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- CITY OP COSTA MESA
� F, B!/ILDING DIVISION
F � 77 FAIR DRIVE, COSTA MESA, CA 92626 • p14) 754-5273 • Fax p14) 754-4856 •
�•,��� FOR INSPECTIONS CALL: (714) 754-5626
PERMIT NUMBER:
PERMITTYPE B MISC STATUS:
APN: 42437110 DATE ISSUED:
Zoning: , ISSUED BY:
. ��
www. ci. costa-mesa.ca. us
BX09-00202
ISSUED
09/30/2009
BJK
JOB ADDRESS: 976 B W 17TH ST CM . - �.._ Suite/Unit: B
Vicinity: ROOF '" PrimaryOcc: ' � - � ��� �� . ConstType :??
SQ.FT: 800 , , �� Valuation:- � $8,000.00,- .
SCOPE OF WORK: '
ALTERATION TO ROOF ON BLDG B. CON$TRUCT NEW 4:12 PITCHED ROOF, INSTALL 1 LAYER OF 30 LB FELT, 1/2"
PLYWOOD AND REROOF WITH 30 YEAR COMP SHINGLES. NEW OVERALL WEIGHT OF BUILDING IS 13'-7". 800 SQ FT
� E. �
OWNER: SALCIDO, DAVID C� Address: 954 W 17TH�ST .,: � • Unit
City/State: COSTA MESA, CA �' ' �� Zip Code: 92627-4403 �'•:
Phone: 949-548-0358 �" . .. � .. '� .. .. ,
APPLICANT: SALCIDO;�DAVID L�, ,�� � �` Address: 954 W 17TH ST � � -� , Unit:
City/State: COSTA MESA, CA "':' Zip Codei.', 92627-4403
Phone: 949-548-0358, _ , .. - � . , - �
CONTRACTOR: OWNER-6UILDER' ` License No.� 000000
Address: - � . � - -� - - - � ' � .. . ' Unit:
City/State: � �
Zip Code:
ARCHITECT:
Phone
ENGINEER:
Phone
FEE SUMMARY
Building PIan,Checki., r
Building Permit:..
Electrical Permit: - - .
SMIP Residential � . _., . ... .
SMIPCommercial -�
Bldg Std Admin Fund �� ' _
TOTALFEES
Phone
$99.61
$15325
$0.00
$0.80
$0.00
$1.00
$254.66
License No.
License No.
Cell:
NOTICE: The work authorized by this permit shall comply wilh all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 72-21-92)
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.
CODEp. INSPECTIONTYPE OATE INTITIALS C O�E� INSPEGiIONttPE DATE IN101AL5
1876 Fixed System Final Fire Preventian /� 206 Final Mechanical
1266 Pool Spa Final �.�C� . 208 Final Piumbing
//
200 Final Re-Roof � � dp .c.�� 210 Final Electrical
201 Final Biock/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Finai Site
204 Final Demolition 250 Final Builtling/Occupancy
i � � � .
WORKERS' COMPENSATION DECLARATION: � Owner ID verifed by driver's/ l�i ense. /Y�es ❑ No
I hereby aRirm under penalty of perjury one of the following declarations: Driver's"Cicense�No� �p ��i
Ex ves: U l �
❑ I have and will maintain a ceRifcate of consent lo self-Insure for workers' �!
Verification of Ownership by ([ype of documeN, i.e. - property [ax bill or deed):
compensation, as provided for by section 3700 of the Labor Code, for the
pertormance o( the work for which this permi[ is issued.
❑ 1 have an0 will maintain workers' compensa[ion insurance, as required by
section 3700 of the Labor Code, for the peAormance of the work for which Ihis DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
pertnit is issuetl. My workers' compensation Insurance carrier and policy � I hereby certdy that no excavation frve (5) or more feet in depth into which a
number are: person is requiretl to descend, vnll be made in connection with vrork authonzed
by this permit, and that no builtling structure, scaFfolding, falsework, ar demolition
Carrier. or tlismantling thereo(, will be more than ihiAy-sia (36) feet high. (Chap. 32, Grp
(T�rs secfun neetl not 6e mmp'eletl d Ihe peim� is valuetl at one huntlretlCollars (S100J w less )
2, Art 2, Sec. 341, Ttle 8, Califomia Administrative Code).
