HomeMy WebLinkAbout453 19TH ST - Building PermitsCITY OF COSTA MESA
o�`p'" ,, BU/LD/NG DIVISION
F`�� 77�AIR DRIVE. COSTA MESA. GA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
� FOR INSPECTIONS CALL: (714) 754-5626
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PERMIT NUMBER: BX10-00182
PERMIT TYPE B_MISC STATUS: ISSUED
APN: 11734130 DATE ISSUED: 11/23/2010
Zoning: , ISSUED BY: RMD
JOB ADDRESS: 453 E 19TH ST CM Suite/Unit:
Vicinity: ROOF TOP Primary Occ: Const Type :??
SQ. FT: 0 Valuation: E9,800.00
SCOPE OF WOF2K:
INSTALL 18 SOLAR PANELS FOR A 3.76 KW ROOF MOUNTED PHOTOVOLTAIC SYSTEM WITH 2 DISCONNECT, MISC
CONDUIT
AND 2 INVERTER9. REVISED: 12/20/10- 1 ADDITIONAL INVERTER.
OWNER: TAYLOR, WARREN G
Ciry/State: COSTA MESA, CA
Phone:
APPLICANT: SONJA GLOBERSON-LAMB
City/State: SANTA ANA, CA
Phone: 510-414-8120
CONTRACTOR: SOLARCITY CORPORATION
Address: 2265 S GRAND AV
City/State: SANTA ANA, CA
Zip Code: 92705
ARCHITECT:
Phone
ENGINEER:
Phone
FEE SUMMARY
Building Plan Check:
Building Permit:
Electrical Permit:
SMIP Residential
SMIP Commercial
Bldg Std Admin Fund
Montlay thru Friday - 7:00 am thru 7:00 pm.
Address:: 453 E 19TH ST
Zip Code: 92627
Address: 2265 S GRAND AV
Zip Code: 92705
License No. 888104
Phone 774-290-9521
$117.81
$181.25
$62.10
$0.98
$0.00
$1.00
5412.14
�TIVITY: EFFECTIVE
-9:00 am thru 6:00 pm. F
License No.
License No.
Unit
Unik
UniC
Cell:
A
� f"' 1 y i`wy`'f�'�'"
'��.��i�J1�-� 1
, •
.
0- PER CMMC Sec. 13-279
311 hours - Sundays and the following Federal Holidays:
�ivina Dav and Christmas Dav
NOTICE: The work Eulhorized by this permit shall comply with all applicable handicap access requiremenls 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 oblain inspections and final approval will result in the expiration of this permil.
C�� INSPECTIONTYVE ��TF INI1TIAl5 CO�E� INSPEC7IONttPE 04TE IN7171RL
5616 Fixed Sysiem Fi��al Fire Prevention 206 Final N�echamcal
12fi8 PoolSpa Final 208 Final Plumbing
200 Final R�Roof 210 Final Electrical
20t Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Pactory PirE Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final �emolition 250 Final Building/OccuOancy
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty oi perjury one of the following tleclarations:
❑ I have and vrill maintain a certifcate ot consent to self-Insure tor workers' �
compensation, as provided for by section 3700 of Ihe Labor Code, for the
pertormance of Ihe work tor which this permit is issued.
❑ I have antl will maintain workers' compensation insurance, as required by
sectbn 3700 of the Labor Cotle, fa the peAormance of the �+ork for which this
pertnit is issued. My workers' compensation Insurance carrier antl policy
number are:
CCartier T�cvG� lr�S. �cx��wp,noeP
(Tlus secion neeCirot ba ncwnpleted I Mepemia 6 vahied at me frwrtlied cbnars (S1001 a�ess )
Poli�Number. -lls3"'�Kbii( �1—
❑ I certify that in the pedormance of lhe work for which this permit is
issued, I shall nol employ any person in any manner so as to become subject
to Ihe workers' compensation lav+s of Califomia. and a9ree that if I should
become subject to Ihe workers' compensalion provisions of Section 3700 of
the Labor Code hall forthwith com _'th these provisions.
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[ � tintbbi aWre UaIG>
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE
IS UNUIWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
wi[h Section 7000) o( Division 3 0! lhe Business and Pro(essions Code, antl
my license is in full force and eRect.
�ic;ttr� �ass�a r"� r_tib � �
� l �2�2��10
aGOr sr$i �Oa e�
CONSTRUCTION LENDING AGENCY:
❑ I hereby affum thai there is a construction lentling age�y for the
peRortnance of the uork for which tNs pertnit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender's Address:
SignaWre Date
OWNER•BUILDER DECLARATIONS:
I hereby aKrm that untler penalty of perjury Ihat 1 am EXEMPT FROM THE
CONTRACTORS LICENSE LAW tor the following reason (Sec. 7031.5,
Business and Protessions Code: Any ciry or couNy which requires a permit to
consWct, alter, improve, tlemolish, or repair any strucNre, prior to its
issuance, also requires lhe applicant for such pertnit to file a signed statement
that he or she is licensed pursuant to the provisions of Ne Contractors
License Law (Chapter 9(commencing vrith Section 7000) of Division 3 of the
Business and Professions Cotle) or that he or she is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicanl for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars (5500).):
❑ I, as ovmer o( the property. or my employees vrith vrages as their sole
compensation, WILL 00 THE WORK, and the str�cture is not intentletl or
oHered for sale (Sec. 7044. Business and Professions Code: 7he Contractors
License Law does not apply to an owner ol property who builtls or improves
thereon, and who does such vrork himself or herself or through his or her ovm
employees, pmvided that such improvemenis are not intentletl or offered for
sale. If, however, the building or improvement is sold within one year of
completioq the ownervbuiltler will have the Durden ol proving that he or she
did not build or improve for purpose ot sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRAC7ING WITH
LICENSED CONTRACTORS to constmct lhe project (Sec. 7044. Business and
Pmfessbns Code: The contractors license Law tices not appty to an ovmer ot
property who builds or improves thereon, and who coniracts for such project with
a contractw(s) license pursuant to che Contractors Ucense Laws.).
❑ I am exempt under sec.
Business and Professions Code for this reason:
305]<6�10])
Owner ID verified by tlriver's license. ❑ Yes ❑ No
Dnver's License No. Expires:
Verifcation of Ownership by (rype o! tlocument, i.e. - propeny tax bill or deed):
' �.
DIVISION OF INDUSTRIAL SAFEN PERMIT CERTIFICATION:
❑ I hereby cerlAy that no excavation frve (5) or mwe feet in tlepth into wfiich a
person is required to descend, vnll be made in connection vrith work authorizetl
by this permit, and that no builtling slrucWre, scaffdding, falsewoM, a demolition
or tlismanUing thereof, will be more �han lhirty-siz (36) feet high. (Chap. 32, Grp
2, M 2, Sec. 341. Ttle 8, Califomia Atlminisl2tive Cotle).
❑ As owner-builder, I will not employ anyone to do work which vrould
require a permit from the Division of IntlusUial Safety, as noled above, unless
such person has a permit to do such vrork from the division.
App�icanfs SpnaWre Date
Division of Indusirial Safety Permit Number.
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. will me applicant or present or future building occupant neetl to file and
certify a Business Plan for emergency rasponse to release or lhreatened
release of a hazardous matenal7 ❑ Yes ❑ No
(Section 25505 of the Califomia Health antl Salery Cotle requires, wilh some
exceptions, that a Business Plan be fled vrith Ihe Costa Mesa Fire
Department by every business which has at any one time tluring a reported
year a quantiry of hazardous matenals equal to or greater than a weighl of
500 pounds, or a volume of 55 gallons, or 200 cuDic feet of compressed gas
at slandartl temperature and pressure).
2. Does or will the applicant or present or fulure builtling occupant need to fle
a registration form lor acutely hazardous materials7 ❑ Yes ❑ No
(Section 25533 0l the Calilornia Health and Safety Code. vrith some
exceptions, requires registration wim lhe Costa Mesa Fire Depanment by
each 6usiness which at any one time has on hantl a quantity o( acutely
hazardous malenals equal to or greater than a weight of 500 pounds. or a
volume of 55 gallons, or 200 cubic feet ol compressed gas at stantlartl
temperature antl pressure).
3. Does or vnll the applicant or present or future builtling occupant need to
prepare an RMPP (Risk Management and Prevention Program for acutely
�azartlous materials)? � Yes ❑ No
(Section 25534 ot the Califomia Health and Safety Code provides that the
Costa Mesa Fire Department may require the preparation, certifiwtion and
filing with the Fire Department of an RMPP by businesses which are requiretl
b register acutely hazardous materials with the Fire Department.
4. It an RMPP is presently required, has Section 25534 ot lhe Calilornia
Health and Safery Code been fully complietl with? ❑ Yes � No
5. Does or will the applicant or preseN or IuWre builtling occupaN require for
Ihe work which is the subjecl of this application a permil for such consWclion
or modification from the South Coast Air Duality Management Distnct or from
any other air pollution control disMct or agency? ❑ Yes ❑ No
(Seclbn 658502 of the Califomia Govemment Cotle requires that the requested
infortnalion be fumished on appliwtions for rrornresidential builtling pertnits).
6. Will any part of the facility lo be construcled untler this pertnit be within
7000 (eel from the outer boundanes of a school? ❑ Yes ❑ No
(If'yes", the facility must meet the requirement of Sections 25534 antl 42303
of the California Health and Safety Code).
7. If a permit from the South Coast Air Quality Management District or other
air polWtion control district or agency is required lor the vrork v+hich is the
subject of this application, have all of the disclosures prescri�etl by Califomia
Heallh and Salety Code Section 42303 been matle? ❑ Yes ❑ No
8. (If'yes', allach certificate of compliance from the appropriate air pollution
controloKceq.
