HomeMy WebLinkAbout309 19TH ST - Building Permits CITY OF COSTA MESA
0011 u BUILDING DIVISION
•
•
r t ,l 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us
.o,,,m`� FOR INSPECTIONS CALL: (714)754-5626
PERMIT NUMBER: BC11-00186
PERMIT TYPE: B_COMBO STATUS: ISSUED
Sub Type: RES ALT DATE ISSUED: 04/14/2011
ISSUED BY: RMD
JOB ADDRESS: 309 T...e . M_
E'19Suite/Unit:
APN: 11725420 rr-x•nZoning: , ,
Vicinity: KITCHEN BATHROOM Primary Occ:
Const Type: V-B SQ. FT: 0 Valuation: $800.00
SCOPE OF WORK: CHANGE OUT WINDOW IN BATHROOM AND KITCHEN, NO CHANGE IN HEADER, REPLACE 1 WASH BAINS
AND 1 WATER CLOSET. REF#: C11-0669
OWNER: THEOPHILE,KAREN E Address: 309 E 19TH ST Unit:
Phone: 949-650-1038 City/State/Zip: COSTA MESA,CA
APPLICANT: THEOPHILE, KAREN E Address: 309 E 19TH ST Unit: :
Phone: 949-650-1038 City/State/zZip: COSTA MESA,CA
CONTRACTOR: OWNER-BUILDER License No. 000000
Phone: Address: Unit:
Cell: City/State: ZipCode
ARCHITECT: License No. PHONE:
ENGINEER: License No. PHONE:
COMBINATION PERMIT FEE SUMMARY
Building Plan Check: $0.00
Building Fees: $32.65
Electrical Fees: $0.00
Mechanical Fees: $0.00
Plumbing Fees: $43.10
SMIP Residential: $0.50
SMIP Commercial: $0.00
Bldg Std Admin Fund $1.00
TOTAL FEES: $77.25
—Refer to fee receipts for all foes paid for project
HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010- PER CMMC Sec. 13-279
Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibited all hours-Sundays and the following Federal holidays:
New Years Day, Memorial Day,Independence Day,Labor Day,Thanksgiving Day and Christmas Day
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 1, INSPECTION TYPE, DATE INTMALS CODES INSPECTION TYPE DATE, INI111ALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical p �(��(
1266 Pool Spa Final 208 Final Plumbing 3 H-if-a I 2d1a t.ag
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 X a-V145_• tb�`
WORKERS'COMPENSATION DECLARATION '' . Claner ID verified by ❑ No
I hereby affirm under penalty of perjury one of the following declarations: rDriver's:Ligense,No.- x ires:,// ?at
L
ID6
I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tai ill 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 hereby certify that no excavation five(5)or more feet m 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,Cr demolition
CC:m= ", or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp
( h.'s . nor be mmp/eted atnePenn"
varued atonehundred eoears(Stoo)°rtes.) 2,Art 2,Sec.341,Title B,California Administrative Code).
0 As owner-builder, I will not employ anyone to do work which would
L-0-1-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
becomct to the workers'compensation provisions of Section 3700 of Applicant's Signature Date
the La r Code.I shall J{qrthhwtth c. orgply with these pro s
� /ilx(/��/[Lh.,Y/Jxn / , / Division of Industrial Safety Permit Number:
/Applicaniesagn ure (Date--> HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No
($100,000), IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST,AND exceptions, that a Business Plan be filed with the Costa Mesa Fire
ATTORNEY'S FEES. Department by every business which has at any one time during a reported
year a quantity of hazardous materials equal to or greater than a weight of
LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons,or 200 cubic feet of compressed gas
I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure).
with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file
my license is in full force and effect. a registration form for acutely hazardous materials? ❑Yes ❑No
Lic.# Class# (Section 25533 of the Califomia 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).