Policy Number:
❑ I certify t�at in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject
to the workers' compensation laws of Califomia, and agree thal if I should
become subject to [he vrorkers' compensation provisions of Section 3700 of
[he Labor Code, I shall forthwilh comply with these provisions.
ApPliranl's SignaWre
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SU&IECT 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 [hat I am licensed under provisions of Chapter 9(commencing
with Section 7000) of Division 3 of the Business antl Professions Code, antl
my license is in full force and effect.
Lic. # Class #
SignaWre Date
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirtn that there is a consWclan lending agency tor the
peAortnance of the v.ork fa wfiich this pertnit is issuetl. (Sec. 3097. Civil Code).
Lender's Name:
Lender's Address:
SignaWre Date
OWNER-BUIIDER DECLARATIONS:
I hereby aKrm that under penalry of perjury that I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW for the following reason (Sec. 703L5.
Business and Professions Code: Any city or county which requires a permit to
constmct, alter, improve, demolish, or repair any structure, prior to its
issuance, also requires the applicant for such permit to file a signed stalement
thal he or she is licensed pursuant b the provisions of lhe Contractors
License Law (Chapter 9(commencing with Seclion 7000) of Division 3 of the
Business and Professions Code) or that he or she is exemp[ there(rom and
[he basis for the alleged exemption. Any violation of Sec[ion 7031.5 by any
appliwnt tor a pertnit subjects the appliwnt to a civil penalty o( not more than
fve huntlred tlollars ($500).):
❑ I, as ovmer of lhe property, or my employees with wages as their sole
compensation, WILL DO THE WORK, antl ihe structure is not intendetl or
oRered for sale (Sec. 7044, Business and Professions Code: The Con[ractors
License law tloes not apply to an owner of property who builtls or improves
[hereon, antl who does such vrork himsel( or herself or through his or her ovm
employees, providetl that such impmvements are not intentled or oflered tor
sale. I(, however, Ihe building or improvement is sold within one year o�
completion, lhe ovmer-Duilder will have Ne burtlen of proving [hat he or she
did not builtl or improve for purpose of sale.).
0�1, as owner of lhe property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to consWct the project (Sec. 7044, Business antl
Pmfessions Code: The coniractors License Law dces no[ apply to an ovmer o!
property wfio builds or impmves thereon, and wfio cont2cts tor such projecl with
a cont2ctw(s) license pursuant to the Contractors License Laws.).
❑ I am exempt untler sec.
Business antl Professions Code for this reason:
�"� �13�1�Y
SignaW�e � 'Da�e._>
305]-a6(3107)
❑ As owner-buiider, I will nol employ anyone to do work which woultl
require a permit from the Division of Intlustnal Sa(ety, as noted above, unless
such person has a permit to do such work from Ihe division.
Appliranl's SignaWre
Division of IndusMal Safety Permit Number _
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the applicant or present or future building occupant need to (le and
certify a Business Plan foi emergency response to release or threatened
release of a hazardous matenal? ❑ Yes ❑ No
(Section 25505 of the Califomia Health and Safe[y Code requires, with some
exceptions, tha[ a Business Plan be fled wit� the Costa Mesa Fire
Department by every business which has at any one time during a reported
year a quantiry of hazardous materials equal to or greater than a weight of
500 pountls, or a volume of 55 gallons, or 200 cubic leet of compressed gas
at standard temperaNre and pressure).
2. Does or will the applicant or presen[ or fuWre building occupant need to file
a regis[ration tortn (or acutely hazardous ma[erials? ❑ Yes ❑ No
(Section 25533 of the Cali(ornia Health antl Safety Code, with some
exceptions, requires registration with ihe Costa Mesa Fire Depanment by
each business which at any one time has on hand a quanti[y of acutely
hazartlous materials equal to or greater ihan a weight of 500 pounds, or a
volume of 55 gallons. or 200 cubic feet o( compressetl gas at stantlartl
lempera[ure and pressure).
