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CITY OF COSTA MESA �
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77 FAIR DRIVE, COSTA MESA, CA 92626 • Q14) 754-5273 • Fax (714) 754-4856 • www wstamesaca.qov
FOR INSPECTIONS CALL: (7'14) 754-5626
PERMIT TYPE MECH
APN: 11733225
JOB AqDRESS: 476 E 18TH ST CM
Vicinity:
SQ. FT: 0
PERMIT NUMBER: M12-00010
STATUS: ISSUED
DATE ISSUED: 01/17I2012
ISSUED BY: RMD
Suite/Unit:
SCOPE OF WORK: MECHANICAL PERMIT TO CHANGE OUT (1) WALL HEATER FOR A SFD. COMPLIANCE FORMS
ATTACHED TO CITY PERMIT AND JOB CARD. REF#: C11-1778
OWNER: BELVISO, MARY N TR
PHONE:
APPLICANT: WOOD, BIL�
PHONE: 714-624-6980 �
CONTRACTOR: OWNER-BUILDER
Address: Unit
Ciry/State: � '
PHONE:
ZipCode:
MECHANICAL PERMIT FEE SUMMARY
MECH ITEM FEE: $34.15
PLAN CHECK FEE: $0.00
INVESTIGATION FEE: $0.00
REINSPECTION FEE: $0.00
TOTAL FEES: $34.15
Addmss: 476 E 18TH ST Unit:
City/State2ip: COSTA MESA, CA
Addfess: Unit: , '
City/State/zZip:
License No. 000000
CELL:
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.
INSPECTIQNS: In order for the work authorized under this permit to be considered legal, such work must comply with all applirable codes, and all
required inspections and final approval must be obtained. Failure to obtain inspections antl final approval will result in the expiretion of this permit.
CODE 1, 1N_5_PEC710N TVPE png iNiRIALS 4QD� INSPECTION TYPE �/ P� A�
7616 fixed System Final Fire Prevention 206 Final Mechanical /� �' d`��� a'"
1266 Pool Spa Final 208 Final Plumbing
200 Findl Re-Roof 210 Final Eleclntal
201 Final BIocWRetaining Wall 212 Final Fire Prevention
202 Finyl Fadory Fire Place 220 Final Planning Approvai
203 Finel Sign 222 Final Sife
204 Finel Demolition 250 Final Building/Occupancy
WORKERS' COMPENSATION DECLARATION: � ",
I here6y affirm under penalty of perjury one of ihe (ollowing declarations:
❑ I have and will maintain a ceAi�cate of consenl lo self-Insure for vrorkers'
compensation, as providetl (or by section 3700 of Ihe Labor Code, for [he
pedormance of the work !or which this permil is issued.
❑ I have and will mainlain vrorkers' compensation insurance, as required by
sectbn 3700 0( the Labor Code, for the peAortnance of the v.ork For which Ihis
pertnit is issuetl. My workers' compensation Insurance carrier antl policy
number are:
Carrier.
(Tnis seGpn needirot be cwnpeletl �the pmm� is valuetl at oneOundretlWllars (E100) w IessJ
Policy Number:
I,cenify that in the performance of the work for which lhis permit is
ssued, I shall not employ any person in any manner so as to become subject
to the workers' compensation laws of Califomia, antl agree that if I should
become subject to the vrorkers' compensation provisions of Section 3700 of
Ihe Labor Cotle, I shall forthvnth comply wilh these provisions.
�i�.i�= h� Gc.�tro{�C /-/7 - / �-
A ppp 'ca0t'S.SignaWre DSt�e -Y
L��'
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOVER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADOITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED fOR IN SECTION 3706 OF THE L480R CODE, INTEREST, AND
AT�ORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affrm that I am licensetl under provisions of Chapter 9(commencing
with Section 7000) of Division 3 of the Business and Pmfessions Code, and
my license is in full /orce and eRect.
Lit. # Class #
CONratlor's Signalure
CONSTRUCTION LENDING AGENCY:
❑ I hereby aHirtn that there is a construction lending agency for the
peAortnance of the wurk fa vfiich this permit is issuetl. (Sec. 3097, Civil Code).
