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295 19TH ST - Building Permits
S CITY OF COSTA MESA • tieBUILDING DIVISION > , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER S /a PERMIT e� B04-00410 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 295 E 19TH ST Status: ISSUED Suite: Applied: 02/23/2004 Vicinity: Issued: 02/23/2004 Parcel Number: 11721412 Zoning: Applicant: VAN BERCKELAER, RICHARD ISSUED BY: Address: Phone: 949 646-4091 Zip: 92627 Owner: VAN BERCKELAER, RICHARD J Address 295E 19TH ST Phone: 949 646-4091 _ COSTA MESA,CA Zip: 92627 Contractor: Address: Phone: Zip: License: Arch : • Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT - RE-ACTIVATE EXPIRED PERMIT B05007 FOR CONSTRUCTION OF 3 CAR GARAGE-698 SOFT.8 1138 SOFT.2ND STORY ADD FEE SUMMARY Plan Check: $0.00 Calc Valuation: so.00 Permit: $0.00 - Claim Valuation: so.00 SMIP Res: $0.50 SMIP Corn: $0.00 • Other: $0.00 • Inspection: $0.00 • Total: 10136 PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 " PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1,12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days,or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2448-46 0/001 DECLARATIONS WORKERS'COMPENSATION DECLARATION: • - I hereby affirm under penalty of perjury one of the following declarations: 0 I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which thiA permit is issued. ❑ I have and will maiie tan 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'comp ation Insurance carrier and policy number are: Carrier: Policy Number: (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 Califomia,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: Date: 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 OYx I ARE($100.0011),IN ADDITION 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 Business and Professions Code,and my license Is In full force and effect.Lie.# Class 4 Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): p' 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 exam Kier/s c. Busin ss aa9d Professions Code for this reason: — Siynature: 'c.An,. Gv_— r"/�A6 t--- 9 � / Date: �'-0)3-0 y/ Owner ID vedfl drivers license. „Oyes 0 No Driver's License Na. / Expires: /1-I 'eo�i 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? 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)? Cl Yes ❑No (Section 25534 of the California Health end 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 ❑No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application apermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 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 facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (11'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- ribed property for inspection pu s.I agr not occupy or allow occupancy of any building authorized by this permit until final inspection. 2_ Signature Of Legal Owner(s) Date And/Or Authorized Applicant Date CODE I INSPECI1ONTYPC DM IIU ODE INSPECTIONTYPE PAIL MAU 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 tfZlC -'Y"( •i CITY OF COSTA MESA 4 0Oat BUILDING DIVISION .' "'`j ' DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER x. irrq PERMIT t / ""`° B99-01812 (714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 295 E 19TH ST Status: ISSUED Suite: Applied: 11/15/1999 Vicinity: 1ST STORY OF HOUSE ONLY Issued: 11/15/1999 Parcel Number: 11721412 Zoning: Applicant:ddress177 RIVERSIDE LIVINGSTONE, TERRY ISSUED BY: Address: 177 RIVERSIDE AV Phone: (949)645-0104 NEWPORT BEACH, CA Zip: 92663 Owner: VAN BERCKELAER, RICHARD J Address 295 E 19TH ST Phone: COSTA MESA,CA Zip: 92627 • Contractor: NEWPORT ROOFING INC Address: 177 RIVERSIDE AV Phone: (949)645-0104 NEWPORT BEACH,CA Zip: 92663 License: 524454 Arch : Eng: Address: - Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT REROOF PORTION OF SINGLE FAMILY RESIDENCE(20 SQ).TEAR OFF EXISTING HOT MOP ROOFING&COMPOSITION SHINGLES WITH EXISTING SHEATHING TO REMAIN. INSTALL 1-LAYER OF 15#FELT UNDERLAYMENT&REROOF PITCHED AREA WITH 30 YEAR-GAF TIMBERLINE-&REROOF FLAT AREA WITH SINGLE PLY TORCHDOWN(1ST STORY OF HOUSE ONLY). FEE SUMMARY Plan Check: $0.00 Calc Valuation: $4,000.00 • Permit: $97.25 Claim Valuation: $4,000.00 SMIP Res: $0.50 SMIP Corn: $0.00 Other $0.00 Inspection: $0.00 Total: $97.75 • PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: • • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned fora period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all 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 l Y \ _ 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 T.-� work for which this permit Is issued. C 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 workeers:rite! compensation lnsurpnce carrier and policy number are: / Carrier: tt!C FLQ/ (A Policy Number: G 6123' (This section need not be completed it the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work r 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 agr t 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: /`/♦W,� 7/,9 WARNING:FAILURE TO SECUR W KERS' PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND Drx I ARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am 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.e L Li cit Y it Class (1 3 Contractor's Signature: � Date: ///r S/ty CONSTRUCTION LENDING AGENCY: O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,CMI Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I em 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).): O 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 properly, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec. 7044, Business and Professions Code:The contractors License Law does not apply to an owner of properly who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. 