3. Does or will the applicant or present or future building occupant need co
prepare an RMPP (Risk Management and Preven[ion Program for acu[ety
hazardous materials)? ❑ Yes ❑ No
(Section 25534 of the Califomia Health antl Safety Code provides that the
Costa Mesa Fire Department may require ihe preparation, certificalion and
filing with Ihe Fire Depatlment of an RMPP by businesses which are required
to register awtely hazardous materials wilh lhe Fire Department.
4. If an RMPP is presenUy require4 has Section 25534 of the Califomia
Health and Safery Code been fully complied vnth? ❑ Yes ❑ No
5. Does or will the applicant or present or future building occupant require (or
lhe work which is the subject of this application a pertnit (or such cons[ruction
or modifcation from ihe South Coasl Air Quality Management District or from
any other air pollution control tlislrict or agency7 ❑ Yes ❑ No
(Sectbn 658502 of the Califomia Govemment Code requires that the requested
information be fumished on applications (a non-residential building permits).
6. Will any part of Ihe facility to be conslructed under this permit be vrithin
1000 feet from the outer bountlanes of a school? ❑ Yes ❑ No
pf'yes", the facility must meet ihe requirement of Sections 25534 and 42303
of the Califomia Health and Sa(ety Code).
7. If a pertnit from [he South Coast Air Qualiry Management Dislrict or other
air pollution control district or agency is required (or the work vfiich is the
suhject of this application, have all o� ihe disclosures prescribed by California
Health and Safery Code Section 42303 been made? ❑ Yes ❑ No
8. Qf'yes", attach certifcate of compliance from the appropriale air polNtion
control oKcer).
CERTIFICATE OF COMPLIANCE: I certify that untler penalty of perjury the
information given above is correct I agree to comply wilh all state lavrs and
city ordinances regarding Hazardous Matenals and Emissions.
SignaWre �ate
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify untler penalty of perjury tha[ I have reatl this application and state Ihat
ihe information given is wrrect I agree to comply with all state laws and city
ordinances relating to building construction, and authonze representatives of
the Ciry o/ Costa Mesa lo enter upon the above-tlescribed property (or
inspection purposes. I a ee not to occupy or allow occupancy of any building
authorize�,[iyjhisyermil ntil mal inspection. 9
�S d- �/�30/�
Signatue`o_iLepalOwner�s)'- �O_Jte-J
Am1br A W �nmM Anoliranl na�e
CITY OF COSTA MESA
o "' B!/ILDING DIVISION
i , . � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
i,.,�, . ,
�. FOR INSPECTIONS CALL: (714) 754-5626
��m fi�
PERMIT NUMBER: BX09-00077
PERMITTYPE B MISC STATUS: ISSUED
APN: 42437110 DATE ISSUED: 03/31/2009
Zoning: , ISSUED BY: RMD
JOB ADDRESS: 976 D W 17TH ST CM
Vicinity: ROOF
SQ. FT: 0 �. �
Suite/Unit: D
Primary-Occ: ' �.- - _. Const Type :??
Valuation: � 58,000.00 . '
SCOPE OF WORK:
ALTERATION TO ROOF ON BLDG��D. COSNTRUCT NEW 4:12 PITCHED ROOF�,�INSTALL,1 LAYER OF 30 LB FELT, 1/2"
PLYWOOD AND REROOF WITH 30 YEAR COMB SHINGLES. NEW OVERALL HEIGHT OPF BUILDING IS 13'-7".
OWNER: SALCIDO, DAVID L' • Addresx: 954 W 17TH ST Unit
City/State: COSTA MESA, CA -- Zip Code: 92627-4403� .�
Phone: 949-548-0358 - . � � � � � � , " ..
APPLICANT: SALCIDO;�DAVID L .� � � � , � � Address: 954�W 17TH ST � - '��` Unit:
Ciry/State: COSTA MESA, CA Zip Code:,, 92627-4403
Phone: 949-548-0358 "
CONTRACTOR: OWNER-BUILDER . �� - --- -- License No. 000000�
Address: ' � � ' �- � � - _-. � � - � . Unit:
City/Stale: ' . - . � � .. '
Zip Code: Phone Cell:
ARCHITECT: . - � � ' ' License:No. � � ��
Phone ' `
ENGINEER:
Phone
FEE SUMMARY
Building Plan Check:, : . "
Building Permit:. �� � . ` � � �
Electrical Permit: -. �
SMIP Residential
SMIP Commercial _ .
