HomeMy WebLinkAbout227 19TH ST - Building Permits •
CITY OF COSTA MESA - ..
,�r ' BUILDING DIVISION
i Y dc�" ,� 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
F i .rL:�az
FOR INSPECTIONS CALL: (714)754-5626
PERMIT NUMBER: E08-00314
PERMIT TYPE ELEC STATUS: ISSUED
APN: 42540416 DATE ISSUED: 08105/2008
ISSUED BY: RMD
JOB ADDRESS: 227 E 19TH ST CM• Suite/Unit:'
Vicinity:
SCOPE OF WORK: REPLACE 21'LIGHT FIXTURES,':33 OUTLETS, 16 SWITCHES AND SERVICE PANEL UPGRADE TO 100 A.
•
•
OWNER: TRENTON,GARY LAND JOANNE D Address: PO BOX 15907 Unit: - '
PHONE: 949-939-7117 ;' City/State/Zip: NEWPORT BEACH,CA 'H
APPLICANT: TRENTON,GARY LAND JOANNE D: Address: PO BOX 15907' Unit:
PHONE: 949-939-7117 - City/State/zZip: NEWPORT BEACH,CA • ,
-
CONTRACTOR: OWNER-BUILDER License No. 000000
Address: Unit:" PHONE:'.: :
City/State: - ZipCode: CELL:
ELECTRICAL PERMIT FEES •
Electrical Plan Check Fee: $0.00 •
Electrical Permit Fee: .- $125.82
Reinspection Fee $0.00
TOTAL FEES $125.82
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord. No.92-28,§ 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
cooEJ, INSPECTION TYPQ LAM 1N1I1ttL$ CODE I INSPECTON TYPE egg INIIML$
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1268 Pool Spa Final 208 Final Plumbing nn �
200 Final Re-Roof 210 Final Electrical f owe, 1
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
� .d
WORKERS'COMPENSATION DECLARATION: Owner ID verified by driveerr'3 lict Yes 0 No �7
I hereby affifm unoer penalty of perjury one of the following declarations: Drivers License No. ? Expires: I—as/0
❑ 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 DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. My workers' compensation Insurance carrier and policy 0 I hereby certify that no excavation five(5)or mom 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.
(This sacro need not be completed s Oe perms u valued at one hundred doeers($rdd)or less) 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).
Policy Number:
�/
0 As owner-builder, I will not employ anyone to do work which would
gyp_ 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
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 subject to the workers'compensation provisions of Section 3700 of
Applicant's Signature Date
the Labor Code,I shall forthwith comply with these provisions.
94��� ��-�-� /� D Division of Industrial Safety Permit Number:
Applicant's��Signature�!llLO Pl eke 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
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
c' r 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
tiling 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? 0 Yes ❑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(Duality 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 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 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 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
J)-4,7 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 contractor(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 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 fl insp n.
• S gnature of Legal Owners) Date
Signature _Date
7.46(3107)
And/or Authorized Applicant Date
Wsta
Mesa Building Department �+ AP CATION FOR PERMIT
'111 EAST 20th STREET 1 V ' BUILDING 1
COSTA MESA, CALIFORNIA
FOR OFFICE USE ONLY
FOR APPLICANT TO FILL INReceipt No. Permit No.
Building p p 0.�tr� j0, S S 6 �[
Address ? C _,,/ ` 7 l/ �" /
Costa eSa, California //�Receiived by Date Reed. Date Issued
Nearest c•� r `V I y� S
Cross St. Z t. ;K. etti-c. Bu ding
VZ� Address
MailOwner , Costa Mesa, California
Address ,2 3 5 / 9� • Nearest
/ � .-��-- /� t, Cross St.
•
City etc2 4.t '✓14. C L4/ No.4�4'•3C8C Zone No.of Type_ / Grobq,,,
Architect oral! {Li/
No. �� I Plans I �f �L ts..'1?I Engineer �'. No. Approvedby Date
''dress CORRECTIONS
' J/ / No. Lie.
...infractor .(, ( ` No.