CERTIFICATE OF COMPLIANCE: I certify thal under penalcy o( perjury the
infortnalion given above is correct. I agree to comply vrilh all stale iaws and
city ortlinances regarding Hazardous Materials and Emissions.
CERTIFICATE OF COMPLIANCE AND AUTHORILITION OF ENTRY: I
cerlify under penalty of perjury lhat I have read this applicaGon and state t�at
the infortnation given is correct. I agree lo wmply wiN all state laws and ciry
ortlinances relating Io building construction, and authwize representatives ot
the City of Costa Mesa lo enter upon the above-tlescribed property br
inspection purposes. 1 agree not lo occupy or allow occupancy ot any building
authorizetl by this permil until fnal inspection.
�� Leqal er ' � ��
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tlwrtzeC�Ap rWK-�
CITY OF COSTA MESA
� o pMFs,p BUILDING DIVISION
F . � 77�FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • waw.ci.costa-mesa.ca.us
°.��FOR INSPECTIONS CALL: (714) 754-5626
c+'
PERMIT NUMBER: BX10-00182
PERMIT TYPE B_MISC STATUS: ISSUED
APN: 11734130 DATE ISSUED: 71/23/2010
Zoning: , ISSUED BY: RMD
JOB ADDRESS: 453 E 19TH ST CM Suite/Unit:
Vicinity: ROOF TOP Primary Occ: Const Type :?7
SQ. FT: 0 ' Valuation: 58,000.00
SCOPE OF WORK:
INSTALL 18 SOLAR PANELS FOR A 3.76 KW ROOF MOUNTED PHOTOVOLTAIC SYSTEM WI7H 2 DISCONNECT, MISC
CONDUIT
AND 2 INVERTERS. �
OWNER: TAYLOR, WARREN G
City/State: COSTA MESA, CA
Phone:
APPLICANT: SONJA GLOBERSON-LAMB
City/Stale: SANTA ANA, CA
Phone: 510-414-8120
CONTRACTOR: SOLARCITY CORPORATION
Address: 2265 S GRAND AV
City/State: SANTA ANA, CA
Zip Code: 92705
ARCHITECT:
Phone
ENGINEER:
Phone
FEE SUMMARY
Building Plan Check:
Building Permit:
Electrical Permit:
SMIP Residential
SMIP Commercial
Bldg Std Admin Fund
TOTALFEES
HOURS FOR CONSTRUCTIf
Monday thru Friday - 7:00 am thru 7:00 pm. Satu
New Years Dav. Memorial Dav
Address:: 453 E 19TH ST
Zip Code:. 92627
Address: 2265 S GRAND AV
Zip Code: 92705
Unit
Unit
License No. 888104 �
Phone 714-290-9521
License No.
License No.
$99.61
$153.25
$62.10
$0.80
$0.00
$1.00
$316.76
:TIVITY: EFFECTIVE 3/18/2010 - PER CN
-9:00 am thru 6:00 pm. Prohibited all hours - Su
Unit:
Cell:
and lhe (ollowing Federal Holidays:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28. § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 780 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
tNSPECTIONS: In order for the work autho�zed under this permit to be considered legal, such work must cAmply with all applicable codes, a�d alt
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
WUEp. INSPECTIONTYPE �RTE INTIPRLS C� INSPECTIONTYPE OATE NTII TIRLS
1616 Fixetl System Final Fire Prevention 208 Final Mechanical
1268 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final BIocWRetaining Wall 212 Final Fire Prevention
202 Final Factory F�re Place 220 Final Planning Approval
203 Final Sign 222 Final Si�e
204 Final Demolition 250 Final Building/puu0ancy
WORKERS' COMPENSATION DECIARATI4N:
I hereby affirm untler penalty of peryury one oi the following tleclarations:
❑ I have and will maintain a certificate of consent to self-Insuie for vrorkers'
compensation, as providetl for by section 3700 0( me Labor Code, for the
p,-e,A/ormance o( the work for which this permit is issued.
Lh I have antl will mainlain v✓orkers' compensa[ion insurance, as requiretl by
section 3700 of the Labor Cotle, for the pedormance of the work for'which this
permit is issued. My vrorkers' compensation Insurance carner and policy
number are:
Ga�'—irrie: TrvrX \�3. �c.nc.ln.a.radP
(This seclion neetl nof be wmpleled Athe permd is valued al one nun�iedWllars (8f 00) or less.)
P,olicy_� �N m�er 41�n�b'�:.���–
v
❑ I certify thal in the pertormance of ihe v+ork 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 Cali(qrnia, and agree that if I should
become subject to tbe workers' compensatiqn provisions o/ Section 3700 of
the Labor Co , I shall forthwith co'm�ply w�ith these provisions.
�P� /1 \l � I �
p�CaM33l nafi6e/ D te_�
WARNING: FAILURE TO SECURE WORKER5' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aKrm lhat I am licensed under provisions of Chapter 9(commencing
with Section 7000) of Division 3 of lhe Business and Professions Code. and
my license is in tull force and eRect.
�iC?# \'� Cla�ss'# �l0 � G�lo � ,Q�
G - l-� U'2S�lo���
�j�',,wuractors'S a �D-e"le� "—"
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirtn Ihat there is a cons[ructbn lending agency for the
pedormance of the wwrk fa wfiich this pertnit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender's Address:
Sipnalure
Da�e
OWNER•BUILDER DECLARATIONS:
I hereby aKrtn that under penalry of perjury thal I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for Ne following reason (Sec. 7031.5.
Business and Protessions Code: Any city or tounty which requires a permit to
construct, alter, improve, demolish, or repair any strucWre, prior to its
issuance, also requires lhe applican[ For such permit to file a signed slatement
that he or she is licensetl pursuant to the provisions of the Contractors
License Law (Chapter 9(commencing with 8ection 7000) of Division 3 of the
Business antl Pro�essions Code) or that he or she is exemp[ theretrom and
the basis tor the alleged exemption. Any vi0lation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty oi not more than
five huntlretl dollars ($500).):
❑ I, as owner of the property, or my empioyees with wages as their sole
compensation, WILL DO THE WORK, antl [he struclure is not intended or
oftered for sale (Sec. 7044, Business and Professions Code: The Contractors
License Law does not apply to an owner of property who builds or improves
[hereon, and who tloes such work himself or herself or through his or her own
employees, provided tha[ such improvemenis are not intended or oRered for
sale. I(, however, the building or improverYient is sold within one year of
completion, the ovmer-builder will have the burden of proving that he or she
ditl not builtl or improve for purpose of sale.).
❑ I, as owner of ihe property, am EXCLUSIVELY CONTRACTING WI7H
LICENSED CONTRACTORS to consWct the project (Sec. 7044, Business and
Professions Cotle: The conlractors License Lgw dces nol apply to an rnvner of
property who builds or improves thereon, and who contracis for such project with
a contracta(s) license pursuam ro the Contractors license Laws.).
� I am exempt untler sec.
Business and Pmfessions Code /or Ihis reasOn:
305]46(YO])
Owner ID verifietl by driv. .oense. ❑ Yes ❑ No
Driver's License No. Expires:
Venfication of Ownership by (type of tlocument, i.e. - property tax bill or tleed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby cert'rfy that no excava[ion frve (5) or more feet in depth into wfiich a
person is requiretl lo descend, will be made in connection with work authorized
by this pertnit, and that no builtling stmcture, scaf(dding, falsework, a demolition
or dismantling thereof, will be more than thirty-six (36) feel high. (Chap. 3.2, Grp
2, M 2, Sec. 341, Title 8, Califomia Administrative Code).
❑ As owner-builder, I will not employ anyone �o do work which would
require a permit from the Division of Intlustrial Safety, as noted above. unless
such person has a pertnit to tlo such vrork from Ihe division.
AOPI¢ant's Signalure
Division ot Industrial Satety Permit Numher.
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 hazartlous matenal? ❑ Yes ❑ No
(Seclion 25505 of ihe California Health an0 Safery Code requires, with some
ezceptions, that a Business Plan be filed with Ihe Cosla Mesa Fire
Department by every business which has at any one time dunng a reported
year a quantity of hazardous marerials equal to or greater lhan a weight of
500 pounds. or a volume of 55 gallons, or 200 cubic leet o( compressetl gas
at stantlartl temperature and pressure).
2. Dces or will the applicant or present or future building occupant neetl to file
a registration fortn lor acu[ely hazartlous materials? ❑ Yes ❑ No
(Section 25533 of [he Calitomia Health and Salery Code, with some
exceptions, requires registration with the Cosla Mesa Fire Department by
each business which at any one time has on hand a quanlity o( aculely
hazardous materials equal to or greater than a weight of 500 pountls, or a
volume of 55 gallons, or 200 cubic feel of compressed gas at standard
temperature and pressure).
3. Does or will the applicant or present or tuture builtling occupant need to
prepare an RMPP (Risk Managemen[ and Prevention Program for acutely
hazardous matenals)? � Yes ❑ No
(Section 25534 0! the Califomia Health and Safety Code provides that the
Costa Mesa Fire Depariment may require the preparation, certification antl
fling with the Fire Department of an RMPP by businesses which are required
to register acutey hazardous materials wilh the Fire Department.
4. I( an RMPP is presently required, has Section 25534 of the California
Health antl Sa(ery Code been fully complied with7 ❑ Yes ❑ No
5. Does or will the applicant or present or future building occupant require for
the work which is the subject o/ this appliwtion a permit for such construction
or modification from [he South Coast Air Qualiry Management District or (rom
any other air polWtion control district or agency7 ❑ Yes � No
(Section 658502 of the Cal'rfomia Govemment Cotle requires that the requested
information be fumished on applications for non-residential building permils).