0 Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i,e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth Into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,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? ❑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 appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? L I Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomla 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? ❑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 pu .• es.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. -I• - _ . Le (s) Date And.94Cized Applicant Date CODE s. INSPECTION TYPE PAIL INTITIAL$ CODE! INSPECTION TYPE PAIL 1NTRIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 6�y 208 Final Plumbing 200 Final Re-Roof /2 O 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 2446-46 ,- CITY OF COSTA MESA a4 a9 BUILDING DIVISION F DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER t i • PERMIT E04-00180 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 295 E 19TH ST Status: ISSUED Suite No Applied: 02/23/2004 Vicinity: Issued: 02/23/2004 Parcel Nunmber: 11721412 /TA__ Applicant: VAN BERCKELAER, RICHARD ISSUED BY: Address: Phone: 949 646-4091 Zip: 92627 Owner. VAN BERCKELAER, RICHARD J Address 295 E 19TH ST Phone: 949 646-4091 COSTA MESA,CA Zip: 92627 . , Contractor: Address: . Phone: Zip: License: SCOPE OF PERMIT RE-ACTIVATE EXPIRED PERMIT E056476;ELECTRICAL FOR CONSTRUCTION OF 3 CAR GARAGE-698 SQ.FT.& 1138 SQ.FT.2ND STORY ADD _ 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) 50.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 ' - Transformers up to 1 kva/kw $0.00 0 • Pool/Spa $0.00 0 - up to 10 kva/kw $0.00 0 Lighting Fixts $0.00 0 " • up to 50 kva/kw $0.00 0 • Recept Outlets . $0.00 0 - up to 100 kva/kw - $0.00 ' 0 ' Switches $0.00 . 0 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 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(& ) 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 Insurance carrier and policy number are: Carder: Policy Number: (This section need not be completed It the penult Is valued at one hundred dollars($100)or ion,) ❑ I certify that in the performance of the work for which this permit Is issued,I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES MD CML FINES UP TO ONE HUNDRED THOUSAND DOUJRE($t00,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37050F THE LABOR CODE,INTEREST,MD 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.tic.d Class 4 Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lenders 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 ha or she is licensed pursuant to the provisions of the Contractors Ucense 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 ' s the applicant to a civil penalty of not more than five hundred dollars($500).): ub : 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 Ucense 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 exem t and r sec. .L /Business and Professions Code for this reason: Signature: . <k i. /le 1,,L Date: E 7 Q^0 t7 Owner ID verili by drivers license. ..„,14 Yes 0 No Driver's License No. Expires: ,^ (3"—al, 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 Safely 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 ❑N0 (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 ❑No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a2pTermit 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 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 Calilomia Health and Safety Code). 7 If a permit from the South Coast Air Quality Management Distect or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (II yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the Information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the aboc9riproperty for insp on purposes.I agree not o occ py or allow occupancy of any building authorized by this permit until final inspection. v Signature Of Legal Owner(s) Dale And/Or Authorized Applicant Date VOLE INSPECTION TYPE PATE TALI CODE! INSPECTION TYPE PATE. =Ma • 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing •w/ 200 Final Re-Roof 210 Final Electrical tif �'.'A* 201 Final Block/Retaining Wall 212 Final Flre Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy se CITY OF COSTA MESA • BUILDING DIVISION F (titer-,I DEVELOPMENT SERVICES DEPARTMENT PERMI NUMBER primina sit I% PERMIT 04-00126 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 295 E 19TH ST Status: ISSUED Suite No Applied: 02/23/2004 Iss ed: 02/23/2004 Vicinity: Parcel Nunmber: 11721412 ISSUED BY: Applicant: VAN BERCKELAER, RICHARD Address: - Phone: 949 646-4091 ' Zip: 92627 Owner: VAN BERCKELAER, RICHARD J Address 295E 19TH ST Phone: 949 646-4091 COSTA MESA,CA Zip: 92627 Contractor: Address: Phone: Zip: License: • , Arch/ Eng: Address: • Phone: Zip: License: SCOPE OF PERMIT RE-ACTIVATE EXPIRED PERMIT P056480;PLUMBING FOR CONSTRUCTION OF 3 CAR GARAGE-698 SOFT.8 1138 SQ.FT.2ND STORY ADD - FEE SUMMARY AMT QTY-- ' AMT QTY - AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain,Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $0.00 0 Drain,Roof $0.00 0 Shower $0.00 0 Water Heater/vent $0.00 0 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 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 it work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all 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(600) •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 Cole,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed li the permit is valued at one hundred dollars($100)or loss.) ❑ 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 provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES MD CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS($103,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3708 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 Class A Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: 1 hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to Its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of ONision 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 