0 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? 0 Yes 0 No
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction
Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from
construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No
issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the 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 ndred 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
ompensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the
offered for sale(Sec.7044,Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California
License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No
thereon,and who does such work himself or herself or through his or her own 8. (If yes",attach certificate of compliance from the appropriate air pollution
employees, provided that such improvements are not intended or offered for control officer).
If, however, the building or improvement is sold within one year of
completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
did not build or improve for purpose of sale.), information given above is correct. I agree to comply with all state laws and
❑�f?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 ues. I agree not to krpy or allow occupancy of any building
c authori et' final sp tion.
yf,
�/ / /r /, (_Signature of Legal er(s) e"/'
---''Signature — C---Date-
3; 7-46(3/07)
And/or Authorized Applicant Date
r'
Th`�` CityofCosta Mesa Budding Division
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Costa Mesa 77 Fair Drive, Costa Mesa, CA 92626
714-754-5273 / Fax 714-754-4856
OWNER BUILDER VERIFICATION
Permit #
Disclosures & Forms for Owner- Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the
property improvements specified at .
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you
aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of
each provision, signed, and returned this form to us at our official address indicated. An agent of the
owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting
authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DDI
f/// CTIONS: Read and initial each statement below to signify you understand or verify this information.
1-I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and
material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any
injuries sustained by an unlicensed person and his or her employees while working on my property. My
homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder
and am aware of the limits of my insurance coverage for injuries to workers on my property.
r49-2. I understand building permits are not required to be signed by property owners unless they are
responsible for the construction and are not hiring a licensed Contractor to assume this responsibility.
Pa
3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that
I yy protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his
p--,.h
er name instead of my own.
4. I understand Contractors are required by law to be licensed and bonded in California and to list their
license numbers on permits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors,
a d'the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may
k
be
considered an "employer" under state and federal law.
k. 6_Lunderstand if I am considered an "employer" under state and federal law, I must register with the state
and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and
contribute to unemployment compensation for each "employee." I also understand my failure to abide by these
laws0-7
1rmay subject me to serious financial risk.
`V 7-,J.understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed
by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of
the work is performed under contract with a licensed general building Contractor.
3148-30 CALBO Jan 1, 2009 OB Packet template 1 of 2
.17-,8, I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable
for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent
construction defects in the workmanship or materials.
9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit
Payments, and the California Division of Industrial Accidents. I also understand I may contact the California
Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information
about licensed contractors,
10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand
at I am the party legally and financially responsible for proposed construction activity at the following address:
''711. I agree that, as the party legally and financially responsible for this proposed construction activity, I will
Abide by all applicable laws and requirements that govern Owner-Builders as well as employers.
7 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
in ormation I have provided on this form. Licensed contractors are regulated by laws designed to protect the
public. If you contract with someone who does not have a license, the Contractors' State License Board may be
unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against
unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed
Contractor or employee of that individual or firm is injured while working on your property, you may be held
liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible
for verifying whether or not those Contractors are properly licensed and the status of their workers'
compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner
and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's
driver's license, form notarization, or other verification acceptable to the agency is required to be
presented when the permit is is ed to verify the property owner's signature.
Gsignature-of-property owner, the
I".:/'ate:, ril��49///
Note: The following Authorization Form is required to be completed by the property owner only when
designating an agent of the property owner to apply for a construction permit for the Owner-Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I
hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents
necessary to obtain an Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent: •
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled
out the above information and certify its accuracy. Note:A copy of the owner's driver's license, form
notarization, or other verification acceptable to the agency is required to be presented when the permit is issued
to verify the property owner's signature.
Property Owner's Signature: Date:
3148-30 CALBO Jan 1, 2009 OB Packet template 2 of 2
rty. CITY OF COSTA MESA
A i :, BUILDING DIVISION '
Ira' DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
0, r
yef / PERMIT
Pomo 4°
M04 0^s20
(714)754-5273 • Fax(714)754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
MECHANICAL PERMIT
Job Address: 309 E 19TH ST Status: ISSUED
Suite No Applied: 10/04/2004
Issued: 10/04/2004
Vicinity:
Parcel Number: 11725420 ISSUED BY:
Applicant: THEOPHILE, KAREN E.