6. Will any part of [he facility ro be constructed under this pertnit be within
1000 leet from the outer boundaries of a school? ❑ Yes ❑ No
(II'yes". the facility musl meet the requiremen[ of Seclions 25534 and 42303
of the California Health and Safety Cotle).
7. If a permit from the South Coast Air Quality Management District or other
air pollution control dishict or agency is requiretl for the work which is the
subject of this application, have all of the disclosures prescribed by Califomia
Health antl Safety Code Section 42303 been made? ❑ Yes ❑ No
8. Qf'yes", attach certi(cate of compliance trom the appropnate air pollution
control officer). � ,
CERTIFICATE OF COMPLIANCE: I certify that under penalry o( perjury the
information given above is correcL I agree to oomply with all slate laws antl
city ordinances re9arding Hazardous Materials antl Emissions.
SignaWre Da�e
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalry of perjury that I have read this application and state thal
the information given is correct I agree to comply with all state laws and ciry
ordinances relating to building construction, and authorize representatives of
the Ciry o( Costa Mesa [o enier upon the above-descnbed pmperty for
inspection purposes. I agree not to occupy or allow occupancy o( any building
authonzed by this pertnit until final inspection.
�gnaWreof Legal Own �I Oale
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CIIX u1M10 D�Lfanl / UTp
(714) 754-5273 • Fax (714) 754-4856
�
CITY OF COSTA MESA �
BUILDING DIVISION
OEVELOPMENT SERVICES DEPARTMENT
PERMIT
Job Address: 453 E 19TH ST
Suite No
Vicinity:
Parcel Nunmber: 11734130
npp�icant: TAYLOR, WARREN G
Address: 453 E 19TH ST
COSTA MESA, CA
Ownec TAYLOR, WARREN G
Address � 453 E 19TH ST �
COSTA MESA, CA
Contractor. (�� � ��
Address:
ISSUE FEE
Temp service�test
Res. a/c package
New Res (1-2 units)
New Res (3+units)
Pool / Spa
Lighting Fixts
Recept Outlets
Switches
Non Res Appl
Res Appl
Service to 200a
Service to 7000a
Service over 1000a
Motors to 1 hp
Motors l0 10hp
Motors l0 50hp
Motors to 100hp
Motors over t00hp
Communication drops
Sub panel to 200a
Pole Light Pkg
Sign Circuits
Temp Pwr Pole
Intertned Pole
ELECTRICAL PERMIT
Phone:
Zip: 92627
PERMIT NUMBER
E99-00947
77 FAIR DRIVE, COSTA MESA, CA 92626
ISSUED BY:
status: ISSUED
Applied: 10/14/1999
Issued: 10/14/1999
Phone: ��7�
Zip: 92627 �� �� �
b°
9�'�
Phone:
Zip:
License:
SCOPE OF PERMIT
RELOCATE 200 AMP ELECTRICAL PANEL FROM BACK OF HOUSE TO SIDE OF GARAGE.
(-ZEf� 13Qq-pOq IS
$23.50
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$30.50
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
so.00
so.00
so.00
$0.00
$0.00
$0.00
Quantity
0
0
0
0
0
0
0
0
1
0
_ 0
0
0
0
0
0
0
a
0
0
0
0
FEE SUMMARY
Temp.Dist System / Lighting
Busway/100ft
Standing Section
Misc Electrical Equipment
Transtormers up to 1 kva/kw
................up to 10 kva/kw
.................up to 50 kva/kw
.................up to 100 kva/kw
..................over 100 kva/kw
Low Voltage Equipment
Low Volt Wiring System / Ckt
Misa Conduit
Misa Conductor
Circus ( gen or ride)
Circus (mech nde or lights)
Christmas Tree Stand
Fireworks Stand
Olher Electncal Fee
Investigation Fee
Plan Check Fee
Reinspection Fee
quantity
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00
$0.00
$0.00
50.00
TOTAL CALCULATED FEES 554.00
COMMENTS / SPECIAL CONDITIONS
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inapectlona and final approval must be obtained. Failure to obtain inspections and final approval vnll result in the ezpiretion of �his permit.
FOR INSPECTIONS CALL: (714) 7545626
WORKERS' COMPENSATION DECLARATION:
I hereby attirm under penalty of perjury one ot Ihe tollowing tledarations:
❑ I heve and will maintain a certificate of consent Io self-Insure br workers' wmpensation, as pmvided tor by section 3700 ot the Labor Cotle, for ihe peAormance ot ihe
wark br which ihis permit is issuetl.
❑ I have end will mainiain workers' compensation insurance, es raquired by section 3700 oi the Lebor Code, for the peAortnence of Ne work for which this pertnit is issued.
My workars' compensation Insurance carner and policy number ere:
Carrier: Policy Number:
(This secHon need nof be complered i! the pertnif is va/ued et one hundretl tlWlaro ($100) or /ess.)
0 I certlfy t�at in the pertortnance of the work tor which this permit is issued, I shall not employ any person in eny manner so es to become su6ject to the workers'
compensation laws ot Celifomia, and agree ihat if I shoultl become subject to the workers' compensation provisions ot Saction 3700 oi the LaDor Code, I shall fonhwith
comply wilh these Orovisions.
Applicant Signeture:
Date:
WAPNING: FAILURE TO SECURE WORKERS' COMPENSATIpJ COVERAGE IS UNLAWFUL AND SHALL SUBIEGT AN EMPLOVER TO CflIMINAL PENALiIES AND CNIL FINES UP TOONE HUNDRED
hKK1SAND DOLIARE (5100.0OO�.IN PDDfTION TO TME W5T OF WMPENSATIIXJ, DAMAGES A$ PROVIDE� FOfl IN SECTION 3]O60F TME LABOR CODE, IMEREST, AND ATTORNE`fS FEES.
LICENSED CONTRAC70RS DECLARATION: �,
I hereby ellirm iha! I em licensed under provisions of Chepter 9(commencing with Section 7000) of Division 3 of the Busineu and Professions Code, and my license is in full
lorce and eNect. Lic, a Class #
Contractors Signatura: Date:
CONSTRUCTION LENDING AGENCV:
❑ I hereby ettirm ihat Ihere is a cronstruction lending egency for the peAormance ot the work Por which this permit is issued. (Sec. 3097, Civil Code).
Lender's Name: Lentlefs Atldress:
Signature: Date:
OWNER•BUILDER DECLARATIONS:
I hereby aflirm�that under penalry of perjury that I am EXEMPT FROM TME CONTRACTORS LICENSE LAW for t�e lollowing reason (Sec. 7031.5, Business entl Professions
Code: Any ciry'or�c'ounry which requires a pertnit to consiruct, elter, improve, demolish, or repair any structure, prior to its issuance, also requires Ihe applicant for such permit
b file e signetl�.sta�ertient Ihat he or she is licensetl pursuent to the provisions af the Conirectors License Lew (Chapter 9(wmmencing with Sectian 7000) of Dlvision 3 oi the
Busineu entl Pr'ofe55ions�Cotle).or �hat he or she is exempt Iherefmm entl tha Dasis tor the allegetl eaemption. Any violation of Section 7031.5 by any applicent for a permit
subjects t�e eppliwnf(o e c�l'vil'penalry�of not more than five hundred tlollars (5500).):
YIl I, as owner of t�e proDerty,�or�my employees with wages as iheir sole compensation, WILL DO THE WORK, and the structure is not imentled or oHered for sale (Sec.
1� 7044, Business antl Professions�Coife: The Conirectors License Lew does not apply to an owner ot property who builds or improves ihereon, and who tloes such work
himseN or herself or through his oT�fier own employees, provided ihet such improvemems are not intended or oflered for sale. If, however, ihe building or improvement is
sold within one yaer of completion, tha owner-builder will have �he burden of proving ihat he or she ditl not build or improve for purpose ot sale.).
cvT
❑' I, es owner of the property, am•E%CLUSIVELV CONTRACTING WI7H LICENSED CONTRACTORS to conSWct Ihe project (Sec. 7044, eusiness entl Professions
Cade: The cbntractors LicensA Law does not epply to an owner of property who builds or improves ihareon, enC w�o contracts for such proiect with e contractor(s)
licen6e oursi�ant to ihe ContradD[s ' se La s.l.
❑ I am mpt nder sac. Business end Professions Code lor this reason:
SignaWre: � A.. _
�%%�
Verification ol Ownership by (type of document, i.e. - propeny taz bill or deed):
Expires:
DIVISION OF INDUSTRIAL SAFE7Y PERMI7 CERTIFICATION:
❑ I hereby cetlify that no ezcavation tive (5) or more feet in tlepth into which a person is requlred to descend, will be matle in connection with work authorizetl by this
pertnit, and that no building structure, sceflolding, telsework, or demolition or tlismantling �hereoi, will De more than Ihirry-six (36) feet high. (Chap. 32, Grp 2, Art 2, Sec.
341, Title 8, Califomia Atlministrative Cotle).
❑ As owner-Duiltler, I will not employ anyone to tlo work which woultl require a permit from Ihe Division of Industrial Sefety, as noted above, unless such person �as a
permit to do such wark irom ihe division.