Bldg Std Admin Fund
TOTALFEES
License No.
$99.61 ,
�. ,�.:$]53.25 . . . . .
$0:00
. $0.80 '
�_ .$0.00� � �
$1.00
���$254.66
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia staNtes 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 aulhorized 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.
GODEa. INSPEC710NTYGE UATE IN1111AL5 COOEt INSPEC710NTYVE ORiE INI1TIRl5
1616 Fizetl System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place _ 220 Final Planning Approval
203 FinalSign 222 FinalSite
204 Final Demolition 250 Final Building/Occupancy � �0 � 6�
WORKERS' COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one o( Ihe following declarations:
❑ I have antl will maintain a certifcate of consent to self-Insure for workers'
compensation, as pmvided /or by section 3700 of [he Labor Code, for the
performance of the work for which this permit is issued.
❑ I have and will maintain v✓orkers' compensation insurance, as required by
section 3700 of the Labor Code, for the peAormance o( the v.ork for which this
permit is issued. My workers' compensa[ion Insurance carrier and policy
number are:
Carrier:
(This sec(bn neetl rql be mmplele0 Rthe peim�t a value0 al are �undietl dollars (5f 00) orlessJ
Policy Number:
■ I certify [hat in the pertormance of the work for which this permit is
issued, I shall nol employ any person in any manner so as to become subject
[o the workers' compensation laws of Califomia, and agree thal if I should
become subject b the vrorkers' compensation provisions of Section 3700 of
the Labor� , I shall fort ; h comply with these provisions/.
�dr— �z,L �%/O�i
Ap li� s SignaNre ��.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVER4GE
IS UNLAWFUL AND SHALL SU&IECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FlNES UP TO ONE HUNDRED THOUSAND DOLLARS
(5100,000), 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 aKrm that I am licensetl under provisions of Chapter 9(commencing
with Section 7000) of Division 3 of [he Business and Professions Code, and
my license is in tull force and eftect.
Lic. # Class #
SignaWre Date
CONSTRUCTION LENDING AGENCY:
❑ I hereby affrm [hat [here is a construction lending agency for the
pertormance of Ihe work fa which this permi� is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lender's Address:
SgnaWre Dale
OWNER-BUILDER DECLARATIONS:
I hemby affrm ihat under penalty of perjury �hat I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW (or the following reason (Sec. 7031.5,
Business and Professions Code: Any city or county which requires a permit to
constmct, al[er, improve, demolish, or repair any s[mcture, prior to its
issuance, also requires the applicant for such permit to file a signed statement
that he or she is licensetl pursuant to the provisions of the Coniractors
License Law (Chapter 9(commencing with Section 7000) of Division 3 of the
Business antl Professions Code) or that he or she is exempt Iherefrom antl
the basis for Ihe alleged exemption. Any violalion of Sec[ion 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
irve huntlretl do��ars (Ssoo).):
❑ I, as owner of the property, or my employees with wages as iheir sole
compensation, WILL DO THE WORK, and the structure is not intended or
offered for sale (Sec. 7044, Business and Professions Code: The Contrectors
License Law does not apply [o an owner of property who builds or improves
thereon, antl who does such work himself or herself or through his or her ovm
employees, provided that such improvements are not intended or oRered for
sale. If, however, ihe building or improvement is sold within one year of
completion, Ihe owner-builder will have the burden of proving ihat he or she
did no[ build or improve for purpOse o( sale.).
tQ/►I, as owner of the property, am EXCLUSIVELY CON7RACTING WITH
��ICENSED CONTRACTORS lo construct lhe project (Sec. 7044, Business and
Professions Code: The contractors License Law does not apply to an owner of
property who builds or impmves Ihereon, antl who contracts for such project with
a con[2ctw(s) license pursuant to Ihe Contractors License Laws.).