Address: 309E 19TH ST ; '- -
- ' Phone: 949-650-1038
COSTA MESA,CA ' Zip: 92627 _
•
Owner:' THEOPHILE, KAREN E
Address: . 309 E 19TH ST
Phone: 949-50-1038
COSTA MESA,CA Zip: 92627 , =
'
Contractor: OWNER-BUILDER
Address: .
Phone:
•
Zip: '
•
• " License:000000
SCOPE OF PERMIT
LEGALIZE INSTALLED1 FAU<100K BTU IN THE ATTIC AND 1 NEW NC UNIT< 100K BTU.
' ,FEE SUMMARY /
Quantity - - Quantity,
ISSUE'FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0
Inst FAU<100 k BTU .. $14.80 1. . , i ,, Repair/Alt Refrigeration Unit $0.00 0 - •
Inst FAU>100 k BTU $0.00 - 0 -_ - Ventillation System ,$0.00 ' 0'
Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler , $0.00 0
Inst/Rep.Recess Wall Htr $0.00 0- Commercial Incinerator $0.00 0
Refrig Sys<100 k BTU $14.80 1 Domestic Incinerator $0.00 0 ,
Refrig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems !
Gas Piping $0.00 0 Up to 3 hp/100 k BTU - - $0.00 0
Factory Fireplace $0.00 0 3 To 15 hp/500 k BTU / $0.00 0, '
Hood w/Mech Exhaust $0.00 0 - 15 To 30 hp/1,000 k BTU
VAV Box' " "v $0.00 0 r� 30 To 50 hp/1,750 k BTU $0.00 ' 0
Vent Fan%Single Duct $0.00 0 �? Over 50 hp/Over 1,750 BTU ‘ $0.00' - 0
Appliance A '$0.00. .0,, Boilers • - -
Fire Dampers - \ "$0.00 0 Up to 3 hp ' - $0.00, ..0
Smoke Dampers /''. - $0.00' . 0 - ' 3 To 15 hp ,$0.00 0
Inst or Relocate Appl Vent ,' $0.00" 0- 15 to 30 hp ' $0.00 0
Air Handlers< 10000cfm ' ',$0.00 0 " '30 to 50 hp- , " '' $0.00 . 0.
Air Handlers> 10000cfm $0.00 0 - - - Over50 hp $0.00 0
Floor Furnace , $0.00 . 0- - Other Mechanical Fee '
Floor or Suspend Heater .' , $0.00 -0- ;_ Investigation Fee $0.00
Plan Check Fee . $0.00
Reinspection yee $0.00
TOTAL CALCULATED FEES $53.10
- . . . i.
•
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
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
244648(WOO)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations: - -
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work 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:
Cartier. Policy Number.
(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 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 AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARS(5100,000),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.Lk.ft Class It
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 Cale).
Lenders 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 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 GNI penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sola compensation,WILL DO THE WORK,and the structure is not Intended or offered for sale(Sec.
7044,Business end 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 Lbws+.
❑ I am exempt u''''er ec. nem!"r .. Business and Professions Code for this reason:
tallL
1 . 4I /07. : L/-/
verified by drivers license.
cacti/. ns
0 No r vers LI e •
. xplres: /!/Q y
Verification of Ownership by(type of document,i.e.-property tax bill or deed): !!!
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(38)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division,
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1 Will the applicant or present or future building occupant need to file 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 then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP Is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 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 apermll for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? U 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? ❑Yes 0 No
(If yes',the facility must meet the requirement of Sections 25534 and 42303 of the Califomia 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 C MPUANCE 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 mply with all state laws end cit ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-descnb roperty for inspectio .. .. - :gr.e not to occupy or allow occupancy of any building authorized by this pe it us' Mal inspection.