Signature: Date:
Division of Indusirial Safety Parmit Number:
COpE �. INSPECTIONTYPE QdjF AL
1616 Fi:ed System Final Fire Prevention
1266
200
Pool Spe Final
Final Re-Roof
201 FIneI BIocWRelaining Wall
202 Final Faciory Fire Place
203 Finel Sign
204 Final Demolition
2uWs
cooe� wsvecnoNTrve
206 Final Mechaniral
208 Final Plumbing
210 Finel Electdcal
212 Finel Fire Preventian
220 Final Planning Approval
222 Final Site
250 Final Building/Oaupancy
o"rE INTffIALS
I`
CITY OF COSTA MESA '
BUILDING DIYISION
DEVELOPMENT SERVICES DEPARTMENT
PERMIT
(714) 754-5273 • Fa�c (714) 754-4856
Job Address:
Suite:
Vicinity:
453 E 19TH ST
MEDIA ROOM 8 LIVING ROOM
Parcel Nunmber: 11734130
BUILDING PERMIT
Zoning:
a
PERMIT NUMBER '
1-I•IIIZ��3�7
77 FAIR DRIVE, COSTA MESA, CA 92626
Status: ISSUED
Applied: O6/17I1999
Issued: 08I03/1999
npp�icant: TAYLOR, WARREN G _ ISSUED BY:
Address: 453 E 19TH ST "-, f_� = %- �' • : _ -' �
�,.
- ��/.- - _ .Phone: � �- , ' � - ��
_ { , `�
COSTA MESA,-CA"; � ;;,� �-'� � _ Zip; 92827 / - - _
�' / _
Owner. TAYL�OR�WQRREN G'� �� �
�
. , � . - / �
Address 453�E19TH�ST `� � - _ � � .. � � ;�.
�%�i � � �� � - - � �-� .Phonef. _ . _ . _- . ; - �
�i%COSTA MESA; ¢A� / .� Zip: 92627 �� \� . � � � . �: ��A �_\,
�
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i i'.,�'` ,Iip�,
;
Phone .
License.` � ,
�—A�ti� � � �j �� � ` �\
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,_� _�- �.� / :,�.
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\; i ,.
� �,Arch : � . - � ' . . / . En9� � , . � \
, Address: � - " . ' �� ' — Address:, L , , �
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� r"� , �� J ' �'�� � � Phone: _ � . . � i � Phone: i
' i�'� _ � � /. •\/� i�l� I . \ . r_ � � ;a
�'% \�Zip �;' ;�%\�� �.License: Zip: \ � ��License:
� n� � f� � ` �✓' V � � �
' ��' / � � . ` SCOPE OF PERMIT � � � �
�`�'� /ADD 420 SF FAMILY ROOM TO SINGLE�FAM RES. ADD 350 8F HOME OFFICE AND BATHROOM ABOVE EXISTING GAR. `�
ADD 420�SF BASEMENT UNDER�PROPOSED FAM ROOM�. ADD 554 SF OF COVERED PATIO/BREEZEWAY. ADD 420 SF � �
�� � "� CARPORT. � - .
� ",
RECORDED LAND USE RESTRICTION RECENED 7 JULY �7999�WHICH,PROHIBITS THE CONVERSION OF � �� .-. , �
�.��� , THE 2ND.$TORY ADDITION OVER THE GARAGETO.A SEPARATE DWELLING UNIT+�LIMITS PLUMBING TO A TOILET �•. ��
,��; .= AND SINK ONLY; AND PROHIBITS SHE BASEMENT FROM BEING CONVERTED TO A DWELLING UNIT+ALLOWS A SUMP '
.��'� ,- PUMP ONLY..IN THE WAY OF PLUMBING. � i ' , , ' T;
� ". j
��, �� �BASEMENT•WINDOW PROVIDED ON LEFT SIDE TO ALLOW LIGHT, - � — — .- i���; •� �_ - ' � �
�,�•.,�� VE,NTILATION & EMERGENCY EGRESS. NO ELECTRICAL PROPOSED. SUMP PUMP IS WILL BE LOCATED ON THE OUTSIDE�
�,�. OFTHE BASEMENT WALL, PER BUILDING DIVISION. WBK7-30-99 . , � ,
�.���A ` � '�,�.,, ... . - - � _ " ,
�.�_
� y`\
'Ian Check � , $515.78;;
Permit: $793.50 ,� . ; �'r �
� �,
SMIP Res:. /$8.44_, �' ; ` �.'�
SMIP Com :��, �$0.00 �- � _ �
Other'.� ���.$OAO �-" ' , ,
Inspection: � ` $0.00 ��. ." �.
�,
Total: $1,317.72 -
� FEE SUMMARY
; , ..
SETBACKS
MAIN STRUCTURE Front 32- 0 Rear 5- 0
ACCESSORY Front 0-0
PARKING
NOTES:
Existina: 2
Rear 0- 0
Re uired: 2
PLANNING 8 ZONING
LeR 5- 0
Lek 0- 0
Pr000sed: 4
� Calc Valuation: Sea,ses.aa
, :.Claim Vaivation: $aa,ass.aa
_ - . , ,�i
� / i
Right 10- 0
Right 0- 0
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements undar Califomia statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
for a penod of 1 BO days. .
INSPECTIONS: In order for the work euthorized under this permit to be considered legal, such work must comply with all applicable codes, and all
requlred inepectlo�a and finel epprovel must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714) 7545626
)�
WORKERS'COMPENSATON DECLARATON:
I nereby eHirm untler penalry ot perjury one of Ihe tollowing declarations: ' �
❑ I �ave antl will maintain a cenificete ot consent to self-Insure for workers' cnmpensetion, as provided for by sectlon 3700 of Ihe Labor Code, for the peAormance oi Ihe
wark br which ihis pertnit is issued.
❑ I have end will maintain workers' compensation Insurance, as reduired by section 3700 of ihe Labor Cotle, for the pedortnence of �he work for which thls pertnit is issued.
My workers' compensation Insurence carner entl policy number ere:
Cerder: Policy Number:
(This section neetl no1 be comp�eted'N ihe Dermit is velued at one hundred doilars j$ I00) or /ess.) '
❑ I certity Ihat In the peAormance of the work far which this percnit is Issuetl, I shell not employ eny person in eny manner so as to became su6ject to the workere'
compensation 1?ws of Celitomia, end egree Ihet if I should become subject to the workero' compensation proWslons of Sectlon 3700 of Ihe Lebor Cotle, I shall forthwith
compty with Ihe9e pmvisions.
Applicant Signeture: Date:
WARNINO: FNLURE TO SECUflE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL rWD SHALL SUBJECT AN EMPI.OVER TO CRIMINAL PENALTIES AND CIVIL FlNES UP TO ONE HUNDRED
TFKKISAND WLLARE (5��.�1. IN A�DITION TO THE WST OF WMPENSATION, DAMAGES AS PROVIDED FOR IN SECiION 3]O60F TME IABOR CODE, IMEREST, AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby eflirm ihat I am licensed untler provisions of Chapter 9(commencing wlth Section 7000) of Division 3 of the Business end Protessions Cotle, and my Iicense is in full
iorce end eflect. Llc. M Class #
Conirector's SlgnaWr�: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby aHirtn Ipat ihere is a consiruction lending egency tor the pedormence of the work for which this permit Is issued. (Sec. 3097, Civil Cotla).
Lentlels Name: Lentlefs Address:
SigneNre: Date:
OWNER-BUILDER DECLARATIONS:
I hateby eflirm that under Denalry ot pe�ury Ihet I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for Iha following raeson (Sec. 7031.5, Business entl Protessions
Coda: Any city or cour�ry which requires e pertni� to consWct, alter, improve, demolish, or repair any structure, pnor to its issuence, also requires the eppliWnt tor such permit
to file e signed stetement that he or she Is Ilcensed pureuent to t�e pmvislans ot the Contrectors License Lew (Chapter 9(commencing with Section 7000) ot Divislon 3 of Ihe
Business and Protesslons Code) or thet he or she is exempt iheretrom end the basis for the allegetl exemptlan. Any vlolatlon af Sectlon 7031.5 by eny applicent tor a permit
subJecls ihe applicant to a civll penalry ot not more then fiva huntlred dollers ($500).):
'�1 ' I, es owner ot Ihe property, or my employees with wages as iheir sole compenseUon, WILL DO 7HE WORK, antl the structure is not intendetl or oNered lor sale (Sec.
r 7044, Business and Professions Cotle: The Contractors License Law does not apply to en owner of property who builtls or improves thereon, anA who does such work
himsel� or herself or ihrough his or her own employeas, providad that such Improvements are not inrendetl or oHered for sele. tl, however, ihe building or Impmvement is
soltl within one year of completion, Ihe owner-builder will have Ihe burden ol proving that he or she did not builtl or improve for purpose of sale.).
❑ I, es owner ol tqe properry, am EXCWSIVELV CONTAACTING WITH LICENSED CONTAACTORS to construct the project (Sec. 7044, Busine55 and Professions
Cotle: 7Te co tractors Licen e Law tloes not epply to an owner oi property wha builtls or impmves thereon, and who contracis for such pro�ect with a comractoqs)
licensa.oursua t[o the Con�r�ors license.lews.).
❑ I em e pt u der sec. Business entl Professians Cotle tor ihis reason:
SigneNre: �
Owner ID ven e�ri�er's licen . es � No Dnver's License No.
Venticalion of Ownersqip by (type ot document, i.e. - property tez bili or deed);
Date:
%% � � � Expires:
DIVISION OF INDUSYRIAL SAFETY PERMIT CERTFICATION:
❑ I hereby certlty ihat no azcavation flve (5) or mora feet in depth into wMch e person is requiretl to descend, will be meda in connection wl�h work euthorizetl by this
permiL and that no building structure, sceXolding, falsework, or tlemolitlon or dismantling Iheraot, will be mora than thirty-six (36) feat high. (Chap. 32, Grp 2, Art 2, Sec.
341, Title 8, Celifomia Atlmini5tretive Code).