❑ I am exempt under sec.
Business and Professions Code (or this reason:
• • � R$(�re � Dale 46�—
305]-4fi�3/01�
Owner ID verified by drive. _ ncense. L)'1'es ❑ No
�Omer' ucense No. �Ekpire�/O--! �' ^�
�Venfi�' —� cation of Ownership by (type of document, i.e. - properiy lax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMiT CERTIFICATION:
❑ I hereby cert"rfy that no excavalion frve (5) or more feet in depth into which a
person is requiretl to descend, will be made in connection with work authorized
by this permit, and that no building sWCNre, sca(folding, falsevrork, a demolition
or dismantling thereof, will be more lhan thirty-six (36) fee[ high. (Chap. 32, Grp
2, M 2, Sec 341, Ttle 8, California Administrative Code).
❑ As owner-builder, I will not employ anyone [o do vrork which would
require a permit from the Division of Industrial Sa/ety, as no[ed above, unless
such person has a permit to tlo such work 6om the tlivision.
AppliWnfs SignaWre
Division o( IndusMal Sa(ety 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 Mreatened
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 of the Califomia Health and Safery Code requires, with some
exceptions, that a Business Plan �be filed with the Cos[a Mesa Fire
Department by every business which has at any one time duiing a repoRed
year a quantity of hazardous materials equal to or greater than a weigh[ o!
500 pountls, or a volume of 55 gallons, or 200 cubic feet of compressed gas
at standard temperature and pressure).
2. Does or will Ihe applicant or present or future building occupant neetl to fle
a registration form for acutely hazartlous materials? ❑ Yes ❑ No
(Seclion 25533 of the Califomia Health and Safety Code, with some
exceptions, requires registretion with the Costa Mesa Fire Department by
each business which at any one time has on hand a quantiry o( acutely
hazardous materials equal to or greater than a weight o/ 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
temperature and pressure).
3. Does or will Ihe applicanl or present or future building occupant need to
prepare an RMPP (Risk Management antl Preven[ion Program for awtely
hazardous malerials)? ❑ Ves ❑ No
(Section 25534 of [he Califomia Heal[h and Safery Code provitles that the
Cosla Mesa Fire Department may require the preparation, certification antl
fling with the Fire Department of an RMPP by businesses which are required
to register acutely hazartlous materials wi[h the Fire Department.
4. If an RMPP is presently required, has Section 25534 of the Califomia
Health and Safety Code been fully complied with? ❑ Yes ❑ No
5. Does or will ihe applicant or present or future builtling occupant require for
Ihe work which is the subject of this applicalion a pertnit for such construction
or motlification fmm the South Coast Air Qualily Management DisUict or fmm
any other air polWtion control dislric[ or agency? ❑ Yes ❑ No
(Section 658502 of the Califomia Govemmen[ Code requires that Ihe requested
infortnation be fumishetl on applications fa non-residential building pertnits).
6. Will any part o( lhe (acility lo be consWctetl under Ihis permit be vrithin
1000 feet from l�e outer bountlaries of a school? ❑ Yes ❑ No
Qf "yes", the taciliry must meet the requirement of Sections 25534 and 42303
of the California Health and Safety Code).
7. Ii a permit from the South Coas[ Air Quality Management Distric[ or other
air polNtion control tlistrict or agency is requiretl for [he vrork which is the
subject ot this applica[ion, have all of [he disclosures prescribetl by Calitomia
Health and Safety Code Section 42303 been matle? ❑ Yes ❑ No
8. Qf "yes", attach certificate of compliance from ihe appropriate air pollution
control oKcer�.
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the
information given above is correcL I agree to comply with all state laws and
ciry ordinances regarding Hazardous Matenals and Emissions.
SignaWre Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certi(y under penalty of perjury that I have read ihis application and state tha[
ihe information given is correcl. I agree to comply vnth all state laws and city
ordinances relating to building construction, antl authorize repre5entatives of
ihe Ciry of Costa Mesa to enter upon the above-described properry for
inspection purposes. I agree not to occupy or allow occupancy o/ any building
authorizcQl�y,tpis per it un' (nal inspection.