Ejects the applicant to a civil penalty of not more than five hundred dollars($500).): I,as owner of the properly,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,em 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 exam under,se . usin end Professions Code for this reason: Signature: t.1 . C., „i--- / ~/ Expires: ,3^0e 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 feel 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 Cale). ❑ 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 appernll for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes t-1 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 8 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 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;eattach 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 abov ribed p party fo Inspe tion purpose I agree n t to cupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) i Dale And/Or Authorized Applicant Date CODE I. INSPECTIONTYPF Qdff, !MIA cODE. INSPECTION rot PATE =Ma 1616 Fixed System Final Fire Prevention 206 Final Mechanical n �1 / 1268 Pool Spa Final 208 Final Plumbing . fJ!",2i t ['7th 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 PLA PROJECT ADDRESS: 295 E 19TH ST UNIT` CITY OF COSTA MESA — BUILDING PERMIT PERM NO: M 05647S OWNER'S NAME: VAN BERCKELAER, RICHARD 3 ADDRESS: VAN BERCKELAER, PATRICIA PERMIT NO: M 056479 PLAN CHECK NO: N GOVT: N SUPP ; N D 295 E 19TH ST CONSTRUCTION TYPE: V—N PERMIT TYPE: MEC PURPOSE: ADD COSTA MESA, CA 92627 ARCH/ENGINEER: \ • REG.ND.: JOB DESCRIPTION : REPLACE 1 CAR GAR W/ 2 CAR GAR & ADD SQ FT; ADDRESS: I UNIT: CLAIM VALUE: CALC—VALUE; GROUP OCC: R-3 /M-1 PERMITTEE: RICHARD VAN BERCKEI.AER ( 715 ) 646-6630 • ADDRESS: 295 E. 19TH STREET COMMENTS: REF B56007 COSTA MESA CA 92627 icxx***Tc#dEa ********** E##yF#*****'*x*** -x*##xN#>E##****** #TE#*'N)t#>E****>Ex##'N#x#x#yF#TEx UCENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z ONING ' REQUIREMENTS 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. SETBACKS CITY LIC.: STATE LIC.: CLASS: Date: Signature: MAIN BUILDING ACCESSORY BUILDING — — WORKERS'COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers' FRNT: FT IN REAR ; FT IN FRNT: FT IN REAR • FT IN Compensation Insurance.ora cenilied copy thereof(Section 3800.Lab.C). LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN POLICY NO.: EXP.DATE: COMPANY: PARKING REQ• PROV: PARCEL: 11721412 ZNE: REF NO: _3 Certified copy is hereby furnished. ❑ Certified copy is filed with the city Building Division. PLANNING NOTES> > Date: Applicant: ",jF#############1E#############x######x lE###!E#******###########x######*********#### EXEMPTION FROM WORKERS'COMPENSAPON DECLARATION: (This section need not be completed it the permit is fa one hundred($110)or less). DEVELOPMENT S E R ¶1 I C E S REQUIREMENTS I certify that in the performance of the work for which this permit is issu'd.I shall not empl• any person in any mariner so as to become . subject to the Workers'Compensation Laws of California. / ` i "'ZONING APPROVED BY DATE: �� Date: 9L G—4 L Signature: Aw L - i[..-- .0 a. / • - NOTICE:If,after making this declaration,you should become subject to the Workers'Compensation provisions al the Labor lB U I LD I NG APPROVED BY : DATE; Code.you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for I.AP PLICATION ISSUED B Y• DATE: Q/-4 which this permit is issued(Section 3O97.Civ.C). ;�*******i(-***#*****#***#. - n'rc A-r** : T ..*****ae#Y:'** # Int**# LENDER: *****************************************' *************************************. ADDRESS: LEGALIZATION:N FEE SUMMARY STRUCTURAL SEGMENT:N OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish,or PERMIT 13 ,50 repair any structure.prior to its issualce.also requires the applicant for such permit to file a signed statement that he/she Is licensed , pursuant to the provisions of the Contractors'Stale License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business 2 5% SMIP/NON—RES and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by PLAN any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars(S500). ISSUE FEE 15. 00 I. as owner of the property or my employees with wages as their sole compensation, will do the work, and the BUILD ING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE ❑ structure is not intended or offered for sale(Section 7044.Business and Professional Code: The Contractors'State License Law TOTALS——--> 13 . 50 15. 00 0 . 00 28 . 50 28 . 50 .00 does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through his or her own employees,provided that such improvements are not intended or offered for sale.II,however the building or improvement is sold within one year of completion,the owner will have the burden of proving he/she did not build or improve REVENUE DIVISION TOTALS--> COLLECTED : 28 . 50 OVER/SHORT- 00 for the purpose of sale). BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044.Business 28 . 50 ❑ and Professions Code: The Contractors'State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with acontractor(s)license pursuant to the Contractors'State License Law).I am aware **###**#****ii'*******##**********#**#***#**#*+h*#***#ih*****x•IF#**#***#x'*x***#>**## that proof of their Worker's Compensation insurance should be provided to me. ID lam exempt under Section: H P 7 0 4 4 B.a P.C. INDIVIDUAL F E E B R E A K D O W N mnnisreaso ;nALL WORK BY OWNER "ZTYPE QTY DESCRIPTIO N UNIT COST TOTAL COST Date: ?�6 �� Owner. MEC 1 INST FORC—AIR/GRAV FURN <= 100 K BTU 9 . 00 9 , 00 I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505,25533.and MEC 1 VENTILATION FAN CONN TO SINGLE DUCT 4 . 50 4 . 