❑ As owner-builOer. � will not employ anyone to do work which would require e permit trom ihe Division of Intlusirlal Safety, as notetl ebove, unleu such person �as a
permit to tlo sucf+ wwk lrom ihe did�sion.
Signature: Date:
Division ot Industnal Sa�ery Permit Num6er:
CERTIFICATE O COMPLIANCE D AUTHO � OF ENTHY: I certity under penalty of perjury that I have read ihls eppllcation and stale Ihat the informatlon given is
corc t I egree t comP�Y with all s� i n s and ciry ar 'nanras relaUng to huUding consWction, aM auNorize representaUves of Ihe Ciry ot Cosla Mesa to enter upon the
abov d� cnhed ropedy for ins purywes. I agre not to occupy or allow occupancy of any builtling authodzed by th� ertnit umil final inspectlon.
19�`�1
Siana pelOwner(s) � Date
And/Or Au�hodzed Applicant
CQDE 1• INSPECTIONTYVE � D9LR IMRIALS
1616 Fixetl System Final Fire Prevention
1266
200
201
202
203
Pool Spa Fina�
Final RaRoot
Final BIocWRe�ning Wall
Final Fectory Fire Place
Final Sign
204 Final Demolitio�
CODEt INSPECTIONTYVE
206 Finel Mechenicel
208 Final PIum6ing
210 Flnal ElecMcal
212 Flnal Fire Preveniion
220 Finel Planning Approval
222 Final Site
250 Final BuiltlinglOccupancy
�.�7\I�Iulti/1�9
4
i
(714)754-5273 • Fax(714)754-4856
�ob Address: 453 E 19TH ST
Suite No
CITY OF COSTA MESA
BI/ILDING DIVISION
DEVELOPMENT SERVICES DEPARTMENT
PERMIT
Vicinity: ADDITION @ REAR OF HOUSE
Parcel Number: 'I'1734130
npplicant: TAYLOR, WARREN G.
Address: 453 E. 19TH ST.
COSTA MESq, CA
Owner: TAYLOR, WARREN G.
Address: 453 E. 19TH ST.
COSTA MESq, CA
C o ntra cto r: O W N E R-B U I L D E R
Address:
ArchlEng:
Address:
MECHANICAL PERMIT
Pho�e: (949)646-2477
Zip: 92627
Phone: (949) 646-2477
Zip: 92627
Phone:
Zip:
License: 0
Phone:
Zip:
License:
�ERMIT NUMBER
M99-00519
77 FAIR DRIVE, COSTA MESA, CA 92626
SWtus: ISSUED
Applied: 11I12/1999
Issued: 1 7 /1 211 9 99
ISSUED BY: �_
SCOPE OF PERMIT
MECHANICAL PERMIT FOR ADDITION TO SINGLE FAMILY RESIDENCE. INSTALL 2-FAU'S,
2-REFRIGERATION SYSTEMS, & 1-VENT FAN.
REF:B99-00915
ISSUE FEE
Inst FAU <100 k BTU
Inst FAU >700 k BTU
Repair/Alt Cooling/Heat
Inst / Rep. Recess Wall Htr
Refrig Sys <700 k BTU
Refrig Sys >100 k BTU
Gas Piping
Factory Fireplace
Hood w/Mech Exhaust
VAV Box
Vent Fan / Single Duct
Appliance
Fire Dampers
Smoke Dampers
Inst or Relocate Appl Vent
Air Handlers < 70000cfm
Air Handlers > 10000cfm
Floor Fumace
Floor or Suspend Heater
$23.50
$29.60
3o.a0
$0.00
50.00
$29.60
$0.00
$0.00
$0.00
$0.00
$0.00
$7.25
$0.00
$0.00
$0.00
$0.00
50.00
$0.00
$0.00
$0.00
Quantity
FEE SUMMARY
Repair / Alt Absorbtion Unit
Repair / Alt Refrigeration Unit
Ventillalion System
Evaporative Cooler
Commercia l I ncine rator
Domestic Incinerator
Compressors / Absorotion Svstems
Upto3hp/100kBTU
3To15hp/500k8TU
15 To 30 hp I 1,000 k BTU
30 To 50 hp / 1,750 k BTU
Over 50 hp / Over 1,750 BTU
Boilers
Upto3hp
3To15hp
75to30hp
30 to 50 hp
Over 50 hp
Other Mecnanical Fee
Investigation Fee
Plan Check Fee
Reinspection Fee
TOTAL CALCULATED FEES
COMMENTS / SPECIAL CONDITIONS
Quantity
50.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00
$0.00
$0.00
589.95
�
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomie statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-g2)
EXPIRATION: This permit shall automatirally expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned
tor a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all�l�
required inspectlone end flnal approval must be obtained. Failure to obtain inspections and fina� approval will result in the expiretion ot this permi�. ��
FOR INSPECTIONS CALL: (714) 754-5626
WORKERS'COMPENSA710N DECLARATON: �
I �ereby aHirtn untler penelty of perjury one ol the lallowing tleclaretions:
❑ I have end will meintain e certificete of consent to self-Insura for workers' compensation, as provided lar 6y 5ection 3700 0l the Lebor Code, For Ihe performance ot the
work tor which this parmit Is issuetl. -
❑ I have and will malnteln wwkers' compensatlon insurance, as requireG by section 3700 of ihe Labor Code, tor ihe peAortnance ol Ihe work for whiU this pertnit is issuetl.
My workers' compensation Insurance cerriar and policy number are:
Cerrier. poliry Number.
(This section need not be completetl i! fhe perml! is ve�ued ef one hundred dollers ($f 00) or /ess.)
❑ I certify ihat in the pehormence of the work tor which this pertnit is issued, I shall not employ eny person in any manner so as lo become su6ject to the workers'
compensation lews of Callfornia, and agree ihat if I should become subf ect to fhe workers' compensetion provisions of Sectlon 3700 of tha Labor Gotle, I shall forihwith
comply wit� Ihdse provisions.
Applicent Signature: Date:
WARNING: FAILURE Ttl SECURE WORKERS' COMPENSATIIXJ CAVERAGE IS UNIAWFUL M1D SHALL SUAIECT AN EMPLOYER TO CPIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
TFKKISAND DOLIARE (41 W.000), IN ADDRIIXJ TO THE COST OF COMPENSATION, OAMAGES AS PROVIDED f-0R IN SEGTION �O60F THE LABOR CODE, INrEREST, AND ATTORNEI^5 FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aHirm Ihat I am licensed under provisions of Chapter 9(commencing with Section 7000) ot Division 3 ot the Busineu and Pmfessions Coda, an0 my license is in full
' force and eHect Lia � Class #
ConlrectoYs SignaNre: Date:
CONSTRUCTION LENOING AGENCY:
❑ I hereby attirm Ihat there is e consiruction lending agency tor ihe peAormence ot the work tor which this permit is issuetl. (Sec. 3097, Civil Code). '�
Lendels Nama: Lendefs Atltlress:
Signeture: Date:
OWNER•BUILDEH DECLARATONS:
I hereby aHirm Ihet undar penelty of perjury ihat I am E%EMPT FROM THE CON7RACTORS LICENSE LAW for the following reeson (Sec. 7031.5, Buslness antl Protessions
Cotle: Any ciry or coUnty which raquiras a pertnit to consirucl, alter, lmprove, demolish, or repair any slrucNre, prior to its iuuance, also requires Ihe applicant for such pertnit
to tile a signed statement Ihe� he or she is licensed pursueN to ihe provisions ot the Contradors Llcense Lew (Chepter 9(commencing with Sedion 7000) oi Divlsion 3 of Ihe
Business and Prolessions Code) or that �e or s�e Is exempt �hereFrom end t�e basis for the ellegetl exempilon. Any vloletion o1 Section 7031.5 by any epplicant lor a parmit
s�ub�ect5 the applican� lo e civll penelty ot not more then live huntlred dollers ($500).):
rCl i, as owner of tha property, or my employees with wages as Iheir sole mmpensation, WILL DO THE WORK, and the structure is not in[ended or oNered for sale (Sec.
704a, Business entl Professions Cotle: 7he Contrectors License Law tloes not epply to en owner oi property who builds or improves thereon, and who tloes such work
himself or herse�� or through his or her own employees, proNded Ihet such improvements are not Intended or oNered for sale. It, however, the builtling or improvement is
sold within one year oi completion, the owner-builder will have ihe burden of proving ihat he or she tlld not builtl or improve lor puryose oi sale.).
❑ I, as owner of he properry, am E%CLUSIVELV CONTRAC7ING WITH LICENSED CONTfiACTORS to construct the pro�ect (Sac. 7044, Business end Professions
Code: Tlie co t�actors License ew ot apply to an owner of property who builtls or Improves thereon, and who comrecis Por such project with e contractor(s)
Ilcens pursu � to ihe Contract icense ws.).
❑ I am e pt u � e. Business and Prolessions Code for this reeson:
Sgnature: �
Ezpire9 ' Z—��
Verification of Owner3hip by (type of document, i.e. - property tar bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certity thet no ezcavation five (5) or more fee� in dapih into which a person Is requiretl to descend, will be metle in connec�ion with work euthorized by ihis
pertnit, and that no Duiltling strudure, scattoltling, falsawork, or demoliUon or dismamling �hereot, will be more ihan thlrty-six (36) leet high. (Chap. 32, Gry 2, An 2, Sac.
341, Ttle B, Celi�omia Administretive Cotle).
❑ As owner-builder, I will not employ anyone to do work which woultl requlre a pertnit irom �he Division of Industrial Safery, es noted above, unless such person has a
pertnii to do such work from the division.