LJ �. :�s /3�/0 9'
Si T � �'Owner(s) ��Q�{¢.'�
Antl�or Aulhorrzetl AOPllcanl Date
`� � CITY OF COSTA MESA
' BYILDING DIVISION
, �
77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa•mesa.ca.us
FOR INSPECTIONS CALL: (714) 754-5626
PERMIT NUMBER. 608-00171
PERMIT TYPE B ROOF2 STATUS: ISSUED
APN: 42437110 DATE ISSUED: 06/02I2008
, . '� �>-:--1SSUED BY: RMD
s
,, �-�';' � ( `,�,:`.��'�
JOB ADDRESS: 976 W 17TH ST;CM �� 1,,,1, ...: �_ ..;1.SuitelUnit ����,','�,
Vicinity: UNITS A AND B ROOF _ r
Squares: 1400 ,;'-, �' " �,� ''� Valuation , $3;859.00
. � ��(�i"'4� ' - 1 � i�p''�V ! , .
SCOPE OF WORK: TEAR OFF. (E) ROOF MATERIALS, INSTALL 2 LAYERS OF 13# FEIT ON A 3:12 PITCHED ROOF AND REROOF
WITH 20 YEAR GAF COMP SHINGLES ON ATI'ACHED UNITS A AND 8•DUPLEX, APPROX 14 SQUARES. '
�
� .��,; .., ' ,
, . ...
FHONE: 949-548-035AVID L� �� �� ' - Address: . 954 W 17TH ST � '� � . " �, . Unit
OWNER: , SALCIDO, D .
8 � 1; � , � +' � ^�t.,�;� � City/State/Zip: COSTA�MESA, CA _ . .
�: _
APPLICANT: UEBHERR�,THOMAS-'�� � � � � � �"��� � � Address 17066PALMDALE�ST � `� � - '.� Unit :
PHONE:� 714-641-4456 , , , , ` _ City/State/Zip HUNINGTON BEACH �CA �, ,.
CONTRACTOR: PRIMO ROOFING CO , � ;=; � ; �- - . - , " Y, License No. 331120
Address: 17066 PALMDALE STUnit: � � � , � PHONE: ' � N4-841-0456 -
City/State/Zip: HUNINGTON BEACH; CA ,94627 `�� ' � � CELL: � ` '
- ..� .. �, , _._ . . . .
. . 1^ :r� . - i � - � , � ... � .. ` .
ARCHITECT: - � � , �License No. - � • . - PHONE: �
- ty ��i.'Y, , . ..,� . , , _
;
ENGINEER: � ��'� . . - License No. _ - . , �- PHONE:-
- . . i . . r . ' ' , � ' ' � .
FEE SUMMARY
Reroof Plan Check: �` , $0.00 -,: . � , _ . - � . � � . � . � ,
Reroof Permit Fee: � $9725 - .—
ReinspectionFee: �50.00 '� � � � �� ' � '�'� ,
� '� .*' ' '' .' 1. ' . --
TOTAL FEES $97.25 ' ` ` . � �- . .. � ' :' . . �,
. . � -. .: .. .. . . . ,..' ":� . .
NO710E: 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 DAVS FROM DATE OF ISSUE OR DATE OF IAST INSPECTIOIJ.
INSPECTIONS: 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 and final approval will result in the expiration of this permit.
OOE INSPECTIONTYPE
1616 Fixed System Final Fire Prevention
1268 Pool Spa Final �
200 Final Re-Roof
201 Final Block/Retaining Wall
202 Final Factory Fire Place
203 Final Sign
204 Final Demolition
1}�jF IN RL
CODE� INSPECiIONTYPE
208 Final Mechanical
208 Final Plumbing
210 Final Electriwl
212 Final Fire Prevenlion
220 Final Planning Approval �
222 Final Site
250 Final Building�OccuOancy
Qyr� iNmtu
WORKERS' COMPENSATION DECLARATION
I hereby affirm under penalry of perjury one of the ._ _.uing declarations: �
❑ I have anA will maintain a certificate of consent to self-Insure�for vrorkers'
wmpensatinn, as pravitled for by section 3700 of the Labor Code, (or the
peAormance of the work tor which this permit is issued.
