HomeMy WebLinkAbout216 19TH ST - Building Permits •
CITY OF COSTA MESA • -
�3,� '- BUILDING DIVISION
>•rte_ `:A;3 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us '
J �� FOR INSPECTIONS CALL:(714)754-5626 •
.�
PERMIT NUMBER: BC07-00350
PERMIT TYPE: B_COMBO1 STATUS: FINALED
Sub Type: RES_ALT O DATE ISSUED: 11/02/2007
ISSUED BY: RMD
JOB ADDRESS: 216 E 19TH ST CM ' Suite/Unit:
APN: 42627120 - - Zoning: , , . •
Vicinity: REAR YARD Primary Occ: POOL .
Const Type: SO. FT: 400 • - Valuation: '$800.00
SCOPE OF WORK: DEMO,(E) 400 SF IN-GROUND POOL, CAP GAS, ELECTRIAL AND WATER FOR SFD.
OWNER: CHRISTENSEN,ERIC Address: 216E 19TH ST , . . ' Unit: .
Phone: 310-913-1625•. City/State/Zip: 'COSTA MESA,CA . ,
•PPLICANT: CHRISTENSEN,ERIC • , Address: 216 E 19TH ST .. . Unit: :
Phone: 310-913.1625 . City/State/zZip: COSTA MESA, CA i; - • • ,
CONTRACTOR: OWNER-BUILDER License No. 000000 ' '
Phone: _ -Address: •• Unit: _
Cell: • • City/State: •ZipCode
•
•RCHITECT: - License No. PHONE: '
•
_NGINEER: License No. - fin PHONE:."
COMBINATION PERMITFEE SUMMARY
Building Plan Check: $0.00
Building Fees: $32.65, ' ...
Electrical Fees: _ ._$41.70 _. - -
Mechanical Fees: $0.00"
Plumbing Fees: $43.10 .
SMIP Residential:
SMTP Commercial: ' , - $0.00 _ ..
Bldg Std Admin Fund ?? "
TOTAL FEES: $117.95 , ' •
^Refer to fee receipts for all fees paid for project ' - ,'
•
•
•
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes-and related
regulations.(Ord.No.92-28,§1. 12-21-92) .
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. •
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
coos P, INSPEC110t1 TYPE Prig l.805.45 COM INSPECm0N0 TYP, ' MTh 91111U.$
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 S=2'-O,/»1 GwY 250 Final Building/Occupancy
WORKERS'COMPENSATION DECLARATION: Owner ID verified by driver_...sense. ❑Yes ❑No
I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires:
❑ I have and will maintain a certificate of consent to self-Insure for workers' • Verification of Ownership by(type of document,i.e.-property tax bill or deed):
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 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
permit is issued. My workers' compensation Insurance carrier and policy 0 I hereby certify that no excavation five(5)or more feet in depth into which a
number are: person is required to descend,will be made in connection with work authorized
y this permit,and that no building structure,scaffolding,falsework,or demolition
Cartier: •.k 'r• thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp
(This sectbn need nol be completed the permit is valued at one hundred dollars MOO or less.) {{2, le 8,California Administrative Code).
Policy Number: /c0 As - 'buil- r, not employ anyone to do work which would
❑ I certify that in the performance of the work for which this permit is require - fr./ the Di kion of Industrial Safety,as noted above,unless
issued,I shall not employ any person in any manner so as to become subject such person h. . . a it t do such work from the division.
to the workers' compensation laws of California, and agree that if I should
become subject to the workers' compensation provisions of Section 3700 of
Applicant's Signature Date
the Labor Code,I shall forthwith comply with these provisions.
Division of Industrial Safety Permit Number:
Applicant's Signature Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes ❑ No
($100,000), IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. 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
LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons,or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000) of Division 3 of the Business and Professions Code,and 2. Does or will the applicant or present or future building occupant need to file
my license is in full force and effect. a registration form for acutely hazardous materials? 0 Yes 0 No
Lic.#_ - - _ Class# (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
Contractor's Signature Date 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name: hazardous materials)? 0 Yes 0 No
(Section 25534 of the California Health and Safety Code provides that the
Lender's Address: 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.
Signature Date
4. If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safely Code been fully complied with? 0 Yes 0 No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes ❑No
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 (Section 65850.2 of the Califomia Government Code requires that the requested
License Law(Chapter 9(commencing with Section 7000)of Division 3 of the information be furnished on applications far non-residential building permits).
Business and Professions Code) or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? 0 Yes 0 No
applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes", the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec. 7044, Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes ❑ No
thereon,and-who does such work himself on herself or through his or her own
employees, provided that such improvements are not intended or offered for 8. (If"yes",attach certificate of compliance from the appropriate air pollution
sale. If, however, the building or improvement is sold within one year of control officer). -
completion, the owner-builder will have the burden of proving that he or she ' CERTIFICATE OF COMPLIANCE: ('certify that under penalty of'perjury'the
did not build or improve for purpose of sale.). information given above is,correct. I agree to,comply with all state laws and
city ordinances regarding Hazardous Materials and Emissions.
