. Temporary Electrical Service or Pole . 52: Pool & Equipment Location '
•
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3. Electrical Conduit,Utility-Undrgrnd. - - 54. forms ,
4. Electrical Conduit Undrgrnd. - 55. Electrical Bonding •
5. Steel Reinforcement • _ ' - - 56: Rough Plumbing & Pressure Test
6. Electrical UF ER Grnd. • - - ! 57: APPROVAL TO COVER-GUNITE
7. Footings - 58. Electrical Conduit-Undrgrnd.
_ 8. Foundation - �: 59. Gas Pipe, 0 Undrgrnd.,Test, .
9. Water Pipe-Undrgrnd. - _ _ 60. Backwash Lines, P-Trap, 0 Undrgrnd. -
10. Structural Floor System ' -. . 61. APPROVAL'TO DECK I
• 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 - rr-• .65: Electrical-Final -
15. Rough Electrica6Conduit 66. Solar SVsten -Final
16. Rough Electric Wiring _ , ' 67. Fencing & Access Approval's
17. Rough Wiring Sign L 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling - . 69. POOL/SPA SYSTEMS FINAL •
19, RoughrHeating & Air Conditioning,- 7.rr - FIRE DEPT. REQUIREMENT •
20. Rough Factory Fireplace APPROVALS Permit #
21. Ducts,in Structure - - - 70. Underground Hydro
•
22. Duct's, Ventilating = •. - :. - • 71. Product Piping 0 Gas 0 Oil
23. Gas Pipe-Rough & Test _ -_ 72. Underground Flush -
24. Roof Framing - - . - 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof.She"athing . 3-,2"7 7' GC/o/i 74.. Overhead Hydro , '
26. T-Bar Ceiling (Structural) & Monocoat _ 75.. Dry Chemical •
27. Frame and Flashing _ _ - - 76. Dry Standpipe'
28. Lathing &Siding77. FIXED-SYSTEM-FINAL
29. Insulation • u' _ ` _ - 7$. FIRE PREY. FINAL
30. Drywall Nailing _ �� ."HEALTH DEPT. REQUIREMENT
31. Plaster Drown.Coat 79. FINAL INSPECTION • _
32. Electrical Power MeterzFinal . ' 80. FOOD CERTIFICATE ISSUED
33. Final-Electric- Notes:
34. Final Heating& Air.Conditioning - `. - ✓ g' e?� F� _ f..� ear��
•
35. Final Gas Pipe-Test -- T#-pt , G.,�i_ ij , a4 7dc_ Anal--/G�l- LL ,
36. Hood or'Canopy `^ti[ _ 0�_" -
37. Final Factory Fireplace •. - - - " •
38. Final Plumbing _ . r
39. Water Service-Final
•
•
40. Gas Service-Final - - •
• -
41. Solar Domestic-Final - - - -
42. Backflow Preventer• - .,
43. Backf low Irrigation - - ,
44. Landscape Irligation System ¢ _ -
•
•
45. Sound Attenuation i . - ,
46. Handicap Regulations
.
47. FINAL STRUCTURE & BUILDING ZSQ, 44{/W - ' ,
•
48. FINAL PLANNING I IJ
•
49. Electric Release to Edison
2.
50. Gas Release to Southern California Gas Co -- -
•
51. CERTIFICATE OF OCCUPANCY -
No. Date
Costa Mesa Building Department ✓ APPLICATION FOR PERMIT
e --' 111 EAST 20th STREET 1464 BUILDING 1
�-
COSTA MESA, CALIFORNIA
I' 10r FOR OFFICE USE ONLY
FOR APPLICANT TO FILL IN
. _ _ Receipt No. Permit No.
Buil
ding 180 East 19th St.
Adddress c
Costa Mesa, California Receiv yDate Recd. Date Iv"
ue`
Nearest
I6 - a7- sem AN2' 1s °
Gross St. Orange Avenue Building
Address .
Owner Leo and Janice Petrocchi Costa Mesa, California
Mall
Address 180 East 19th St. Nearest
Tel. Cross St. .
1 city Costa mesa , Ca1.No .Li 8-291f Zone f I NNo.rosf Type I Group 7''
Architect or Lie. /r-- J.�
Engineer No1956 :
. Approved r/G �j Alia
Address j R TINS Re•
City Lic. INYO
,itractor owner No.