Lentler's Name:
Lentler's Atldress:
SignaWre Date
OWNER-BUILDER DECLARATIONS:
I he�eby affirm that under penalty of perjury ihat I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5,
Business and Professions Cotle: Any city or county which requires a permi[ to
construct, alter, improve, demolish, or repair any struc[ure, prior to its
issuance, also requires the applicant for such permit to file a signe0 statement
that he or she is licensetl pursuant to the provisions of the Con[ractors
License Law �Chapter 9(commencing vrith Section 7000) ot Division 3 of the
Business antl Professions Cotle) or that he or she is eaempt [herefmm and
the basis lor the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalry o( not more �han
five hundred dollars ($500).):
��l,as owner of the property, or my employees with wages as iheir sole
Eompensation, WILL DO THE WORK, and the sWcture is not intended or
oftered for sale (Sec. 7044, Business antl Professions Code: The Contractors
License Law does not apply to an owner of property who builds or improves
lhereon, antl who does such vrork himself or herself or thmugh his or her own
employees. provided thal such improvements are not intended or oHered�For
sale. If, however, the builtling or improvement is sold within one year of
complelion, Ihe owner-builder will have the burden of proving lhat he or she
tlitl not build or improve for purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH
IICENSED CONTRACTORS to construct the project (Sec. 7044, Business and
Professions Code: The cont2ctws License Law dces not appty to an owner of
property who builds or improves lhereon, and who contracts for such prqect with
a contrac[or(s) license pursuant to the Contractors License Laws.). .
❑ I am exempt under sec.
Business and Professions Code for this reason:
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namre � ""� �-oale
3057�46(3I0])
Owner ID verified 6y driver's license. es ❑ No �.
���
�river's�Llcense No. Expires;,� 2D(�
Verilcation of Ownership by (rype of d cument, i.e. - property tax bill or deed):
DIVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICATION:
❑ I hereby certify that no excavation frve (5) or more (eet in depth into w4ich a
person is required to descend, will be made in connection with work authonzed
by this permil, antl that no building structure, scaf(dding, falsework, or tlemolition
or dismantling thereo(, will be more than lhirty-siz (36) feet high. (Chap. 3.2, Gry
2, M 2, Sec. 341, Title 8, Calilomia Administ2tive Code).
❑ As owner-builder, I will not employ anyone to do work which vrould
require a permil fmm the Division of Industrial Safety, as noted above, unless
such person has a permit ro do such vrork from ihe tlivision.
Applitanfs SignaWre Dale
Division of Industrial Safely Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. will the applicant or present or fuWre builtling occupant neetl to fle and
certify a Business Plan for emergency response lo release or threatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 0! Ihe Calitomia Health and Safety Code requires. with some
exceptions, that a Business Plan be filetl with ihe Costa Mesa Fire
Department by every business which has at any one lime tluring a reportetl
year a quantity of hazardous materials equal to or greater than a weight of
500 pountls, or a volume of 55 gallons. or 200 cubic feet ol compressed gas
at standard temperewre and pressure).
2. Does or will ihe applicant or present or fuWre building occupaN need to file
a registration form for acutely hazartlous materials7 � Yes ❑ No
(Section 25533 of the Calitomia Heallh antl Safery Code, with some
exceptions, requires registretion with the Costa Mesa Fire Department by
each business which at any one time has on hand a quantity of awtely
hazartlous materials equal to or greater Ihan a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressad gas al stantlard
temperature and pressure).
3. Does or will the applicant or present or future Duiltling occupant need lo
prepare an RMPP (Risk Management ana Prevemion Program for aculely
hazardous materials)? ❑ Ves ❑ No
(Section 25534 of the Califomia Health antl Safery Coda pmvitles that the
Costa Mesa Fire Department may require the preparetion, certifcation and
fling with the Fire Department of an RMPP by businesses which are requirea
to regis[er aculely hazardous materials with the Fire Department.
4. If an RMPP is presently required, has Seclion 25534 of the California
Health and Safely Code been fully complied with7 ❑ Yes ❑ No
5. Does or will Ihe applicant or present or fulure buildinq occupant require for
lhe work which is the subject of this application a permit for such construction
or modification from the South Coasl Air Qualiry Manaqement District or fmm
any other air pollution control disMct or agency? ❑ Yes ❑ No
(Section 65850.2 of the Califomia Govemment Code requires Ihat lhe requestetl
infortna['ron be fumished on applitations (a non-residential builtling pertnits).