• /f' / /O '
Ignatu a 0 Leg: 0. er(s) -ate
And/Or Authorized Applicant Date
CODE L INSPECTION TYPE WE Its ODE It INSPECTION TYPE•
gATf.
1616 Fixed System Final Fire Prevention _ 206 Final Mechanical y9/o 5 ,Al it
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final BlocldRetaining 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 '
Oji - CITY OF COSTA MESA•
BUILDING DIVISION ,
rj ,) .
DEVELOPMENT SERVICES DEPARTMENT PERMIT A UMBER
4 Iei
PERMIT
E04-01 4
, '
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 309 E 19TH ST . Status: ISSUED
Suite No Applied: 10/04/2004
Vicinity: Issued: 10/04/2004
Parcel Nunmber: 11725420
Applicant: THEOPHILE, KAREN E ISSUED BY:
Address: 309E 19TH ST .. .
- Phone: 949-650-1038
COSTA MESA,CA. '%' Zip: 92627 i
1
- . v ,�
Owner THEOPHILE, KAREN E- " .
Address ' 30/ 9 E-19TH ST - , -
Phone: 949-50-1038 - j' . ,
.COSTA-MESA,-CA,. Zip: 92627
Contractor , OWNER-BUILDER , ,
Address: 4 -
Phone: -
. u ,..: Zip. - ...
License: 000000 - _ -
SCOPE OF PERMIT
INSTALL 1 FAU<100K BTU IN THE ATTIC AND 1 A/C UNIT< 100K,BTU. -
-1 LIGHT, 1 SWITCH AND 1 MOTOR) . ,
FEE SUMMARY'
.Quantity Quantity i - "
ISSUE FEE $23.50 Z• - - ' -- - - - Temp Dist System/Lighting - $0.00 0 : ' ,
Temp service test $0.00 Busway/100 ft 1: $0.00 0
Res.a/c package' II'' $0.00 , Standing Section - $0.00
New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00
New Res(3+units)• $0.00 0 Transformers up to 1 kva/kw $0.00 ,,:0,`,
Pool/Spa • '' l; \�� $0.00 . 0 . \'-Iup to 10 kva/kw $0.00 ;0' �`i! , ,; i
LI htin Fixts \ . ��'-$1.10 1 ,,:44:2.,1'.;41P, u u to 50 kva/kw '-
9 9. 'i • , p $0.00!;1. i0
Recept Outlets $0.00 0 - up to 400 kva/kw $0.00: -„,4,' 0 '
Switches - x$1:10 1 - - over 100 kva/kw,;- - $0.00"' 0 c"
1 a
Non Res Appl ., $0.00,,, •-0"% " -Low Voltage Equipment -$0.00 0 '
Res Appl y. -$0.00 l.' 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 _$0.66,::://:,o /, 7Service over 1000a'v , $0.00', 0�_-� Circus(gen.or ride) $6:0Q.:; 0/ A
Motors to 1 hp $0.00 0 •" - Circus(meth-ride-or lights) , $000- , 0,'./
Motors to 10hp ,, 112.30 ,, - 1 .- , Christmas Tree Stand • ' $0.00, ,-0%
Motors to 50hp ,, $0.00 '- • 0 . - Fireworks Stand., , $0.00. / 0
Motors to 100hp '$0.00 ' ' 0 `. , 1; ,, Other Electrical"Fee - '/ -$0.00 7
Motors over 100hp $0.00 - -• - 0' ` ,�
Communication drops $0.00 .i.. 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.
i
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
2446-46(6/00)
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:
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 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 AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($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.# Class#
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).
Lenders Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ . - e ,• under sec C' Business and Professions Code for this reason:
S•n. ure: _ I .-'.. Arra' D!: ti►Allerr r
Owne I ver led by driv:rs license. /..0.48a_____0 No Drive ‘ lair r L1
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).
eppli...ant__ .._..____.._.._ _..._ _ _ —
3 Does or will the applicant or present or future building ocoupent neetl 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 Cale been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 0 No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes ❑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 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-descpb property for ins 'on purposes.I agree not to occupy or allow occupancy of any building authorized by this permit, til fin/nspection.