•
•
Address
Description
Lot
_
Legal I No. I Block I Tract _ C
(Attach Metes and Bounds)/' Nip- 6,{-/.. A:. t g fF��
•
No.of Bldgs. FP JLC) N 1Size of Lot Sd K�3a. �3 Now onLot g�-JI0
Use of No.of ✓ No.of i '- a)
Existing Bldg. aw I Families I Rooms✓- _ •
Setback Line from 4-')‹ Rear Yard ZfJUN r� 2 rl '�C�S�j Z 1 i_
Center of Street Side Yard b J - D
DESCRIPTION OF WORK r
fl MESA-New I I Alteration I I Addition I X CITY -OF COSTA MESA•
Repair I I Moving I I Demolish I
Building ,,�>;No.of /
Size /2. ' Rooms �
X' "AYStories
'erior Wall / Roof
_ :ring Stn'/C Coveringkin&Si Imc APPROVALS
DseBuilding oT New
� 'Foundation Location Inspector Date
Building f��fl 7� as /,t A D n2 '('evt Forms,Materials, p
IA
Under-Pinning
Frame: Fire Stops,
- Bracing,Bolts
I hereby acknowledge that I have read this Application Lath.Int.
and state that the above is correct and agree to comply Lath.Ext.
with all City Ordinances and State Laws regulating
building construction. p
SignaturePermittee 7/ /- Plaster,int.
Permittee f e L. �4. -C-C_Al
Plaster,Ext.
Authoriz d Agt. •
Masonry Reinforced
Valuation Permit Fee $ /0.
T Iplancheck $
/. --- Bond Beam
$ �/ 3 Total
/ Fee $ / /. FINAL
FORM 204 O-H 2M 5.54
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1 /9u Street - .. .^i'.. �- .� ,
.n :` -
PLOT PLAN
Show location and distances iron I l• - "�' �:-' -
property line and between buildings. •,-,-,,C .,, ,i,.
-- . - -
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•
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Costa Mesa Building DepartmentPLICATION FOR PERMIT
P. O. Box 317 38_� BUILDING
COSTA MESA, CALIFORNIA
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY R j h2
_A Receipt No. Permit /J
Building U4
Address / O , .
Costa M•sa, California Re iv by I
/,Date Re � / Date Issued
Nearest A 6-g,- (n ��-J t
Cross St. (O#Q e HI/ Building
{{�, J // Address
Owner/g0 d- �,;c e. %t,Qn«h,' Costa Mesa, California
Mail
Address /6 , . if S 1. Nearest
,1�{ // Tel. / Cross St.
City C. / /C..S K.- No.�, /f-.2G/�j Zone y I No. of I Type Group]
Architect or Lie. / Plans y
Engineer No. Approve
by Date
Address CORRECTIONS
City Lic.
ntractor n /0 L2 ple No.
Address -
Legal I Lot I I _
Description No. Block I Tract
(Attach Metes and Bounds)P 1/f - 057- 8
No.of Bldgs. A ,
Size of Lot, OX i,3o,/3I Now on Lt 7i •L)Vekt JrI, PCAS,
Ilse of No.of No.of �,f " �-�-� ��-P �� x
Existing Bldg,�1,J p�';n I Families/ I Rooms 0
Setback Line from Rear Yard eAS -70—• •' • .• �J Z
Center of Street C 7( Side Yard �D/— Q V I i 0 i S55 x.
DESCRIPTION OF WORK r
New I I Alteration I I Addition I X -ITS nF PnQTf team
d.di nnLati
Repair I I Moving I I Demolish I ,C///�>'-
Building ,/ No.of //— ' "`"^�
Size �.Z )( Zr Rooms Stories
2$11/54564
' tering aIIPC, 1• I Roof g ,� — APPROVALS
_ ie rin pd! n Roof
/ •
Use of ewQC- / oom /i'drJ oJ7
Buildingr,) Foundation Location Inspector Date
Forms,Materials,
Under-Pinning
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 con ction. Lath.Ext
Signatur.4Iy� L /J-ef-Ce-- //�.
Permittee i 01 A...�Z� o� - ^ Plaster, Int
Authorl- • Agt Plaster, Ext a ��
V uatloo Permit Fee $ .'r-� Masonry Reinforced �e /LVJc-r.-� d
r Plan Check $ Bond Beaml/9�1� /vZ
,.$ sg 1`�' Total
Fee $ ,C--- FINAL
•
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'C Y
J C
J COSTI
d POCK r.: ir= =5 nQ
L o lUl B SGPDnesr
• 0
••
.
Street
PLOT PLAN
Show location and distances from
property line and between buildings.
•
. 998 IL• IL A i..u!.' v ._..J
COSTA MESA BUILDING-SAFETY DEPARTMENT .
(IL 2 (; 1959
P.O.BOX 317 COSTA MESA. CALIFORNIA FINANCE DEPT.