50 25534 and that I or any future building occupant will/will not(circle one)need to comply with said state codes and the requirements for a permit for construction or modification from the Air Quality Management District.Residential construction applications are exempt from END OF FEES these provisions. Date: Applicant: _ I hereby certify that I have read this application and state that the above information is correct.I agree to comply with at city and county i`1 C^11: - _ • ordinances and state laws relating to building construction and here authorize representatives of this city to enter upon the above-mentioned 10 YE- G.., • 3 ; f• ; property forinspeclion purposes. . _ „_1 Date: Lp"'foZ Signature' (- try �-12. ✓�/�`��/� l// Driver's License on Social Security.: 1641.46 While—Ouildinn:Green—Code Enforcement:Canarv—Aoolican4 Pink—Revenue:Goldenrod—Assessor • CONSTRUCTION AND PLANNING POO, SPA APPROVALS Permit# Date Inspector APPROVALS Permit # Date Inspector 1 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 •T 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical OF 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,O Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 1 62. Backwash & Receptor-Final 12. Sewer Cap • - 63. Heater & Vent-Final 13. Roof Drains 64. Plumbing System -Final - 14. Rough Plumbing 65. Electrical-Final 15. Rough Electrical-Conduit 66. Solar System-Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign - 68. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating&Air Conditioning 61611 Z. LEQ FIRE DEPT. REQUIREMENT 20. Rough Factory Fireplace APPROVALS Permit # 21. Ducts,in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil 23. Gas Pipe-Rough& Test 72. Underground Flush 24. Roof Framing 73. Undergrnd.Storage Tank OGas ❑Oil 25. Roof Sheathing 74. Overhead Hydro 26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing& Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric . '1 Notes: 34. Final Heating & Air Conditioning - �,./a. 35. Final Gas Pipe-Test ��%%jjJ� 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service-Final 40. Gas Service-Final 41. Solar Domestic•Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No Date A 9ROlECT ADDRESS: 295 E 1924-ST UNIT: CITY OF COSTA MESA - BUILDING PERMIT PERM NO: d u:,bUU , OWNER'S NAME: VAN BERCKELAER, RICHARD J ADDRESS: VAN BERCKELAER, PATRICIAD PERMIT NO: B 056007 PLAN CHECK NO; 04753-91 L GOVt ; N SUYY: N 295 E 19TH ST CONSTRUCTION TYPE: V-N PERMIT TYPE: STE PURPOSE: ADD Vt. COSTA MESA,CA 92627 ARCH/ENGINEER: REG.ND,: JOB DESCRIPTION : REPLACE 1 CAR GAR W/ 2 CAR GAR & ADD SQ FT; 1 , 836 ADDRESS: UNIT: CLAIM VALUE: 60, 000 . 00 CALL-VALUE: 90, 597. 40 GROUP OCC: R-3 /M-1 PERMITTEE: RICHARD VAN BERCKELAER ( 715) 646-6630 ADDRESS: 295 E. 19TH STREET COMMENTS: ADD TO SFD & GARAGE COSTA MESA CA 92627 #***tE****#x•##tE#tE****tE**+E+E* tE#K##>E*rE*r6*>F#***tE>EN+E******+EIE+t *>E**•x TE****f*iEtc.**Fe.>EtEX•If* LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z ONING REQUIREMENTS 7000)of Division 3 of the Business and Professions Code.and my license is in lull force and effect. SETBACKS CITY LIC.: STATE LIC.: CLASS: MAIN BUILDING -- ACCESSORY BUILDING Date: Signature: FRNT: 39 FT 7 IN REAR : FT IN FRNT: FT IN REAR: FT IN WORKERS'COMPENSATION DECLARATION: Ihereby affirm that I have a certificate of consent to self-insure or a certificate of Workers' LEFT: 5 FT IN RGHT: 5 FT IN LEFT: FT IN RGHT: FT IN Compensation Insurance.or a certified copy thereof(Section 3800.Lab.C). POLICY COMPANY:: EXP.DATE: PARKING REQ: 2 PROV• 3 PARCEL: 11721412 ZNE: R1 REF NO: • PLANNING N TES.> 1138 SF 1ST & 2ND FLR & 3 CAR GARAGE ADDIT TO REAR OF EX SFD Certified copy is hereby lumisheQG❑ Certified copy islifed with the city Building Division. ONLY •y- R•ES .DENCE PERMITTED ON THIS SITE. PER ZONE & GEN PLAN .ef .. ******iE*******rx-****dE*'***,yE*lE*************-}F*********i!-******IE***0E****iE******dE**Y*iE • A°°I�°t 52L SERVICES REQUIREMENTS EXEMPRON FROM WORKERS'COMPENSATION DECLARATION: (This satin need not be completed it the panel is kw one hundred(51 W)or less). a I certify that in the performance of the work•for which this'permil is issued.I shall not employ any person in any manner so as to become /; ��'' i t /� DATE: ( Z`-1 / �,[— subject to the Workers'Compensation Laws of California. ZONING AP PROV Eb BY >, :n yr ..n Vi Date: Signature'' +• BUILDING APPROVED BY: : .-• . F, DATE: NOTICE:If,aper making this declaration,you should become subject to the Workers'Compensation provisions of the Labor ,ry Code.you must forthwith comply with such provisions or this permit shall be deemed revoked. ' i r Z CONSTRUCTION LENDING AGENCY: I hereby affirm than thergis:s construction lending agency for the performance of the work for APPLICATION ISSUED B'Y" .. .- ln1I L lbALS/ 'a .• DATE: l L which this permit is issued(Section 3097(Civ.C). / ************1ELf1E*****tf .. t " *****iE****# **)E * *** LENDER: **********H-yE******‘****if**************************1E************0E**********-***** ADDRESS: LEGALIZATION:N F E E S U M M- AR Y STRUCTURAL SEGMENT:Y OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors'State License Law for the f°flowing reason BLDG PMT PLUMBING ELECTRIC 'MECHANIC FIRE SMIP/RES GRADING (Section 7031,5 Business and Professional Code: Any city of county which requires a permit to construct,alter,improve,demolish,or PERMIT 5 9 9 , 0 0 9 , 0 6 repair any structure,prior to its issuance.also requires the applicant for such permit to file a signed statement that he/she is licensed % t' f'' SM I P/NON-RES pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7003)of Division 3 of the Business p LAN 389 , 35 and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 byj ,/� any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars(SSW). ISSUE FEE I / . I:' I. as owner of the properly or my employees with wages as their sole compensation, will do the work, and the BUILDING-DIV-> PERMIT ISSUE PLAN-CHECK:7' ,. TOTAL PAID DUE TOTALS----> 608 . 06 0 , 0 0 489 . 35' 997. 41 9 9 7, 4 1 , 0 0 ❑ structure is not intended or offered for safe(Section 7044,Business and Professional Code: The Contractors'State License Law does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through his or her own employees.provided that such improvements are not intended or offered for sale.If,however the building or REVENUE DIVISION TOTALS--> COLLECTED• ) .