SignaWre: Dete:
Division ot Indusinel 5afety Permit Number:
CERTIFICATE OF C�MPLJANCE AND UTMORI ON OF ENTRV: I certity under penalty of per�ury thet I heve read this application and s�ate Ihet the intormation given is
conect. I agrpe to w np�y with all sta a antl ciry rGinances relating to building consWction, and euthodze representatives ol the Ciry ot Cosfa Mesa to enter upon the
above-descn6' ro BNy �or Ins e f n rposes. I a ae no1 to occupy or ellow occupancy ot any building aut�orizetl by this Dermit until tinal inspection.
(f-IZ-GG
Signature Ot L Owneds) Date
Authodzed
400E t. INSPECTIONTYPE
1676 Fixetl System Finel Fire Prevemion
1266 Pool Spe Fina�
200 Finel RB-Roo� �
201 Finel BIocWReteining Wall
202 Finel FeCtory Flre Plece
203 Final Sign
204 Finel Demolition
zaas ae
QdE 1ti�dLS
LODE I INSFECTION TYPE
206 Finel Machanical
208 Final Plumbing
270 Final Electrical
212 Finel Fire Preventian
220 FinalPlanning Approvel
222 Flnel Site
250 Finel Bui4
PdIE INfiTIALS
.ri-ti-ol n/
CITY OF COSTA MESA
BUILDING DIVISION
DEVELOPMENT SERVICES DEPARTMENT
PERMIT
(714)754-5273 • Fvc(714)754-4856
�ob Address: 453 E 19TH ST
Suite No
Vicinity: ADDITION � REAR OF HOUSE
Parcel Nunmber: 11734130
Applicant: TAYLOR, WARREN G.
Address: 453 E. 19TH ST.
COSTA MESA, CA
Owner: TAYLOR, WARREN G.
Address 453 E. 19TH ST.
COSTA MESA, CA
Contractor: OWN ER-BU I LDE R
Address:
ArchlEng:
Address:
PLUMBING PERMIT
Phone: (949) 6462477
Zip: 92627
Phone: (949) 646-2477
Zip: 92627
Phone:
2ip:
License: 0
Phone:
Zip:
License:
PERMIT NUMBER
J P99-00654
77 FAIR DRIVE, COSTA MESA, CA 92626
ISSUED BY:
Status: ISSUED
Applied: 11112/1999
Issued: 11/72/1999
SCOPE OF PERMIT
PLUMBING PERMIT FOR ADDITION TO EXISTING SINGLE FAMILY RESIDENCE. INSTALL 1•BATHTUB,
4-GAS OUT�ETS, 1-SHOWER, 1•SUMP PUMP, 1-WASH BASIN SET, 1-WATER CLOSET, 6 1-WATER
HEATER.
REF: 699-00915
ISSUE FEE
BackFlow irrigation
BackFlow Preventer
Bathtub
Clarifier System
Connect (Ice,Soda,etc)
Dental Units
Dishwasher
Drain, Floor
Drain, Rainwater
Drain, Roof
Drinking Fountain
Expansion Tank
Gas Earthquake Valve
Gas (1-4 outlets)
Gas (Over 4 outlets)
Gas Repipe
Gas Service
Interceptors (Grease, Oip
Interceptors (Sand Auto )
AMT
$23.50
$0.00
30.00
$9.80
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
80.00
$0.00
$0.00
$6.15
$0.00
$0.00
$0.00
$0.00
so.00
QTY
FEE SUMMARY
AMT
Laundry Tub / Washer $0.00
Landswpe Irrigation $0.00
P-Trep $0.00
Pressure Regulator 50.00
Process Piping (per 10 R) $0.00
Receptors $0.00
Septic Tank $0.00
Sewer Cap for Demo $0.00
Sewer Connect $0.00
Sewer Private Line $0.00
Shower $9.80
Sink, bar $0.00
Sink, commercial 50.00
Sink, Floor $0.00
Sink, kitchen $0.00
Sink, service/mop $0.00
Spa (private) 50.00
Spa (public) $0.00
QTY
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
COMMENTS / SPECIAL CONDITIONS
SumpPump
Swimming Pool
Trap Primer
Urinal
Vacuum Brkr Bkflow(7-4)
Vacuum BrkrBkFlow(5+)
Wash Basin
Wash Basin Set
Waste and Vent System
Water Closet (foilet)
Water Heater I vent
Water Piping (Inst or Rep.)
Water Re-pipe
Water Service
Water Softener
OTHER
VIOLATION
PLAN CHECK
REINSPECTION
TOTAL CALCULATED FEES:
AMT
$9.80
$0.00
$0.00
$0.00
50.00
50.00
$0.00
39.80
$0.00
59.80
572.30
$0.00
50.00
$0.00
$0.00
$0.00
ao.00
$0.00
$0.00
$90.95
.
Qn
1
0
0
0
0
0
0
1
0
1
1
0
0
0
0
NOTICE: The work euthorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes end related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This pertnit shall aulomatically 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 ihe work euthorized under this permit to be considered legal, such work must comply with all applicable codes, and ell
required Inspectiona 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) 7545626
�
/
WORKEflS' COMPENSATION DECLARATION:
I hareby attirm under penalry of periury one of Ihe tollowing tleclarations:
❑ I heve antl wlll maimain e certiticate at conseN to selt-Insure for workers' compensation, es proviaetl tor by sectlon 3700 of the Labor Cotle, for t�e peAormance ot the
work for whlch ihis pertnil Is issuetl.
❑ I have end will maintaln workere' compensatlon Insurance, as requiretl by sectlon 3700 of Ne Labor Code, for �he peAortnance ol Ihe work ior which Ihls pertnil Is Issuetl.
My workers' compensation Insurance carrier entl policy number are:
Cerrier: Policy Number:
(This secNar need nat be complefed ll Ihe permit Is valued et one hundred dollero ($100) or less.) '
❑ I cenity ihet In the peAormance of the work lor w�ich this pertnit Is Issueq I s�all not emplay any person In eny manner so es lo bewme subJect lo the workero'
compensation laws at Celifamia, end agree Ihet It I s�ould become su6�ect b Ihe workers' compensallon provlslons of SecNon 3700 ot the Labor Cade, I shall fotlhwith
compty with these provisions.
Applicant Signeture: Dete: '
WARNING: FAILURE TO SEWRE WORKERS' COMPENSATION COVERAGE IS UMAWFU� M'D SHML SUBJEGT AN EMPLOYER TO CRIMINAL PENALTIES Ml� CM� FINES UP TO ONE HUNDRED
TIN)USAND DOILARE (5100,000). IN ADORION TO THE C06T OF CQMPENSATION, DAMAGES AS PROVI�ED fOR IN SECfION 31O80F TNE IABOR CODE, IMEflEST, AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aHirtn thet I am licensed under provisions ot C�apter 9(commencing with Sectlon 7000) of Divlsion 3 0l the Busineu an0 Professions Code, entl my license is in full
lorce entl ettacL Lic. a Class q
Contractors Signature: Dete:
CONSTRUCTION LENDING AGENCV:
❑ I hereby aflirm that thera Is e conslructlon lending egency for t�e peAormence af t�e work for which this pertnit Is Issued. (Sec. 3097, Civil Cotle).
Lenders Name: Lendefs Atldress:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby aNirtn Ihat untler penalty of per�ury Ihat I em E%EMPT FROM 7ME CONTRACTORS LICENSE LAW for t�e following reason (Sec. 7031.5, Business and Professions
Code: Any ciry or counry which requires e permit to construd, alter, improve, demolish, or repair any stmcture, prior to its issuance, also requires the applicani for such permit
to file e signed stetement thet he or sha Is licensed pursuent to Ihe proNsions of Ihe Conirectors License Lew (Chapter 9(commencing with Section 7000) of Division 3 of Ihe
Business end Prolessions Code) or Ihet he or she Is exempt therefrom end t�e basls for the alleged exemptlan. Any violatlon of Sealan 7031.5 by eny epplicant tor a permit
subJec .the appllcent m e dvll penelty ol not more then five hundretl tlollers ($500).):
I, es owner of the property, or my employees with wages as t�eir sole compenselion, WILL DO THE WORK, and the structure is not intendetl or oHeretl lor sale (Sec.
7044, eusineu antl Protesslons Cotle: The Contrectors License Lew tloes not epply to en owner ol property who builds or improves thereon, and who does such work
himself or hereeli or through his or �er own employees, provided that such improvements are not intended or oHeretl lor ula. If, however, the building or improvement is
sald within one year of completion, the owner-builtler will have ihe burden oi provinp ihet he or she did not build or improve tor purpose of sale.).
❑ I, es owner f Ihe property, em EXCLUSIVELY CONTRACTING WITH LACENSED CONTiiACTORS to consiruct ihe proJect (Sec. 70d4, Business end Protessions
Cotla: The nUectors Ucepse Lew does not eppy to en owner of Omperry who 6uiltls or improves thereon, entl who coniracts tor such pro�ect with e coNractor(s)
Iicen{e purs eM to the Conpqctlg.Lkacse Lews.).
❑�
Business antl Professions Code for this reason:
Owner ID vVntie�by dnvefs licens�: " � Yes ❑ No Drivels License No.
Verlflcation of Ownership by (type of documeni, i.e. - properiy �ax bill or tleed):
Expires:
DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION:
❑ I hereby certity t�at no excavetlon Ilve (5) or more feet in depth Into whlch a person is reQuiretl to Oescend, will be matle In connectlon with work authorized by this
pertnit, and Ihat no builtling swdure, sceNoltling, talsework, or Aemolltlon ar Eismantling thereol, wlll ba more Ihan thirty-six (38) teet high. (Chap. 3.2, Carp 2, Atl 2, Sec.