❑ 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 ' - Signature Date •
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF' COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
0 I am exempt under sec. •
the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: - 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 Legal Owner(s) Date
Signature ' Date -
3057-46(3/07)
And/or Authorized Applicant Dale
N
CITY OF COSTA MESA
BUILDING DIVISION
Fy .�1� 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
�.�. FOR INSPECTIONS CALL:(714)754-5626
tv I PERMIT NUMBER: BC07-00350
PERMIT TYPE: B_COMBO DATE STATUS: ISSUED
Sub Type: DEMORRIP DATE ISSUED: 11/02/2007
ISSUED BY: RMD
JOB ADDRESS: 216 E 19TH ST CM . - Suite/Unit:' `
APN: 42627120 , Zoning:
Vicinity: REAR YARD Primary 0cc: .'
Const Type: SQ. FT:: 400 Valuation: $800.00
SCOPE OF WORK: DEMO(E)400 SF IN-GROUND POOL, CAP GAS, ELECTRIAL AND WATERFOR'SFD.
OWNER: CHRISTENSEN,ERIC- ' / Address: 216 E 19TH ST _-- Unit:
Phone: 310-913-1625 City/State/Zip: COSTA MESA,CA'
APPLICANT: CHRISTENSEN,ERIC - Address: 216E 19TH ST ,. ' ' -`Unit: :
Phone: 310-913.1625 1 •City/State/zZip: COSTA MESA,CA' --.1�, ,',,l,', .- •;‘,.
CONTRACTOR: OWNER-BUILDER License No. 000000
Phone: " . 'Address: Unit: -;._ - • . ;
Cell: - City/State: - - ZipCode
ARCHITECT: - - License No. — - ' PHONE:
ENGINEER: -- -License No.- -_-. /- - •PHONE: 10
:• /
- ,',.'r p'-217 lig
COMBINTATION PERMIT-FEE SUMMARY
Building Plan Check: , ` $0.00 --
Building Fees: - • $32.65
Electrical Fees: $41.70 •
Mechanical Fees: - , $0 00 - k
Plumbing Fees: $43.10
SMIP Residential: \ $0.50 ' " 1'
SMIP Commercial: +. '$0.00 - '- '= 1 /p
'
TOTAL FEES: - '$117.95 • ..,
-
**Refer to fee receipts for all fees paid for project -'
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
CODER INSPECTION TYPE PATE INTmAL$ CODE I INSPECTION TYPE, DATE IN1mAL$
1818 Fixed System Final Fire Prevention 208 Final Mechanical
1288 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
i.
ar
WORKERS'COMPENSATION DECLARATIO . Owner ID verified by driver's. .se. Yes ❑N a
I hereby affirm under penally of perjury one of the following declarations: / ���2'7i//C)
ve 'Ltcense No.
O I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-propertyEzp des:—
tax?
or deed):
compensation, as provided for by section 3700 of the Labor Code, for the
performance of the work for which this permit is issued. ,
0 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 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: .
permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a
number are: person is required to descend,will be made in connection with wort authorized
by this permit,and that no building structure,scaffdding,falsework,a demolition
Carrier: or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2.Grp
(This seam need not be completed the pem4 is valued at one hundred dollars($100)or lea)
2,Art 2,Sec.341 Title B,California Administrative Code).
Policy Number: '
❑ As'owner-builder, I will not employ anyone to do work which would
2�iTcertify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless
issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California, and agree that if I should
become sub' the workers' compensation provisions of Section 3700 of Applicants Signature Date
the Labo II forthwrith'comply with these provisions.
//z/p 7 Division of Industrial Safety Permit Number:
Aeolic/nit-Signatureat HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No
($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEYS FEES. 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
LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons,or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is in full force and effect. a registration form for acutely hazardous materials? 0 Yes 0 No
Lic.# Class Si (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
Contractor's Signature Date 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
O I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
hazardous materials)? 0 Yes 0 No
Lender's Name:
(Section 25534 of the California Health and Safety Code provides that the
Lender's Address: 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.
9na
s. tore ' ate • 4. If an RMPP is presently required, has Section 25534 of the California
•
OWNER-BUILDER DECLARATIONS: • Health and Safety Code been fully complied with? 0 Yes 0 No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the Califomia Government Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits).
License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or sho is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes ❑No
applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes", the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
jR'y, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
co pensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec.7044,Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No
thereon,and who does such work himself or herself or through his or her own 8. (If"yes",attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for control officer).
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 CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions.