„608 . 06 OVER/SHORT: 0 0 ibfor sold one year of completion.the owner will have the burden of proving he/she did not build or improve BLDG PMT PLUMBING ELECTRIC MECHANIC 1. FIRE SMIP/TOT GRADING PLAN-CHECK for the purpose of sale). I,as owner of the properly,am exclusive contracting with licensed contractors to construct the project(Section 7044,Business 599 . 00 ... 9 . 06 The Stateapply to an owner of properly who Mulls or Improves ❑ and who contra tsdfo Contractors' License Law ices not rrytyI thereon and who contracts for such projects withacontractpr(sl license pursuant to the Contractors'State License Law),I am aware ****#*******#*#***#***IE*IF***#*#******-lE***.**iE********IE******IE**********9E******** that proof of their Worker's Compensation insurance should be provided to me. I N D I V I D U A L / F E E J RREAKDOWN N I am exempt under Section: B P 7 0 4 4 B.B P.C. 9, for mason: ALL WORK BY Ot'INER TYPE QTY DESCRIPTIOj 4 UNIT COST TOTAL COST Date: / Owner (-1----aa- SFR 1138 DWE-TYPE V-WOOD FRAME -GOOD 69 , 00 78, 522 . 00 I do hereby certify that I am aware of and understand the requirements of Calif ria Health and Safety Code Sections 25505,25533,and SFR 698 RES-GARAGES TYPE V . .' 17, 30 12, 075 . 40 25534 and that I or any future building occupant wilVwill not(circle one)need to comply with said state codes and the requirements for a 1END,! OF FEES permit for construction or modification from the Air Duality Management District.Residential construction applications are exempt from r these provisions. , el i • Date: Applicant: EXPIRED y ,r I hereby certify that I have read this application and state that the above information is correct.I agree to comply with all city and c my Incomplete I r:�lections 7 11 51 lir_•:.::7'; --- ',- ordinances and state laws relating to building con tion and hereby authorize representativ of this d to enter upon Ili bove-men vied •� -_ property for inspection purposes. / //}� [/3A— /yy� -. D:71-i. 1 .•, _ t ' Date: tures ii L/'s�/e..i� Z.� Date � 2 I ,�.,�.SIgK �' :)' -- !• Driver's License or Social Security 0: /// C . 1641-46 White—Buffeting:Green—Code Enforcement:Canary—Aool.canC Pink—Revenue:Goldenrod—Assessor - _ ., I . . .P CONSTRUCTION AND PLANNING P00WA 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-Undrgmd. 54. Forms 4. Electrical Conduit-Undrgrnd. / 55. Electrical Bonding 5. Steel Reinforcement 3t/Q.L?Z (yW/�- 56. Rough Plumbing & Pressure Test 6. Electrical UF ER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 1-,}04-6 ¢ 58. Electrical Conduit-Undrgrnd. 8. Foundation 2,I ro_pL kits/ 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 11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final 12. Sewer Cap 63. Heater & Vent-Final 13. Roof Drains 64. Plumbing System • Final 14, Rough Plumbing 65. Electrical-Final 15. Rough Electrical-Conduit 66. Solar System-Final • 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling 69. POOL/SPASYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT 20. Rough Factory Fireplace APPROVALS Permit # 21. Ducts,in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas 0Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil 25. Roof Sheathing • -22r412. �CN74, Overhead Hydro 26. T-Bar Ceiling {Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing I zg-YZ 76. Dry Standpipe • 28. Lathing& Siding t-2-gL 77. FIXED SYSTEM FINAL e 29. Insulation O 28 t. &cart 78. FIRE PREV. FINAL 30. Drywall Nailing ra2, 4 HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat ss�� 79. FINAL INSPECTION 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating& Air Conditioning 35. Final Gas Pipe-Test 6 w� 36. Hood or Canopy d t ts/4z - 37. Final Factory Fireplace lQ bi(4L �•� @ r1/� • 1 0_�'4t � 38. Final Plumbing 8•,GT�...� ,g2 • 39. Water Service•Final 7` 40. Gas Service-Final 41. Solar Domestic-Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co • 51. CERTIFICATE OF OCCUPANCY • No. Date PRO�'I�T ADDRESS: UNIT: CITY OF COSTA MESA — BUILDING PERMIT PERM NO: P 05648( -.,r OWNER'SMME: 295 E 19TH .ST VAN BERCKELAER, RICHARD J ADDRESS: VAN BERCKELAER, PATRICIA PERMIT NO: P 056480 PLAN CHECK NO: N GOVT: N SUPP: N D 295 E 19TH ST CONSTRUCTION TYPE: V—N PERMIT TYPE: PLU PURPOSE: ADD ARCHIEN6INEER: COSTA MESA,CA 92627 gEG.NO.: ADDRESS: UNIT: JOB DESCRIPTION : REPLACE 1 CAR GAR W/ 2 CAR GAR & ADD SQ FT: CLAIM VALUE: CALC—VALUE: • GROUP OCC : R-3 /M-1 PERMITTEE: RICHARD VAN BERCKELAER ( 715) 646-6630 ADDRESS: 295 E. 19TH STREET COMMENTS- REF B56007 COSTA MESA CA 92627 >F*sE*>E>t*x*xx************xr>***x*>F#*****x** xx+Fxx**x***>E* *n*x*+tEFfE*>Ex**ux>EaE*k **x * LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section Z ONING REQUIREMENTS 70001 of Division 3 at the Business and Professions Code.and my license is in full force and effect. SETBACKS t CITY LIC.: STATE UC.: CLASS: WIDate: signature: MAIN BUILDING ACCESSORY BUILDING WORKERS'COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers' FRNT: FT IN REAR: FT IN FRNT: FT TN REAR : FT IN Compensation Insurance,or a certified copy thereof(Section 3800.Lab.C). LEFT; FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN POLICY NO.: EXP.DATE: COMPANY: PARKING REQ' PROV: PARCEL : 11721412 ZNE: REF NO; ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the city Building Division. PLANNING NOT ES> N > date: Applicant i *************************************** ****3F**********************)(N.********** EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (The section need not be mnpleted if the permit is for one haired(5100)a less). DEVELOPMENT S E R V •I C E S '.:11 E) QUIREMENTS I cenif that in the performance of the work for which this permit is issued,I shall not employ any erson In dny m ner so as t0 become • to the Wotke/q'Compensation Laws of California. (� ''/, ZONING APPROVED BY 4 , . T DATE: r 3-*-92 Date: Signature: dX+.