Address �
Lel I
!qs!
De cr ption I No. /f I Block 0 I Tract J j` r
(Attach Metes and Bounds)Ac e#�/{ -, a/ 5 4,
Size of Lot /i,4 /.9A.0 Now on Loth
Use of We r7� No.of No.of 700
Existing Bldg T-'yyypFp I Famllles*,SRooms E
Setback Line from _ 1.,,� ?/ Rear Ya et
Center of Street �� Side Yard ,gD
DESCRIPTIONrOF WORK
New I [P Alteration I I Addition I
Repair I I -Moving I I Demolish I
Building No.of
Size Rooms Stories
:rim.Wall . I Roof
• .ering Covering APPROVALS
Use of New
Buildingq�tr� Foundation Location Inspector Date
Forms,Materials,
Under-Pinning
Frame: Fire Stops,
Bracing,Bolts , -
I hereby acknowledge that I have read this Application
3
and state that the above is correct and agree to comply Lath.Int.
with all City Ordinances and State Laws regulating n
o
building construc ' n. // Lath.Ext. v.
Signature of
Permittee x�j // ^� • Plaster, Int -
Authorized Agt. Plaster,Ext R
Valuation 4 y/ Permit Fee $ 3 C. Masonry Reinforced
•
l - Plan Check$ Bond Beam r
$ / ! Total c 0
Fee $ ,9 FINAL ?
c ao- . -'iu_
_ c _
` a. .,
a 0 .
"- _ -- .- - a.- .
. _
._ _ ', . • . , r,,,. .oma ` • . .
C, '/ -
Street _ ..'� •
._ _
• , 'f•. -
-PLOT PLAN - . .
Show location and distances from •
.
property line and between buildings. -
4 --- - . -
11
• - ,
.. .
ilk
r CITY OF COSTA MESA
"
^, Re BUILDING DIVISION
iak a)1 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • w wv.ci.costa-mesa. s
r
JFOR INSPECTIONS CALL: (714)754-5626
�°"°�M ��\ '------ PERMIT NUMBER. P08-00048
: ir . \- i C--- p
PERMIT TYPE PLUM i / l� STA/TUS : ISSUED
APN: 42540416 �DATEYISSUED: 02/12/2008
ISSUED BY: SOK
JOB ADDRESS: 229 E 19TH ST CM Suite/Unit:
Vicinity: .
SCOPE OF WORK: INSTALL DOMESTIC TANKLESS WATER HEATER. •
OWNER: TRENTON,GARY.L AND JOANNE D Address: PO BOX 15907
PHONE: 949-939-7117 - City/State/Zip: NEWPORT BEACH, CA
APPLICANT: TRENTON,JOANNE 0 Address: PO BOX 15907 :
PHONE: 949-939-7117 City/State/zZip: NEWPORT BEACH,CA
CONTRACTOR: OWNER-BUILDER License No. 000000
Address: PHONE:
City/State: ZipCode: - • ' -`CELL:
ARCHITECT: License No. , - PHONE:
ENGINEER: - License No. PHONE:
•
' PLUMBING PERMIT FEE SUMMARY •
PLAN CHECK FEE: $0:00 '
PERMIT FEE: $35.80
TOTAL FEES: $35.80
•
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 P INSPECTWN TYPE auINTTal11 CODE INSPECTON TYPE OAT Ix1111AL
1816 Fixed System Final Fire Prevention 206 Final Mechanical 'p
1266 Pool Spa Final 208 Final Plumbing �'I�'O p
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention _
202 Final FactoryFire Place 220 Final Planning Approval
203 Final Sign 222 Final Site _
I 204 Final Demolition 250 Final Building/Occupancy _
WORKERS'COMPENSATION DECLARATION:# Owner ID verified by drive e. _`/❑Yes 0 No
I hereby affirm under penalty of perjury one of the following declarations: DmerSticense.No('" .-expires:7-25-/O
❑ 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.
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
Carrier: or dismantling thereof,will be more than thirty-six(36)feel high. (Chap. 3.2,Grp
(This section need not be completed A the perms is valued et one hundred dollars($100)or less.)