6. Will any part of the facility lo be consWcted under this permit be wilhin
1000 feet from the outer boundaries of a school? ❑ Yes ❑ No
Qf yes", the faciliry must meet Ihe requirement of Sections 25534 and 42303
of the Califomia Health and Safely Code).
7. If a permil from the South Coast Air Qualiry Management Dislnct or other
air polWtion control disirict or agency is requiretl for the work which is the
subject of this application, have all of the disclosures prescribetl by Califomia
Health and Safety Code Section 42303 been made? ❑ Yes ❑ No
8. (If yes", a[lach certificate of compliance from the appropnate air pollution
control officer).
CERTIFICATE OF COMPLIANCE: I certify that untler penalry of perjury the
information given above is correct. I agree to comply vrith all state laws and
city ordinances regarding Hazardous Materials and Emissions.
SignaWre Oate
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certi(y under penalty o! perjury that I have read this application and state that
the information given is correct. I agree ro comply with all state laws and city
ortlinances relating to building conswction, antl authorize representatives ot
the City ot Costa Mesa to enter upon the above-descnbed propeny for
inspection purposes. I agree not to occupy or allow occupancy of any building
authonzed by this permit until fqal inspe�ction.
U�/-PL�-�'�sC�1�a—�-- /—� —lz
Slgnetur2"oilegai Ovmer�s) �e�,
AnE/or Aut�onietl Appli�nt Oale
/ � ''�-�`����
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Costa Mesa
r .
City of Costa �l�lesa �uiCding lnivision
77 Fair Drive, Costa Mesa, CA 92626
714-754-5273/Fax 714-754-4856
OWNER BUILDER VERIFICATION
Permit# ml2 v�r�
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 /¢r/( E, /b'7� �
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
DIRECTIONS: Read and initial each statement below to srgnify you understand or verify this information.
� I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder' builtling permit that erroneously implies that the propeRy 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.
I understand building permits are not required to be signed by property owners unless they are
e ponsi�ile for the construction and are not hiring a licensed Contractor to assume this responsibility.
,I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that
ay protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his
or her name instead of my own.
��I understand Contractors are required by law to be licensed and bonded in California and to list their
icense numbers on permits and contracts.
5,1-understand if I employ or otherwise engage any persons, other than California licensed Contractors,
nd the total value of my construction is a[ least five hundred dollars ($500), including labor and materials, I may
be considered an "employer" under state and federal law.
�understand if I am considered an "employer" under state and federal law, I must register with the state
—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
laws may subject me to serious financial risk.
„�J�Z�understand under California Contractors' State License Law, an Owner-Builder who builds single-family
V��idential structures cannot legally build them with the intent to offer them for sale, unless all work is performed
by ticensed subcontractors and the number of structures does not exceed four within any caiendar year, or aN of
the work is performed under contract with a licensed general building Contractor.
314830 CALgO Jan 1, 2009 OB Packet template 1 of 2
jj�l� 8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable
"fdi� ariy 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
-venue Service, the United States Small Business Administration, the California Department of Benefit
Payments, and th� California Division of Industrial Accidents. I aiso 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 understantl
�`at'I"am the party legally and financially responsible for proposed construction activity at the following address:
1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will
a i e'by all applicable laws and requirements that govern Owner-Builders as well as employers.
2. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
i 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, /orm notarization, or other verification acceptable to the agency is required to be
presented when the permit is issued to verify ihe propeRy owner's signature.
.�-�-�-'-'�_--`'=''-== - 1 �/,, I
Signature�of prope�ty owner �ilJ�— � �! �Date:� / � � �' ���-
Note: The following Authorization Form is required to be completed by the property owner only when
designating an agent of the properfy 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 foilowing 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:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address Iisted above and I personally filled
out the above information and certify its accuracy. Note: A copy of the owner's driver's license, form
notarizafion, or other verification acceptable to the agency is required to be presented when the permit is issued
to verrfy the prope�ty owner's srgnature.
Property Owner's Signature:
Date:
3148-30 CALBO Jan �, 2009 OB Packet template 2 Of 2
Costa Mesa Building Department � APPLICATION FOR PERII�TT—
. P.o.B°"3'' BUILDING
^�• : COSTA MESA, CALIFORNIA �5g� �
FOR OFFICE USE ONLY
� FOR APPLICANT TO I�'II�L IN Receipt No. I Permft No.