347, Title 8, Califomia Atlminisiretive Cotla).
� As owner�0uilder, I will not employ enyone to tlo work which wou10 require e pertnit irom the Division ot IndusMel Satery, as noted above, unleu such person has e
pertnit to do such work irom t�e Eivision.
Signature: Date:
Division of Industrial Safery Permit Number.
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATON:
1 W III the apD�icant or present or luture bullding occupant need to tlle entl cenlfy a Business Plan for emergency response to releese or threetened release of e hezardous
matedal? ❑ Yes ❑ No
(Section 25505 oi Ne Calitomia Health antl Satery Code requires, with some exceptions, that a Busineu Plan be liled with the Costa Mesa Fire Depanment by every
buslness which has at any one time during a reported year e Quentiry of hazardous matarials edual to or greater than e weight ot 500 pountls, or e volume of 55 gallons,
___ .. . . . . . . . .. . . .
a
5
6
uoes or wm me appucam or presem or mmre omiamg occupam neea w me e regiscrauon iorm ror acu�eiy nazemous me�enaisr u res u no
(Section 25533 ot tha Califomia Heelih end Setery Code, with some exceptlons, requlres registratlon with Ihe Costa Mesa Flre Depariment by each business which at any
one time hes on hand a puantlry ol ecutey hazardous ma[edals equal lo or greater than a weight at 500 pounds, or e vWume oi 55 gallons, or 200 cubic feet oi
compressed gas ai standard tempereWre end pressure).
Does or will ihe flppliwN or presenl or future builtling occupant naetl m prepere en RMPP (Risk Management entl Prevention Program for ecutely hazeNous materials)7
(Secilon 25534 oi the Celifomia Heallh and Safery CoOe proNdes Ihet the Costa Mesa Fire Depenment may n
Depenment of en RMPP by businesses whic� ere requiretl m regisier ecutely hazerdous materials with Ihe Fire
If en RMPP is presently required, has Section 25534 of the Califomia Heelth and Sefery Code been fully com011e
Does or will the epplicant or present or tuture building occupent requlre for iha work which Is the subJect at Ihi:
from the Soulh Coast Air Ouelity Manegement Dlsidct o� from any other elr polWtlon wnirol Eisldct or egenc�?
(Sectlan 658502 0l the Califomia Govemment Code reQulres that the requested Infortnetlon be lumishatl on ap�
W ill eny part of the facility to be con5trutted under thl5 permit be withln 1000 Ieal trom the outer bountledes ot e
(II yes', tha faciliry must meet the requirement of Secfions 25534 and 42303 0l the Califomia Health end Safery
II e permit tfOm Ihe SOuth COBS� Air Ovelity Managemeni Distdct or ot�e� fli� polWllon coNrd distdct or eg[
e0olication, have ell oi Ihe disclosures prescdbed by Calilomia Health end Satety Cotle Sedion 42303 been mei
ihe preperatlon, cenificatlon and tiling with the Fire
lmeni.
7 ❑ Yes...... ❑ No -..— -���—
ation e Permit tar such construction or motlilicetion
i9 �J No
�ns tor non-resitlentlal builtling pertnits).
No
CER7IFICATE Of COMPLIANCE: I certity that under Denalry ot perjury ihe Intormation given aDove is correct. I agree to wmply with all state laws and dry ortlinances
regartling Harardous Matenals end Emissions.
Slgneture: Date:
ITI CATE F COMPLIANCE AN UTHORIZATON OF EMRY: I certiy under penalry of perjury that I have read this aDD�iwtion and state that the information given is
ac I agree o comply wi all sta iry ordinances relaGng Io builAing wnstruction, and authodze represamatives ol the Ciry of Costa Mesa to enter upon the
�e criDe pro, _ perry for i c' urposes. agree not to occuDY or ellaw occupancy of any building euthorizeE by thls p(rmit until fing� in�pectlon.
�,L� 1 � Z UCl
SI im M 1 nl Clwnwr(sl F DeIB �
AnNOr AuNorized Applicant
CODE t. INSPECf10NTYGE
1616 Fixetl System Final Fire Prevention
1266 Pool Spa Final
200 Finel Re-Roof
201 Final BIocWRe[aining Wall
202 Final Factory Fire Place
203 Finfll Sign
204 Finel Demolition ,
241&a6
PAIE
��
�$ ��( INSPECI10NttPE
206 Final Mechanicel
208 Finel Plumbing
210 Finel ElecMcal
212 Final Flre Preventlon
220 Final Planning Approval
222 Final Site
250 Finel Builtling�Occupancy
PdIE INfifIALS
�-%l�OI �I
(714) 754•5273 • Fax pia� �sa-aess
Jobnddress: 453 E'19TH ST
CITY OF COSTA MESA
BUILDING DIVISION
DEVE�OPMENT SERVICES DEPARTMENT
PERMIT
Suite No
Vicinity: ADDITION @ REAR OF HOUSE
Parcel Nunmber:
Applicant:
Address:
Owner:
Address
Contractor:
Address:
11734130
TAYLOR, WARREN G.
453 E. 79TH ST.
COSTA MESA, CA
TAYLOR, WARREN G.
453 E. 19TH ST.
COSTA MESA, CA
OWNER-BUILDER
ELECTRICAL PERMIT
Phone: (949)646-2477
Zip: 92627
Phone: (949)646-2477
Zip: 92627
Phone:
Zip:
License: 0
PERMIT NUMBER
E99-01070
77 FAIR DRIVE, COSTA MESA, CA 92626
status: ISSUED
Applied: 1 111 211 9 9 9
Issued: 11112/1999
ISSUED BY: ��
SCOPE OF PERMIT
ELECTRICAL PERMIT FOR NEW SINGLE FAMILY ADDITION & REMODEL. INSTALL 12-LIGHTS,
26-OUTLETS, 15-SWITCHES, 8 1-MOTOR UP TO 1HP.
REF: B99-00915
ISSUE FEE
Temp service test
Res. al¢ package
New Res (1•2 unils)
New Res (3+units)
Pool I Spa
Lighting Fixts
Recept Outlets
Switches
Non Res App1
Res Appl
Service to 200a
Service to 1000a
Service over 1000a
Motors to 1 hp
Motors to 10hp
Motors to SOhp
Motors to 100hp
Motors over 100hp
Communication drops
Sub panel to 200a
Pole Light Pkq
Sign CircuitS
Temp Pwr Pole
Intermed Pole
$23.50
$0.00
50.00
$0.00
$0.00
$0.00
$1320
$24.38
516.50
$0.00
$0.00
$0.00
50.00
50.00
$4.75
$0.00
$0.00
$0.00
$0.00
50.00
$0.00
50.00
50.00
$0.00
$0.00
Quantity
0
0
0
12
26
15
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
FEE SUMMARY
Temp Dist System I Lighting
Busway /100 ft
Standing Seclion
Misc Electrical Equipment
Trensformers up to 1 kva/kw
................up to 10 kva/kw
.................up to 50 kvalkw
.................up to 100 kvalkw
..................over 100 kva/kw
Low Voltage Equipment
Low Volt Wiring System / Ckt
Misa Conduit
Misc. Condudor
Cirws ( gen or ride)
Circus (mech ride or lights)
Christmas Tree Stand
Fireworks Stand
Other Electrical Fee
Investigation Fee
Plan Check Fee
Reinspedion Fee
Quantity
$0.00 0
50.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
50.00 0
$0.00 0
50.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00 0
$0.00
$0.00
50.00
$0.00
TOTAL CALCULATED FEES E82.33
COMMENTS ! SPECIAL CONDITIONS
NOTICE: The work authorized by ihis permit shell comply with all applicable handicap access requiremenis under Califomia statutes and relatetl
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandonetl
for a period qf 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required inapectlone end final approval must be obtained. Failure to obtain inspections and tinal approval will result in the expiration of ihis permit.
FOR INSPECTIONS CALL: (714) 7545826 �
WORKERS' COMPENSATION DECLARA710N: �
I �ere0y eflirtn under penalry oi per�ury one ol ihe following tleUarations:
❑ I have end will meintain e ceniticete of consenl to self-Insure for warkero' compensatlon, as proWaetl for by sectlon 3700 of the Lebor Cotle, lar the peAortnence ot t�e
work lor w�lch this permit Is Issued. �
❑ I have and will maintain workers' compense�ion insurance, as required 6y section 3700 of !he Labor Code, for the pertortnanca of the work for which this pormit is issued.
My workere' compensatlon Insurence carder end policy number ere: �
Carder: Policy Number.
(Thls sectlon neetl nat be complered ll fhe permlNs veluetl et one hundred dollers ($ I00) or less.)
❑ I cenify thet in the pertortnence at tha work for which this permit is iuued, I shall not employ any person in eny menner so as to become subJect to the workers'
compensatirn lews ot Celitomla, end agree that if I s�oultl become subl�� �a �he workers' compensation provislons ol Section 3700 at the Lebor Catle, I shall forthwith
wmply with those pmvislons. �
Applicant Signature: Date: �
WARNING: FAILUflE TO SECURE WORNERS' COMPENSATIIXJ LOVERAGE IS UNLAW FUL AND SHALL SU81ECi AN EMPLOYER TO CRIMINAL PENALTIE$ ANO CML FINES UP TO ONE HUNDRED
THWSAND OOLLARE ($100,000), IN ADOITIIXJ TO THE COST OF COMPENSATON, DAlMGES AS PROVIDED FOR IN SECTIIXJ 3'l08 OF TME LABOR CODE �MEREST, AND ATfORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby afllrm thet I am licensetl untler provislons of Chap�er 9(wmmencing wlth Section 7000) of Divislon 3 of Ihe Business ena Professions CoAe, and my Ilcense is In full
force antl ettecL Lic. N Class #
Coniractofs Signature: Dete:
I CONSTRUCTION LENDING AGENCV:
'❑ I hereby ettirm that thera is e cronswctian lentling agency for ihe peAormance at t�e work tor which this permit Is issued. (Sec. 3097, Civil Code).