- J� NOTICE:If.afler;making this declaration,you should become subject to the Workers'Compensation provisions of the Labor BUILDING APPROVED BY : < DATE Code.you must lOnhwilh comply with such provisions or this permit shall be deemed revoked. 4. --�- -— CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the•perlormance of the work for _ase which this permit is issued(Section 3097,Civ.C). -�' `� *P*APPLICATION**ON S)e ISSUED Y Y V�`_ _ DATE; o3(9G�7i LENDER: I ) • ****IF*****lE***!E******)e*****if***X-IEIf*** :**********************W*******)f*$**M%**** ADDRESS: LEGALIZATION:N F E E SUMMARY STRUCTURAL SEGMENT:N OWNER BUILDER OECLARATIDN: I hereby affirm that l am exempt from the Contractors State License Law for the following reason BLDG PMT PLUMBING ELECRIC MECHANIC FIRE SMIP/RES GRADING (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,alter.improve,demolish,or BERM I T 10 . 0 0 repair any structure,prior to its issuance.also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business 2 5 8 SM I P/NON—RES and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by PLAN any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). ISSUE FEE 3 . 00 --..'x1, as owner of the property or my employees with wages as their sole compensation, will do the work, and the BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE ❑ structure is not intended or offered for sale(Section 7044.Business and Professional Code: The Contractors'State License Law TOTALS——--> 10. 00 3 . 00 0 . 00 13 . 00 13 . 0 0 . 00 does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If.however the building orLS__ Ira theposeofsae) BLDGPMTPLUMBING ELECTRICMECHANICFIRE /TOT epurl within one year of completion.the owner win have the burden of proving he/she did not build or improve REVENUE DIVISION OD13 . 00 SMIP /SHORT: 00 GRADING PLAN—CHECK I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business 13 . 00 ❑ and Professions Code: The Contractors'State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractor(s)license pursuant to the Contractors'Slate License Law).I am aware ****.**********************************************************************if**** that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUAL F E E BREAKDOWN © l am exempt under Section:B P 7 0 4 4 0.8 P.C. for this reason: CALL WORK BY OWNER /� / ' Y1�4/4 TYPE QTY DESCRIPTION UNIT COST TOTAL COST Date: 3—b—` Z Owner: �✓L/a J PLU 1 BATHTUB ♦♦ 2 . 00 2 . 00 I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505,25533,and PLU 1 SINK, BAR 2 . 00 2 . 00 25534 and That I or any future building occupant wiMvif not(cirde one)need to comply with said state codes and the requirements for a Wanly for construction or modification from the Air ahty Management District.Residential construction applications are exempt!tom PLU 1 WASH BASIN 2 . 00 2 . 00 these provisions. PLU 1 WATER CLOSET ('TOILET) 2 . 00 2 . 00 Date: Applicant. PLU 1 E X P'�§ EPDPING SYS OFEND 10TOF4 OUTLETS 2 . 00 2 . 00 I hereby certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ) piste Inspections ordinances and state laws relating to building construction and hereby authorize representatives of this ' to enter a on the bovamentioned property for inspection purposes. xel J:l ....:"....M. " , - .'7 '" ' • : S-/ Q7 LME Yr DateSignature. i — L.: Driver's License or Social Security a: ,1-j 1641-46 White—Budding:Green—Code Enforcement;Canary—Applicant:Pink—Revenue:Goldenrod—Assessor I .� J cer CONSTRUCTION AND PLANNING POOL ?A 1 APPROVALS Permit# Date Inspector APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole ' 52. Pool & Equipment Location r 2. Soil Pipe-Undrgrnd. Q/ry % 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. `- . - 54. Forms 1. 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding '2 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UF ER Grnd. 57. APPROVAL TO COVER-GUNITE 9. Footings - 58. Electrical Conduit-Undrgrnd. 8. Foundation - 59. Gas Pipe, 0 Undrgrnd., Test '9. Water Pipe-Undrgrnd. .f 60. Backwash Lines,P-Trap, 0 Undrgrnd. • 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 2/9/pa /J`20" A2. Backwash & Receptor-Final 12. Sewer Cap [ LT 63. Heater & Vent-Final 13. Roof Drainsrrryyy �A 64. Plumbing System - Final th14. Rough Plumbing z_I' 65. Electrical-Final 15. Rough Electrical-Conduit _! /- 66. Solar System-Final 16. Rough Electric Wiring • 67. Fencing & Access Approval ' 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING- 18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT 20. Rough Factory Fireplace APPROVALS Permit# 21. Ducts, in Structure 70. Underground Hydro • • 22. Ducts, Ventilating 71. Product Piping 0 Gas 1:1 Oil 23. Gas Pipe-Rough& Test 72. Underground Flush 24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro • 26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Goat 79. FINAL INSPECTION 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe-Test ,Hill/- 2 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service-Final I/G/11/QZ 40. Gas Service-Final I.��0 ,� ��j�f YYY ^_!/� � � v 41. Solar Domestic-Final 42. Backflow Preventer • 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co • . 51. CERTIFICATE OF OCCUPANCY No. Date • 295 E 19TH. ST UNIT: CITY OF COSTA MESA - PERM NO; E 056478 ,• PROJECT ADDRESS: , BUILDINGPERMITT \ 'PI OWNER'S NAME: VAN BERCKELAER, RICHARD J .. . •noDREss: VAN BERCKELAER, PATRICIA PERMIT NO: E 056478 PLAN CHECK NO: N GOVT; N SUPP; N D !� 295 E 19TH ST CONSTRUCTION TYPE: V-N PERMIT TYPE: ELE PURPOSE; ADD ARCH/ENGINEER: COSTA MESA, CA 92627 REG.NO.: ADDRESS: umJOB DESCRIPTION : REPLACE 1 CAR GAR W/ 2 CAR GAR & ADD SQ FT: CLAIM VALUE: CALC-VALUE: GROUP OCC; R-3 /M-1 PERMmEE: RICHARD VAN BERCKELAER ( 715) 646-6630 ADDRESS: 295 E, 19TH STREET COMMENTS: REF B56007 COSTA MESA CA 92627 #**** **if****NN#>E>E***40*** ¢*,<#>F*sd#Nx** **#*..x.4c+c..x..