FOR APPLICANT TO flit IN COMPLETELY APPLICATION'TFOReP
TYPE OR PRINT BUILDING
BUILDING (�j/� 1 l/.���tt
ADDRESS / JS l.' -It 1 I / •
COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY
RECEIPT NO. I PER In NI,fIO.
OWNER e `-cyckV
MAIL <<�� RECEIVED BY DATE RECEIVED DATE ISSUED
ADDRESS ;�.1 � �'L,L.9 I y-.z. -t1 * 7 4 if/
TEL.
BUILDING
CITY NO.
ADDRESS
ARC'-'SECT LIC.
Ca
OR WEER NO. COSTA MESA. CALIFORNIA
FIRE
ADDRESS ZONE
tGROUP
. fit/
CONTRACTOR CIC.NO. BY ATE V/z'/ • ("6
{' STATE APPROVED57
ADDRESS d g 7 I r i ... . ZONING \
LEGAL I LOT ZONE ('//JT NO.OF USE OF NEW } OP
DESCRIPTION
/ NO. q// BLOCK TRACT
K IPLANB I BUILDING /7���'f"r�/ '
A.P.NO. / /,' —p C 1 � BYPROV D L%/L�� DATE 1/y7 7 ,
SIZE J C/ / /30
INO.OF SLOGS.
NOW ON LOT 'L�
OF LOT C/ /X YARDS EVES
REQUIRED ALLOWED
USE OF (CENTER LINE ST.) A
EXISTING BLDG. FRONT �{y+ FT. i , IN.
SETBACK LINE FROM ��// nQ � �.aa 7
CENTER OF STREET ^, 1 1.)... X_' REAR YARD R.SIDE FT. IN.
SIDE YARD I LEFT I I I RIGHT 7 L.SIDE FT. IN.
DESC TION OF WORK
REAR FT. IN. _
NEI I II ALTERATION I II ADDITION I
REPAIR I I MOVING I II DEMOLISH I
BUILDING / - ,/' ONO.OF
SIZE /,. T- ROOMS STORIES
EXTERIOR WALL I ROOF
COVERING COVERING
USE OF BUILDINg AND WORK TO BE-PERFORMED
t.
ATI HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND ST - T THE ABOVE IS CORRECT AND A EE TO COM- THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
PLY WI ALL ITT ORDINANCES AND STATE LA REGULATING PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. \
BUILD 0 CONS -UCTION. VALUATION
SIGNA URE I l • PERMIT FEE S p�-
PERMI E - �-
$ PLAN CHECK $
(///,J�/ �� Oma'
AUTHORIZED AGENT (�f� iLL � �./"E- sal-- race TOTAL FEE $ /LY --
.: .. ci ,. .e
• �. <`a-185 AUG 17 1959
COSTA MESA BUILDING-SAFETY DEPARTMENT FINANCE DEPT.
P.O.BOX 317 COSTA MESA. CALIFORNIA, CII OF nnSI 1!I(-Cn,
I fOR APPUCANT TO FILL IN COMPLETELY APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
ADDRESS tie EC / 1 /1 St.
t/1 �f/
rCOSTAnMESA, CALIFORNIA/ MR OFFICE USE ONLY
i- O Pe f M 0 e c I1 I I RECEIPT NO. I- pERry R,
OWNER IIiIi Ill l%J
73
MAIL {� ` REV^¢IVED BY DDA,Tfi RECEIVED p DATEISSUED
ADDRESS ,(�/ $ C /9 `. (`d'{�Y 9 -I i-5 /12-'
CITY l` , M TN O.�`�-s-z1'L BUILDING ('f U
ADDRESS / t• C' I /.�L .\��~-` ^
ARCHITECT LIC. COSTA MESA, CALIFORNIA
OF 'GINEER W YLe 1+
ADDRESS FIRE
ZONE TYPE GROUP \
STATE APPROVED
CONTRACTOR 61" may.* 1.' LIC.NO. BY DATE r"-_
ADDRESS ZONING
H
LEGAL LOT - � ONE Ar NI.LOA. USE OF NEW
DESCRIPTION NO. BLOCK �'� ' , P�LLAANNS BUILDING / - 7//-/)I
A.P.NO. j O s-7 — Ci BYPROV Ep I.Lam^ . `Q F DATE // `. 1\t
SIZE
OF LOT �- I30 I No.OF YARDS
NOW ON LOTS '� REQUIRED C/V7 ALLOWED I
USE OF (CENTER LINE ST.) 1 .
EXISTING BLDG. FRONT ,SDFT. -T IN.
SETBACK LINE FROM
CENTER OF STREET REAR YARD R.SIDE FT. SIN.