�/ Signature Legal Oivner(s /0
Dfier
And/Or Authorized Applicant Date
CODE t INSPECTIONTYPE PATE IyrTIAL$ OBE INSPECTION ME DAIS 2032.1.2
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final i 208 Final Plumbing
•
200 Final Re-Roof 210 Final Electrical I OtGl'f Vl V
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
"�il.t CITY OF COSTA MESA
'i °
4 -�, BUILDING DIVISION
f; ..7.4...,......;: '; DEVELOPMENT SERVICES DEPARTMENT 115-010:0
Te.414:41•444041.
Irak ; PERMIT PERMIT NUMBER
� en
am B98-01706
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT ebb
Job Address: 309 E 19TH ST Status: ISSUED
Suite: Applied: 09/23/1998
Vicinity: Issued: 09/23/1998
Parcel Nunmber: 11725420 Zoning:
Applicant: BRICE, MARK
Address:
_
1 ,
Owner TEMPLIN;DOUGLAS SCOTT _ N
Address TEMPLIN;LISA -, _ ' ' (� . _N ��
i i� , - ,-
COSTA MESA CA Phone:,
309,E 19TH STS, f - Zip 92627 :lAN '' / V N
Contractor MARK BRICE ROOFING
\:,:A,� :, / 'k ,�,
Address: 2925 NIPOMOAV7 � ; . �
\
%� ;i"� Phone: ,562421-3393 � ' � -
-,A.,: Cl/LONG BEACH,CA Zip:?...,90815
i
License696739
Arch/Eng ,./ ;•��.-' I i
Address:` .`_
�I. r�l. _`Phone:=__ - A
( , _ Zip: A
License: P-
SCOPE OF PERMIT
, / '
,T/0 EXISTING ROOF-AND REROOF WITH COMP:SHINGLE, HOUSE ONLY, ROOF CERT ATTACHED TO
` ,PERMIT. <, %. . - 1
FEE SUMMARY :,'
Plan Check: , $0.00 — - ' = ' -✓" - -' Calc Valuation: $2,300.00
Permit: $74.75 — —. Claim Valuation:;' $2,300.00
/
SMIP Res: $0.50
•
SMTP Com: $0.00 , ,
Other: $0.00
Inspection: $0.00
Total: $75.25 ` - .„
- , : PLANNING`S ZONING '
_% /
SETBACKS /,
MAIN STRUCTURE Front 00 , Rear_ 0-0 Left 0-0 Right 0-0-',"
•
ACCESSORY Front 0L01 ' Rear • 0-0- - ' Left . 0-0 , ' , Right -- 0,0
PARKING Existing: 0 - Required: 0 - Proposed: 0 - ,
NOTES: -
•
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections end final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
DECLARATIONS
WORKERS'COMPENSATION DECLARATION: r.
I hereby affirm unaer penalty of perjury one of the following declarations:
❑ I have end will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑ 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 canter and policy number are:
Cartier: 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 C Ilfomia,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 ?
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 DOLLARE(mom,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 andeffect.Lic. ./yJ " D #
Contractors Signature: Date: 9. 2? - ••••/
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 he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I,as owner of the properly,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec. 7044, Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. 0 Yes 0 No Drivers License No. Expires:
Verification of Ownership by(type of document,i.e.-property lax 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 end 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 apemlit 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 U No
(Section 65850.2 of the California Govemment 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 ryes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes ❑No
8 (If'yes",attach certificate of compliance from the appropriate air pollution control officer).
CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above Is correct.I agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
/ i re Of Legal Owner(s) �7 2 3 Dia
And/Or Authorized Applicant ( Date
fat. INSPECTON TYPE - DEE IMfflALS CODES INSPECTION TYPE DAIS IBIMALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof N5 Cl// 7 210 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 Anal Building/Occupancy
2446.46