>E*****X*X EMx*x->E*#x******#->E#**** LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section ZONING R EQU IR EMEN TS 7000)of Division 3 of the Business and Professions Code.and my license is in lull force and effect. SETBACKS CITY LIC.: STATE LIC.: CLASS: Dale: X. y Signature: MAIN BUILDING ACCESSORY BUILDING WORKERS'COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers' FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN Compensation Insurance, or a certified copy thereof(Section 3800.Lab.CL LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN POLICY NO.: EXP.DATE: COMPANY: PARKING REQ; PROV: PARCEL : 11721412 ZNE: REF NO: ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the city Building Division. PLANNING NOTES> > Date: Applicant: *************IF*if*3i***********##*#*#****####*##**iP#**##*3E***1(•IF***#ii***)E**ii**3c**iF EXEMPTION FROM WORKERS'COMPENSATION DECLARATION: (This section need not be completed if the permit is for one hundred($100)or less). DEVELOPMENT SERVICES REQUIREMENTS I certify that in the performance of the work for which this permit is issu'.,I shall not employ any person in any manner so to become subject to the —s�Workers/Compensation Laws of California. / 4 ZONING APPROVED BY DATE: Date: •� -97_— Signature: 4j...r. NOTICE:If,after making this declaration.you should become sto the Workers'Compensation provisions of the Labor BUILDING APPROVED BY DATE: Code.you must forthwith comppermit with such provisions or this permit shall be deemed revoked. • CONSTRUCTION LENDING AGENCY:'t I hereby affirm that there is a construction lending agency for the performance.of the work for APPLICATION ISSUED BY• '' DATE: f�3o6 Z which this permit is issued(Section 3097.Civ.C). ****************** .6:z -� . . --x>• c C • " ' - .n-*****IE****zn Pr-&iFi"i,7ii, ** LENDER: **************************************# .***************************************. ADDRESS: LEGALIZATION;N F E E SUMMARY STRUCTURAL SEGMENT:N OWNER BUILDER DECLARATION: I hereby affirm that l am exempt from the Contractors'State License Law for the following reason BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct,after,improve,demolish,or PERMIT 59 45 repair any structure,prior to its issuance.also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors'State License Law(Chapter 9(commencing with Section 7000)of DlvMsion 3 of the Business 'At SMIP/NON-RES and Professions Code)or that he/she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by PLAN z-15,_,. 7 4, any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). ISSUE FEE 1 5, b0 I. as owner of the property or my employees with wages as their sole compensation, MI do the work, and the BUILDING-DIV-> PERMIT ISSUE PLAN-CHECK TOTAL PAID DUE ❑ structure is not intended or offered for sale(Section 7044,Business and Professional Code: The Contractors'State License Law TOTALS----> 59 . 45 1 5 . 0 0 �• 0 , 00 74 . 45 7 4 , 4 5 . 00 does not apply to an owner of a property who builds or improves thereon,and who does such work himself/herself or through f ,,' • 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 will have the burden of proving he/she did not build or improve REVENUE DIVISION TOTALS--> COLLECTED; 74 , 45 OVER/SHORT; 00 for the purpose of sale). BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TUT GRADING PLAN-CHECK I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044.Business 74 . 45 ❑ and Professions Code: The Contractors'State License Law does not apply to an owner of property who builds or improves thereon f and who contracts for such projects with a contractor(s)license pursuant to the Contractors'State License Law).I am aware ***#*************************************************************************** that proof of their Worker's Compensation insurance should be provided to me. INDIVIDUA Lj F E E BREAKDOWN © I am exempt under Section:0P7044 B.It P.C. •�'r for this reason: /ALL WORK BY OWNER j / J TYPE QTY DESCR IP T I<0 N UNIT COST TOTAL COST Date: 3 — G-,, — Owner: C/ .� I do herebycertil that l am aware of and understand the requirements of California Health and SafelyCode Sections 25505,25533,and ELt 2 0 FIXTURES, L'CHT I NG 1 S T 2 0 EA. . 75 1 5 , 0 0 25534 and that I or any future building occupant will/will not(circle one)need to Comply with said stae codes and the requirements for a EL 1 FIXTURES LAGHTI NG,, ADDITIONAL EA, . 45 4 5 permit for construction or modification from the Air Quality Management District.Residential construction applications are exempt from EL ' 20 REC EPT/OCTTLgT I 1 ST 20 EA. . 75 15 . 00 these provisions. ELE 1� �4 C '.PT/OUTLET `1 ADDITIONAL EA, , 45 4 . 50 ELE 15;11"P 17-LCd'PT/SWITCH ' 1 ST 20 EA, 75 10 . 50 Date: Applicant: ELE IncoMplete lr pe�LQ9S1EL I 11 . 00 11 . 00 I hereby certify(hat I have read this application and state that the above information is correct.I agree to comply with all city and county ELE 1 MOTO POWR APPARATUS 0 . 0 - 1 . 0 HP 3. 00 3 , 00 ordinances and state laws relating to building construction and hereby authorize representatives of thiscity to enter upon the above-mentioned sig END OF FEES property for inspection purposes. _ (� Dee �� Wg . - -. —� s :'1 l'1ilii da—. 'ii _� Date: 3.-Co-9� Signature: �[.��'c+` Qom— .... C_. .. ... - -. ... i� Driver's License of Social Security x: 1641-46 White—Building:Green—Code Enforcement;Canary—Applicant;Pink—Revenue;Goldenrod—Assessor ' ' a4 j CONSTRUCTION AND PLANNING POOL ` ,'A APPROVALS Permit# Date Inspector APPROVALS Permit# Date Inspector 1. Yemporary Electrical Service or Pole 52. Pool & Equipment Location • 2. Soil Pipe-Undrgrnd. - - 53. Steel Reinforcement _ 3. Electrical Conduit Utility-Undrgrnd. A 54. Forms •' 4. Electrical Conduit-Undrgrnc3, I'3-9-Z•, 55. Electrical Bonding 5. Steel Reinforcement !!�� 56. Rough Plumbing& Pressure Test 1 6. Electrical UF ER Grnd.. 57. APPROVAL TO COVER-GUNITE •7. Footings 58. Electrical Conduit-Undrgrnd. • 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. .. 60, Backwash Lines, P-Trap, O Undrgrnd. 10. Structural Floor System61. APPROVAL TO DECK .r - . 