❑ I. as owner of the
UCENSED CONTRACTORS to constrict the project(Sec.7044,Business and
Professions Code:The contractors License Law does not apply to an owner of Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contracta(s)license pursuant to the Contractors License'Laws.). certify under penalty of perjury that I have read this application and state that
❑ I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: the City of Costa Mesa • enter upon the above-described property for
••
inspection purpose -•ree not to occupy or,allow occupancy of any building
authorized • .. •t,•- it m ' mal inspection.
el.60457 //,2/D 7 / Signature eget Owner(s) L "- Dat
Slgna ( Dates .
3057-46 0/07)
Andlor Authorized Applicant Date
_ CITY OF COSTA MESA
• 44-3 - BUILDING DIVISION ,j • •
F77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
FOR INSPECTIONS CALL: (714)754-5626
PERMIT NUMBER: BX10-00134
PERMIT TYPE B_MISC STATUS: ISSUED
APN: 42627120 DATE ISSUED: 07/09/2010
Zoning: , ISSUED BY:
JOB ADDRESS: 246YEr197H ST CM Suite/Unit:
Vicinity: FRONT OF HOUSE -Primary Occ: 32 Const Type :17
SQ. FT: 336 Valuation: $5,416.32
SCOPE OF WORK:
REMOVE AN EXISTING 35.5 SF FRONT ENTRY PORCH AND REBUILD A NEW 35.5 SF FRONT ENTRY,ADD 2 FALSE
DORMERS,
FRAME UP A PORTION OF FRONT WINDOW AND EXTEND WINDOW TO CENTER ON WALL(HEAD ER WILL REMAIN THE
SAME),
CUT BACK EAVES,ADD NEW INSULATION AT FRONT AND (1) SIDE OF HOUSE AND PUT BACK WITH JAMES HARDIE SIDING
(NER-405); UPGRADE SERVICE PANEL TO 200A,ADD 6 NEW EXTERIOR OUTLETS AT EAVES, REWIRE 10 INTERIOR
OUTLETS.
OWNER: GULBRANSON COREY AND KATHLEEN Address:: 216 E 19TH ST Unit
City/State: COSTA MESA,CA Zip Code: 92627
Phone: 949-294-8717
APPLICANT: GULBRANSON COREY Address: 216 E 19TH ST Unit:
City/State: COSTA MESA,CA Zip Code: 92627 •
Phone: 949-294-8717
CONTRACTOR: OWNER-BUILDER License No. 000000
Address: Unit:
City/State:
Zip Code: Phone Cell:
ARCHITECT: License No.
Phone
ENGINEER: License No.
Phone
FEE SUMMARY
Building Plan Check: $81.41
Building Permit: $125.25
Electrical Permit: $71.60
SMIP Residential $0.54
SMIP Commercial $0.00
Bldg Std Admin Fund $1.00
TOTAL FEES $279.80
HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 -PER CMMC Sec. 13-279
Monday thru Friday-7:00 am thru 7:00 pm. Satrudays-9:00 am thru 6:00 pm. Prohibited all hours-Sundays and the following Federal Holidays:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord. No.92-28,§1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
CODE! INSPECTION TYPE pen IN1lAE$ CODE! INSPECTION TYPE DATE, IN1111At5
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof X 6—0�I I /YIP�q GF.� 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
lb
WORKERS'COMPENSATION DECLARATION: Owner ID verified by drivers license. DC ❑No OO
I hereby affirm und1 penalty of perjury one of the following declarations: Do versticense.No. Expi es:344y, 3
❑ I have and writ maintain a certificate of consent to self-Insure for workers' Verificationll� - — of Ownership by(type of document,i.e.-property tax bill r deed):
compensation, as provided for by section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
O 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 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a
number are: 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
Cartier: or dismantling thereof,will be more than thirty-sin(36)feet high.(Chap.3.2,Grp
(This sects need not ne completed tine penny is valued at one hundred dollars(5100)or less.)
2.Art 2Sec.341.Title 8,California Administrative Code).
Policy Number:
0 As owner-builder. I will not employ anyone to do work which would
C2C11
>I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless
sued,I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division.
to the workers' compensation laws of California. and agree that if I should
become subject to the workers' compensation provisions of Section 3700 of Applicant's Signature Date
the
A�6 II with comply with these p-7/fn .
a —7/G� Division of Industrial Safety Permit Number:
'TCdtmnt's Signature // L' HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
W NTNG: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST.AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. 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
LICENSED CONTRACTORS DECLARATION: 500 pounds.or a volume of 55 gallons.or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is in full force and effect, a registration form for acutely hazardous materials? ❑Yes 0 No
Lic.# Class# (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
Contractor's Signature Date 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
CONSTRUCTION LENDING AGENCY: temperature and pressure).
❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to
performance of the work for which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely
Lender's Name: hazardous materials)? ElYes IDNo
(Section 25534 of the California Health and Safety Code provides that the
Lender's Address: 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.
Signature Date 4, If an RMPP is presently required, has Section 25534 of the California
OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑Yes 0 No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Govemment Code requires that the requested
that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits).
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 6. Will any part of the facility to be constructed under this permit be within
the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes 0 No
applicant for a permit subjects the applicant to a civil penalty of not more than (If'yes", the facility must meet the requirement of Sections 25534 and 42303
five hundred dollars($500).): of the California Health and Safety Code).
i;as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other
'mpensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec.7044, Business and Professions Code:The Contractors subject of this application.have all of the disclosures prescribed by Califomia
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes ❑ No
thereon,and who does such work himself or herself or through his or her own
8. (If"yes",attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of control officer).
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
El I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH
city ordinances regarding Hazardous Materials and Emissions.
LICENSED CONTRACTORS to construct the project(Sec. 7044,Business and
Professions Code:The contractors License Law does not apply to an owner of Signature Date
property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
a contractors)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that
El I am exempt under sec. the information given is correct. I agree to comply with all state laws and city
ordinances relating to building construction, and authorize representatives of
Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described property for
inspection urposes. I agree no to occupy or allow occupancy any building
ae----------
3057-46
/� authoriy t is pe I inspection. � `('o1 1 `-1 . 01 Legal Ormerlsl l._..�^ D to1 ) And/or Authorized Applicant Date
° 2ioa<. FEE RECEIVED
COSTA MESA BUILDING-SAFETY DEPARTMENT MOV-2 1 lybS
P.O.BOX 317 COSTA MESA,CALIFORNIA rr 77FIINn(ANC((++EE� DEPT.
For Applicant to Fill In Completely APPLCA7 6Mit NM
TYPE OR PRINT BUILDING
For Office Use Only
BUILDING 216 E 19TH STREET
ADDRESS RECEIPT NO. PERMIT NO.
COSTA MESA, CALIFORNIA
IVED
OWNER
HARRY HUBBEL p .%/Ez/ ' //-4/-43.
BUILDING
MAIL ADDRESS 216 E 19TH
ADDRESS RAW - FIR
'/ /
TEL. ZONE GROUP . J
CITY T� NO. _ ,{
ARCHITECT T CARY
SON TEI8P32210 BFROVE DATE //--7+/4
OR VENEER N9. / e ✓
ZONING `
Aor 9 5871 FIRESTONE BLVD :DNEy� HOOF USE OP NEW r} jN
+l I I PUNS BUILDING (/{�/� �,
CONTRACTOR ANTHONY POOLS l
5871 FIRESTONE BLVD. DERIPION67/-,. 17 3� - �
BC _
ADDRESS ES/
�/�/j
CITY SOUTH GATE A.P.NO. i i L/ ' 0 !, —/ 7
NOTE: NO EAVE OVERHANG SHALL BE LESS THAN
STATE TEL. 30"TO SIDE a REAR F.L.
LIC.NO. //1p907 79 NO' SP3297 0 (/
VES
OF LOT C/ Q y I NNO.
OK=� 1 �LOWED Y YARDS
APPROVEDBUILDIVIACCE YARDS
APPROVED VE NG)
USE OF
EXISTING BLDG.
/J (FROM C/L STREET)
SETBACK LINE FROM (/ , /
CENTER OF STREET O RF�R YAR ids(
FRONT Q�/FT. Q Fy(T(-./
SIDE YARD I LEFT Jr I RIGHT k R.SIDE ]I FT. /3--P/i• ,ry �b IFT �/�
DESCRIPTION OF WORK L.SIDE / /SFT. /'T' . FT.
NE' _ A ALTERATION ADDITION REAR 22FT. I/ FT.
: DISTANCE BET. BET.MAIN&
MAIN BLOCS. ACCESS.BLDG'S.
REPAIR MOVING DEMOLISH
-BUILDING 39 NO.OF
VAR.# DATE
SIZE ROOMS STORIES C.U.P.# APPROVED
EXTERIOR WALL ROOF APP yj/E 9 /
COVERING COVERING BT TP' ' 6/�'/DATE /(/-7I IC A
USE OF BUILDING AND WOPERFORMED
H LD FOR IAL REQUIREMENTS
.
0
SD.FT.
I HEREBY A WLEDGE T T I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE
AND STA THAT THE ABOV IS CORRECT AND AGREE TO COM. PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. G
PLY W ALL CITY ORDINANCES AND STATE ULATING VALUATION / q
Or
BUIL NG CONST CTIONN
6PIE ATURE O-0 PERMIT FEE $
ITT I
re
AUTHORIZED AGENT (�f'`./etet Ccel /tU°It CO
? 4
TOTAL FEE 5/J