2,Art 2,Sec.341,Title8,California Administrative Code).
Policy Number:
_ 0 As owner-builder, I will not employ anyone to do work which would
fri .iertify 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
ssued, 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
the Labor Code,I shall forthwith comply with these provisions. Applicants Signature Date
Division of Industrial Safety Permit Number:
cosa/J�/JZPr-a- O/Y!�im ,,.-9-/a7',4 er
/s r rtts'AppiieanrsSgnawr� ^- rrDate--.- 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? ❑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
Contractors Signature Dale 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)? ❑Yes ❑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 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 ❑No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California 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 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
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 or herself or through his or her own 8 (If es'", attach certificate of compliance from the
employees, provided that such improvements are not intended or offered for y' P 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: 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
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 Dale
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
the information given is correct. I agree to comply with all state laws and city
❑ I am exempt under sec. 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 fins pection.
[JQ/J�-02'O'-�/-•/�O/Y�./�YJ 107-[/O %egal Ovmer(s)...—.AJ . `Date_ _L-
.07.- //37 _Signature.,r,- - - Da1e'-
3. 7) And/or Authorized Applicant Dale
r CITY OF COSTA MESA
BUILDING DIVISION
).:0-4 .Al� 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
ci . FOR INSPECTIONS CALL:(714)754-5626
s.
PERMIT NUMBER. E08-00052
PERMIT TYPE ELEC STATUS: ISSUED
APN: 42540416 DATE ISSUED: 02/12/2008
ISSUED BY: SOK
JOB ADDRESS: 229 E 19TH ST CM Suite/Unit:
Vicinity:
SCOPE OF WORK: REPLACE 13 LIGHT FIXTURES, 15 OUTLETS, 16 SWITCHES AND 1 NEW SERVICE METER
OWNER: TRENTON,GARY L AND JOANNE D Address: PO BOX 15907 Unit:
PHONE: 949-939-7117 City/State/Zip: NEWPORT BEACH, CA
APPLICANT: TRENTON,GARY L AND JOANNE D Address: PO BOX 15907 Unit:
PHONE: 949-939-7117 City/State/zZip: NEWPORT BEACH, CA
•
CONTRACTOR: OWNER-BUILDER License No. 000000
Address: Unit: PHONE: . .. ..
City/State: ZipCode: CELL:
•
ELECTRICAL PERMIT FEES
Electrical Plan Check Fee: $0.00 _
Electrical Permit Fee: $102.40 - _
Reinspection Fee $0.00
TOTAL FEES $102.40 . - - '
•
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 r, INSPECTION TYPE DATE, IN11ALD CODES INSPECTION TYPE DATE IN11f1AL6
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
WORKERS'COMPENSATION DECLARATION Owner ID verified by driv t. . �❑Yes ❑ No
I hereby affirm under penalty of perjury one of the following declarations: �Ortoe11-License No. -- `Expires:7=-7.C-.10❑ I have and will maintain a certificate of consent to self-Insure for workers' r dfication of Ovmership 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 ❑ 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
Carrier: or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp
(This seeon need nor be mrrpie/ed the perm a valued e/one hundred dollars(stop)or less.) 2,Art 2,Sec.341,Title 8,California Administrative Code).
Policy Number:
❑ As owner-builder, I will not employ anyone to do work which would
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
'S ed,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 Dale
the Labor Code,I shall forthwith comply with these provisions.
r��/n.�y,,�yy�) q -� _ D� Division of Industrial Safely Permit Number:
•J��I '<Slonu�e� r- Odle 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
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 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? ❑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 fcr 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? 0 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).
❑ 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 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
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.,,nn�ottb�build or improve for purpose of sale.). information given above is correct. I agree to comply with all state laws and
� `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 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.Zmi
T/ /� -7 �j o nature oL er
.,-0/ � rD�
—/— CTIh ',l�.s42,0(T f, _ (1 � j' Date �.
Signatflie
3051 (3Po7) Md/or Authorized Applicant Date