SIDE YARD I LEFT I RIGHT L.SIDE FT. �N.
DESCRIPTION OF WORK
REAR FT.
NE' I X II ALTERATION I II ADDITION I
REPAIR I II MOVING I II DEMOLISH I
BUILDING NO.OF
SIZE ROOMS STORIES
EXTERIOR WALL I ROOF
COVERING COVERING
USE OF q
BUILDING AND WK TO BE PERFORMED
r3/c�f 1.4,,a9/
d `" D/c <k C ' /h94 /cc7,,1
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
AND STATE THAT THE AB VE IS CORRECT AND AGREE TO COM-
PLY WITH ALL CITY OR ANCE D STATE LAWS REGULATING PURPOSE OP ESTABLISHING A PERMIT FEE ONLY.
BUILDING CONSTRUCTI /may, VALUATION
SIGNATURE OF j,,. / PERMIT FEE $ 4/ c Q
PERMITTEE ✓ r "KKV//[[[444
$ 3 2 , 62) PLAN CHECK $
AUTHORIZED AGENT TOTAL FEE $ G C7
/ N
•
•
J•
28170
JAN ani°
'COSTA MESA BUILDING-SAFETY DEPARTMENT 31' 68001.187+► ****31.50
P.O. BOX 1200 COSTA MESA. CALIFORNIA 92626
•
For Applicant to Fill In Completely APPLICATION FOR PERMIT
TYPE OR PRINT BUILDING
h1 For Office Use Only
BUILDING
ADDRESS / ',U 9 RECEIPT NO. at NIT OA
COSTA MESA. CALIFORNIA Q('/ N.
/ P / RECEI BY DATE REECCEIVED DATE IISSUEDD \
OWNER AeO / e /ho cc-4/ `-"' iti/,to
yK/7'-6S µc7 --IY �O[/�
MAIL. Cl !NNW: /.J(/ !I• /74t \%I///I/"
ADDRESS //n _, / f LJ f�G9
CITY - ` - Al NO e Vi-2-", ZONE FIRE �5 TYPE( TT GROUP . 7 '
ARCHITECT TEL APPROVEDY %A/ /�j�_ATE 2-11 -I�
-NGINEBR D_ K /.4., es NO. ✓{' '/ �' M."'J.�/V/J
ADDRESS 4/G G 5/ ae1y A" ZONING
ZONN[E�� NO.OI UBEOF NEW 1
�^ I/ -J� I PLANS y I BUILDING 2-A-7.),—/L
CONTRACTOR l'W tt �- LEG l� /� n /� 1
ADDRESS 5 a 1'T'1 e AL
DISCRITON 00 1I I. U I 17 .. I yJJ/y�ift
CITY A.P.NO. ,I 8'- U S 1- U /] J
NOTE: NO SAVE OVERHANG SHALL BE LESS THAN
STATE TEL. SO'TO HIDE O REAR P.L
LIC.NO. NO.
EAVES
OFLOT ' C A / 3 0 •7-3I NOWON S. / ALLOWED CU.B-C-REQUIREMENT/
YARDS APPROVED YARDS APPROVED
USE OF MAIN BUILDING ACCESSORY BUILDING
EXISTING BLDG, G,5 {pROM C/L DiRER/�`J-/, /�
SETBACK UNE FROM FRONT [/`tel L[ ._e_/ PT.
CENTER OP STREET REAR YARD
SIDE YARD I LEFT I RIGHT R.DID[ RT.
DESCRIPTION OF WORK L.SIDE ���PT
i��P�T) FT.
ALTERATION ADDITION REAR .7 PT. PT
-
DISTANCE BET. BET.MAIN&
MAIN BLDSS, ACCESS.BLDGS.
REPAIR -MOVING DEMOLISH
BUILDING NO.OF VAR.# DATE
SIZE ROOMS STORIES C.U.P.* APPROVED
EXTERIORERINWALL I COVERING eTPROVEDIi /� M DATE !�Q
COVERING L U / (((
USE OF BUILDING AND WORK TO BE PERFORMED h
4W .
2 si d Ebel tel 4210 SQ.FT.
Ol
I HEREBY AC OWLEDOE THAT I NAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
AND STATE THAT THE ABOVE IS CORRECT*ANDAGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT PEE ONLY. 1R
PLY WITH ALL CITY GRD/ NCES • TE LAWS REGULATING VALUATION
BUILDINGCONSTRU O
SIGNATURE OF �_' - A / SCO PERMIT FEE E 2 /, 00
PERMITTER $ clic- PLAN CHECK S ,'O'rQ k
AUTHORIZED AGENT /!!�� �j C O
TOTAL FEE S a7/
f