11. Property Sewer Line & House Connection 62, Backwash & Receptor-Final - 12. Sewer Cap ' 63. Heater & Vent-Final ' 13. Roof Drains 64. Plumbing System - Final ' . 14. Rough Plumbing -" 65. Electrical-Final - - 1. 1 15. Rough Electrical-Conduit ,, ;if Solar System-Final 71,1 16. Rough Electric Wiring 7-27- Fencing & Access Approval 17. Rough Wiring Sign ...-68. APPROVED FOR PLASTERIN 18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL ' 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT 20. Rough Factory Fireplace APPROVALS Permit# 21. Ducts, in Structure I 70. Underground Hydro - 22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil 23. Gas Pipe-Rough & Test 72. Underground Flush l 24. Roof Framing 1 73. Undergrnd.Storage Tank 0 Gas 0 Oil "t - 25. Roof Sheathing 74. Overhead Hydro -. 26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe . 28. Lathing & Siding ' ' 77. FIXED SYSTEM FINAL 29. Insulation - 78. FIRE PREY. FINAL 7 30. Drywall Nailing 1 HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat i 79. FINAL INSPECTION 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED/� / 33. Final Electric Notes: Go-2.7�i. ti,4 - Arris #.2 34. Final Heating& Air Conditioning • 4 ,e G_ if 35. Final Gas Pipe-Test 36. Hood or Canopy S , 37. Final Factory Fireplace . 38. Final Plumbing I 39. Water Service-Final 40. Gas Service-Final 41. Solar Domestic-Final 42. Backflow Preventer . ' 43. Backflow Irrigation 44. Landscape irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING • 48. FINAL PLANNING • 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date G Aosta Mesa Building Department APPLICATION FOR PERMIT 1.�.- P. O. Box 317 078't3 BUILDING 1 COSTA MESA, CALIFORNIA FOR OFFICE USE ONLY FOR APPLICANT� -yTO FILL IN Receipt No. Permit No. - Adildingdress �2 qS ed. 2/t/ /Q A. Address 6 3 7 Costa Mesa, Calif rnia liAer byate R 'd. Date Issued Nearest I 7-/ 17- 2/ Cross St.�,/�. anti /AAA-, Building _ , the /,� AI� Q,,, i — Address — elf / s,// MailOwner / il-a i o` ' - I� to Mesa, California Address„2.74"(� , 19,I, .FP , Nearest C !� � � ty``nn / TelNo. , Cross S a ACrchitecto Lic. �,/ Zo tel► No.of Plans I TYpf� Group Engineer No. Approve. y by Date Address CORRECTIONS I City tic. infractor No. Addressg .APP.n� ^R' `--D Legal Lot �ht ry 7•' pvB Y Description I No. .2 J I Block / 1 I fractal)/ ` f1TY 01- fY..TA 1.^1:S4 (Attach Metes and Bounds) 007—L .,/41 — /Y pi,a.: KING DEPT. f, No.of Bldgs. �t SUEJEC'f l'G BLDG. DEPT. REG. Size of Lot .5-0 A 13.. I Now on Lot a,lJ 0 io Use of No.of No.of ,/ Existing Bldg.rom—.y} .I Families LI Rooms �} .53 Setback Line from`Q t f� Rear Yard �I BY ---- DAT' ii����•5 Z C Center of Street 70 'Y' Side Yard S PLAN IcLH. D DESC ON OF WOR B;I New I Alteration I I Addition I Repair I I Moving I I Demolish I Liel Building$?{/ No.of i / N _Size ��`` Rooms Stories terror Wal �// I Roof #ering ! / Coverrn.��Ljr/ APPROVALS I Use of New CC . S 4,./OF enc / BuildingFoundation Location Inspector Date Forms,Materials, Under-Pinning Frame: Fire Stops, tv Bracing,Bolts F— I hereby acknowledge that I have read this Application O and state that the above is correct and agree to comply Lath. Int. with all City Ordinances and State Laws regulating A. building construction. Lath.Ext. Signature ( �/j • Permittee /lV�l J !e» * fvts Plaster, Int. Authorized Agt. Plaster,Ext. a P ValuationO Permit Fee $ OZ eMasonry Reinforced pa ��„� Plaiiijnchesio11 Q Bond Beam $ / Total C o Fee $ O . FINAL . Y 4 % - , • t -i .41, 1 . , \ \ Ct. \ .. a - 1 t . \,. 1. A ' . . .. , ,1\ • o .. , • • I Street I •; \ • - - — PLOT PLAN Show location and distances from N. \ M ri 52 property line and between buildings. N t u 1 \- •` • VI V .1 0 O M - .. Ai2056 1201 5/15/72 73069 TL COSTA MESA BUILDING-SAFETY DEPARTMENT 1201 5/ 16/70 76e69C1(T0 P.O.BOX 1200 COSTA MESA,CALIFORNIA 92626 1201 000g1;L,6C 56 1 A APPLICA ION FOR STRUCTURAL PERMIT For Applicant to Fill in Completely — Use Ink Only RECEIVEd� DATE RECEIVED' DA IS$5J€D BUILDING 7�^ f /g71—. q1/ 55" /((ffff(( ADDRESS P 7 7 y // "'reeve_OWNER /lr,i� r Wain i3 tJ4A!-✓ A.P.NO. //7 —p//"'/ ✓/ � e AMAIL. DDRESS fR"LC F , / f'� BUILDING /�j` r / 5,TE �j��"_ / J ryr— ,�j ADDRESS 0� (J • CITY Gm S/s�1�tc Sg NO. S44-y?y, TRACTNS54 LOT23 BLOCK CONSTRUCTION NEW ADD ALTER REPAIR MOVING DFMOLLSH LENDER Na49p. BRANCH , , I , , • 0 NER , Y4 .� / /` y/i /.� , ADDRESS --� fin; • / `' `; BLUE '♦O ARCHITECT TEL. }: $ i� OR ENGINEER NO / FIRE r -VI ,t\]vis ADDRESS • ZONE J�T�YPE GROUPeor ,I ` - r--- APPROVED /L!Y DATE%—`g-7t/ CONTRACTOR DS.z�ar- BY !/W/ (/¢��� ADDRESS 2�S %lt•�r � TEL. ZONE ✓IL PLANS Z BUILDING NEW % CITY NO. K F STATE CITY YARDS APPROVED YARDS APPROVED LIC.NO. LIC.NO. MAIN BUILDING ACCESSORY BUILDING ri fy SIZE INO.OF BLOCS. (FROM C/ � CoET)/ �� �� `_ IS OF LOT NOW ON LOT FRONT FT. FT. a USE OF 7 s CO EXISTING BLDG. R SIDE FL FT• IA r F Separate permits are required for L.SIDE & FT. FT. . electric,plumbing and heating work. GII REAR 4 ^(] /CJ r' FT. FT.GU - USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET.MAIN& MAIN BLOCS. ACCESS.BLOCS. .# DATE ..7 /L� _ �Y4 j3 .l-J.Se4rJ.+•...rK CORP,.sW APPROVED a � — ›. _SROVEAi/e -:/9'/8rpisn, a �/Vf Y DATE d LIG 0.. I hereby acknowledge that I have read this application and state N IL' that the above Information is correct and agree to comply with m Cl" all laws regulating building construction, and I shall not employ Zany person in violation of the workman's compensation laws of m Withe State of California. m I hereby certify that I am properly licensed as a contractor under SO. FT. H the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m Chapter 9, and that such licenses are in full force and effect,or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: e am exempt from the provisions of the State of California BusinessVALUATION PERMIT FEE �a nn et $ and Professions Code ivislon 3,Chapter 9. a/ qa� In PLAN CHECK $ mo Signature of ef/f� n -�- �4 u Permittee L�Aw $ G�/OC TAX $ e 4 Z {/v 72, 4 Authorized Agent TOTAL PAID $