Lendefs Nema: Lenders Atltlress:
Signeture: Dete:
OWNER-BUILDER DECLARAT10N5:
I hereby eHirm ihet untler penalry ot perjury thet I am EXEMPT FROM TME CONTRACTORS LICENSE LAW tor Ihe following reason (Sec. 7031.5, Business entl Professions
Code: Any ciry or counry which requires a pertnii to consimct, elter, improve, demolish, or repair any sWCWre, pnor to Its issuence, elso requires the epplicam lar such permit
to tlle a signad statement ihat he or she Is Ilcensed pursuant to the provisions of ihe Conirectors License Lew (Chepter 9(commencing with Section 7000) ol Division 3 ot the
Business end Professions Cotle) or t�at he or she is exempt therefmm antl the besis tor the allegetl exemption. Any violation oi Section 7037.5 by any applicant tor a permit
sub�eds lhe eppliwnt to a civil penalty oi nat more t�an tive hundred tlollers (5500).): '
��es owner of the D�aPerty, or my employees wit� wages es ihelr sde compensetlon, WILI 00 TME WORK, entl the structure is not Intentletl ar aHered for sele (Sec.
7044, Business anC Professions Code: 7he Contractors License Lew Ooes not epply ta an owner of propeny who builtls or improves thereon, antl who does such work
himself or hersetl or through his or her own employees, provided that such impmvemenis ere not intended or oflered tor sale. It, however, tha Duilding or improvement Is
soltl within on year ot completion, Ihe owner-builder will have the burden of proving thet he or she ditl noi builtl or Improve for purpose ot sale.).
� as owner of �a properry, m E%CLUSIVELY CONTRAC7ING WIiH LICENSED CONTRACTORS to construa t�e project (Sec. 70M14, Business en0 Prolessians
Code: The co rectars Licen not epDly to an awnar ol property w�o builds or impraves Ihereon, en0 who conirens far such project with e coniractar(s)
licens pursua t to the C tors Licens Lews.).
❑ I am pt der sec. Business end Professians Cotle tor Ihis reason: �
SlgneWre: Oete: —
Owner ID verilied by drivals licensa. es ❑ No Ddvefs License No. � Expires: I%O �
Venfcation of Ownership by (rype of document, i.e. - property ta< bill or deed):
DIVISION OF INDUSTRIAL $AFETY PERMIT CERTIFICATION:
❑ I �ereby certify ihat no excavation five (5) or more feet in depth Into which a person Is requiretl to tlescend, will be made in connection vrith work euthonzetl �y thls
pertnit, end Ihat no building slructure, scatlolding, falsework, or tlemoliUon or tlismantling tliereof, wlll be mare then INrty-six (36) teet high. (Chap. 32, Grp 2, Art 2, Sec.
341, Ttla B, Celitomia AtlminlstretNe Coda).
❑ As owner-builCer, I will not employ anyone to do work which would raquire a pertnii irom Ihe Division of InAusirial Selery, as noted above, unless such person has a
pertnit ta do such work irom the divisian. .
Slgneiure: Date:
Division of Industrial Safery Permil Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: �
1 WIII Ihe epplicam or presenl or tuture building occupant need to file end certlfy e Buslness Plan for emergenty response to release or Ihreeiened release of a heiardous
matenel7 ❑ Yes ❑ No �
(Section 25505 0l iha Califomia Health end Sefery Gode requires, with some e:ceptlons, that a Business Plan be filed with the Costa Mesa Fire Depanment by every
buslness which has at any one tlme dudng e reportetl year a quantiry ol hazardous meteriels equal m or greater then e weight of 500 pounds, or e vduma o155 gallons,
or 200 cubic leet of compresseG gas at stantlartl tempereture and pressure�.
2 Does or will Ihe applicant or preseN or tuWre building occupant neetl ro lile e registretion form br acutely hazardous matedals7 ❑ Yes ❑ No
(Section 25533 of iha Calitomia Health end Safery Code, with some exceptions, requires registration with the Coste Mese Fire Department by each business which et any
one tlme has on han0 a quentiry ot acutely hazartlous materlels epuel to or greeter than e weig�t of 500 pounds, or e volume ot 55 gallons, or 200 cubic feet of
compressetl ges et stendertl tempereture entl pressure).
3 Does or will the applicant or presant or future builtling occupent neetl to prepare en RMPP (Risk Manegement end Prevention Program for acutety hazerdous materials)?
25534 of ihe Californie Heelih en0 Setety Cotle provitles that Ihe Costa Mesa Fire Department mey requlre the preparetian, certification antl filing wlih ihe Fire
ent ol an RMPP by businesses which ere requlred to reglster ecutely hezardous metenels with the Fira Depariment.
4 II en RMPP Is presently requiretl, hes Sectlon 25534 of Ihe Calilornl9 Healtn entl Salery GO�e DBBn fully complletl wltn7 �„J Yes �J No
5 Does or will the epplicant or present or future 6uiltling occupam require for Ihe work which is the subjact at lhis e plication a Eertnit tor such construction or
trom the South Coast Air Oueliry Menagement District or tram any olher eir pollutlon conlrol disirict or egenc�? � Yes LJ No
(Section 658502 of ihe Califomia Govemment Cade requires thet Ihe requestetl intormatlon be fumishetl on applicetlons for non-resiAentiel builtling pertnits).
6 W iil any pan of the faciliry to be conswctetl untler tNs permit be wlthin l00o iee� trwn che outer boundades of e sc�ool4 ❑ Yes ❑ No
Qt yes', ihe Fadliry must maet Iha requirement of Sections 25534 antl a2303 ot lhe Calilomie Health antl Safery Code).
7 If e pertnit tmm the South Coest Air �ualiry Management Distdct or oNer eir pollullon wntml CisMct or agency Is reqNrea for me work which is the su
epplicatlon, heve ell ol the disclosures prescribed by Califomia Health entl Salery Code Section 42303 Deen matle? � Yes ❑ No
Signature:
I certify ihet under penalry ol perjury the Inlortnatlon given above is conect. I egree to compty with all sWta lews entl city ortlinances
Emissians. .
Dete:
CERTFlCATE OF bMPLIANCE AND 1UTH TION OF EMAY: I certily under penelry of pe�ury ihet I heve reatl Ihis application antl state t�at ihe inlormation given is
wrtect I agree to mply with II sta ws entl d ordinances reletlng to bullding consWcNon, and euthodze representaUves oi ihe Ciry oi Costa Mese to enter upon the
ebov�nbed p operty lor Ins a urposes. 1 ree nat to occupy or ellow occu0ancy oi any buliding euthorized by this pertnit until final inspectlon.
��� ��� ll-lZ-�
—� � Signewre gelOwner(s) Data
AnNOr Authodzed Applicant Date
GO�E I, INSPECTIONTYPE
1618 Flzetl System Final Fire Preventlon
1266 Pool Spa Finel
200 Finel Re-Roof
201
202
203
204
Final Block/Heiaining Well
Finel Faciory Flre Place
Final Slgn
Final Demdition
It{�lLS
COOEI INSPECTIONTYVE ,
206 Final Mechenical ,
208 Final Plumbing �
210 Finel ElecMcal .
212 Finel Flre Preventi0n
220 Final Planninp Approval
222 Flnel Slte
250 Final
2a48d8 I
�
li�es5
: . .
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y
. . 6580
COSTA MESA BUILDING DEPARTMENT
P.O.BOX 31�
COSTA MESA. CALIFORNIA
FOR APPLICANT TO FILL IN
BUILDING
ADDRE55
/
OWNER :
ARCHiTECT
OR ENGINE
ADO ,
>'3 L , � 9 � .a.l`
COSTA MESA. CALIFORNIA
� T) �
�[cn� ILOT
DESCRIPTION NO.
A.P. NO. �
SIZE � O ✓
OF LOT ��
USE OF
EXISTING BLDG. �
9ETBACK LINE FROM
CENTER OF STREET
TEL.
NO.
LIC.
NO.
] CI�iM'CIC./��l
��'
TEL.
NO.
BLOCK TRACT
— � OF 9LOG5.
NOW ON LOT
� �.
i
7 REAR YARD �
' � �
SIDE YARD RIGHT � LEFT �
DESCRIPTION OF WORK
NEW ALTERATION ADOITION
REP. MOVING �EMOLISH
BUILDING G NO.OF
SIZE 'L ROOMS � STORIES
EXTERIOR WALJ�J�� ROOF // �, �
COVERING /� n /i. C�VER���'�d�•rr
�ice nv wie.., // r iL
STATE THiT TNE ABOVE IS
CITV OHOINANCES /ND STP
TION.
SIGNATURE�
PERMITTEE
/!`
AUTHOR ZF ED AGENT
PGREFJ TO
SbNfIG BU
��� ��������
,I,3_� S{ V�.._
rr r�
APPLI��A��iIOr.N' Ir'-�rOR PERMIT
Cli'B�U I�LDPI IV GA
FOR OFFICE USE ONLY
PECEIPT NO. �PER`I �
7S
RECEIVEO BY �A RECEIVlEO O TE ISSUF
�! —J
BUILDIN
ADDRE55
COSTA MESA. CALIFORNIA
FIRE
RRECTI
CITY G
p
�Ll
tUC-
VALUATION
PERMIT FEE S
/ � �J�� PLAN CHECK 5
g �
TOTAL FEE $