Builtling [/
Addresa % - S ��' .S Ti �.S �T
Costa Mesa, California Received by Date Rec'd. Date Issued
Nearest � I �'%�" �l G -c� -�
CrossSt. f/QViAI� r � Building
Address
Owner �/�/Ar�LC-S �' S� I'1A-/� �d0 CostaMesa,California
Mail
Address �'7 ,C- 'f ��� ,$' T • Nearest
Tel.1 Cross St.
City (LQ$ /� hf �S/{ No.l.j, �-�e'}C,S Zone '/ No.oi 7ype Group
Arehiteetor �ic. Y- I Plans I
Engfneer �,• L No. Approved
b Date
� "'•e� �c9� C�FST /P� Sj CORR-ECTIONS
City Lic.
ContrecMr C h.' N E!Q No.
Address �1q L_
Deurption I Not %O.s I BlockyOD f� Tract��SSr-
(Attach Metes and Bounds)
I No. of Bldgs
Size ot Lot � O X/ J L Now on Lot � U�� � � n
E� iing Bldg. tS i� GA /Q I Familles � � aooma�e ���� A.
c�
SetbackLlneirom ��/ �q earVard �'� Alr�i -
CPnLn.fOfRtrnlf .�L7'_/.L�ftdaVand ././.../ %f7�1T�7 Tll u.-.._ - Z
Repair I I Moving � � Demolish I
Building y-C X A No. of �
R`-� y� b'� x/ I„c Rooms � Siories �
rior Wall Rooi E.uiyPo iT�o•Y
1.,,.ering p� c iQ � Coveriog S'N /N�t.L[' APPROVALS
Use of New
Bullding re p p iy� �, Foundatlon Location Inspector � Dat
Forms, Mater(als,
' S - u o Under-Pinntng
Frame: Fire Stopa,
Bracing, Bolts
I hereby acknow]edge at I have read thls ApplicaUon
and state that the above is correct and agree to comply �ath. Int.
with all Clty Ordlnances and State Laws regulating
bUllding COnStTUctio�1n. � Lath. Ext.
Signature of � �( (� � �1 ��LI/
Permittee ��-�'"�'� « �n� `- Plaster, Int
Authorized Agt. Plaster, ExL
Valuation Permit Fee $ ." `u Masonry Reintorced
I � � � .� Plan Check $ �• � � Bond Beam
$ � Total
Fee ��• � O FINA�
___.. __. ._ __ .. .. . � J
- - �
PLOT PLAN
Show lowtlon and dlsFancea irom
property Ilna and between bulldinga
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cosrr.
"O9—?-S.P�tlES!_ '�Si'_�':irt:�Z.rO
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�Costa Mesa Bnilding Department
� � P, O. Box 3! 7
� ,' COSTA MESA, CALIFORNIA
� FOR APPLICANT TO FILL IN
Building i.
Addresa �.{- r ,r i
Costa Mesa,, California
Nearest
Crosa st.�.�>/Q V( N� /� 6� �.
oW,�a� `!aN� 9�971a., (� fa �. i,".r
Costa Mesa, California
Nearest
Cross Sf.
-6{QS Zone � No.ot � Type �
:�PPLICATION FOR PERMIT '�
3�60 BUILDING �
FOR OFFICE USE ONLY
_ Receipt No. Permit No.
3s�.� �
- Rece� by Date Redd� � � te Issue� '
�f (a i �
�u
New
i Q
or
I Lot �
tion No. ��' �s Bloek � Tre�
Metes and Bounds) f / % -3 � �
.ot 6� X' 1 c+ o� � o. o� f a�dgs
Now on Lot
h�GSip�NCG I No.of ( I Ni
BId9• �� FLK N a �� Famliles R�
Line from � Rear Vard Y
I4s...� � mw_ v.._a ., /
1/5
�
� �No. ot
� /C�� � �� Rooms � Stories
JJ,,,,_�__�Rooi Ec��
I hereby acknowledge that I have mad this Applicatlon
and state that the abwe is correct and agree to comply
with all City ONinances and State Iaws regulating
building rnnst�ryuc�on. /1
Permittee �f `�f�`+�-c 4� c : " `l F �' A �
AuthoNzed Agt '
Valuation Permit Fee $ �
$ ia 7 �- P�an Check $ � �
Total
Fee �—
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Foundation Locatio�
Forms, Materials,
Int
Ext
Inspector
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property Iine antl between buildinpa
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