1 have antl wiil maintain v.orkers' cwnpensation insurance, as required by
seclion 3700 of the Labor Code, for the perfortnance of the work fa which this
pertnit is issued. My workers' wmpensation Insurance cartier and policy
number are:
Carrier .STi`�� �/.1,�.�/�
' (ifusseqmneediplEamnpele0d^tne7pema4vahmdatdr�eh/urM�Mcb6ars(Et00)aleu)
Policy Number ����� /� �n�� /
❑ I certify that in the performance ot the work for which this permit is
issued, I shall no[ employ any person in any manner so as to become subject
[o the vrorkers' compensalion laws of Cali(omia, and aqree that if I should
become subject to the workers' compensation provisions of Section 3700 of
[he e, I shall fort,h,w�t�h co ply ��tj these provisi s.
/ �r�r-�CI Y i-��"�ilil o? n
AppllWnfs$9ne1 re �Date 9
/
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SU&IECT AN EMPLOYER TO CRIMINAI
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 aKrtn thal I am licensed untler provisions of Chapter 9(commencing
with Section 7000) of Division 3 of ihe Businass and Professions Code, and
my license is in full force and effect.
Lic. # . � �O2 27 . Class # C �
. � ' —
. `
� Conlractor' ignaWre D e /
CONSTRUCTION LENDING AGENCV:
❑ I hereby affirtn that there is a constmction lentling agency for the
pertortnance of the work tor which this permit is issued. (Sec. 3W7, Civil Code).
Lender's Name:
Lentler's Adtlress:
SignaWre
OWNER-BUILDER DECLARATIONS:
I hereby aKrm that under penal[y of perjury lhat I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW (or the lollowing reason (Sec. 7031.5,
Business and Professions Cotle: Any city or counry which requires a permit to
wnstruct, �alter, improve, demolish, or repair any structure, prior to its
issuance. also requires the applicant tor such permit to file a signed statement
lhat he or she is licensed pursuant ro the provisions of the Contractors
License Law (Chapter 9(commencing with Section 7000) of Division 3 of t�e
Business and Protessions Code) or that he or she is exempt t�erefrom and
the basis for the allegetl exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the appliwnt to a civil penalty of not more [han
five hundred dollars ($500).�:
❑ I, as ovmer of the properry, or my employees with wages as their sole
Gompensalion, WILL DO TME WORK, and Ihe sVucture is not intendetl or
oflered for sale (Sec. 7044, Business and Protessions Code: The Contractors
License Law does not apply to an owner of property who builtls or improves
thereon, antl who tices such vrork himself or herself or through his or her ovm
employees, provided lhat such improvements are not intended or offered for
sale. If, hovrever, the building or improvement is sold within one year o(
completion, the ovmer-builder vnll have the burden of proving that he or she
did not build or improve for purpose of sale.�.
❑ I,. as ovmer of the property, am EXCWSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to construct the prqect (Sec. 7044, Business antl
Professbns Code: The contractors License Law dces not apply to an ovmer of
property vfio builds or improves thereon, and v+ho conlracis tor such project wi[h
a contractor(s) license pursuant to the Contractors License Laws.). �
❑ I am exempt under sec.
Business and Professions Code for [his reason:
305]J6 (3/0])
Owner ID verifietl by dri� ise. ❑ Yes ❑ No
Driver's License No. Expires - _
Verifcation of Ownership by (type of document, i.e. - property Wz bill or deed):
� OIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:� ,
❑ I he2by certify that no exwvation frve (5) w more feet in depth into wfiich a
person is required to descend, will be made in connectbn vnth vrork authorized
by this permit, and that no building strucWre, scaffdding, talsework, a demolition
or tlismantling Ihereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp
2, Art 2, Sec. 341, Title 8, Califomia Administrative Code�.
❑ As ovmeo-builder, I will not employ anyone lo do work which would
require a permit from the Division of Intluslrial Safety, as noted above. unless
such person has a permit to do such work from the tlivi5ion.
Appliwnfs Signalure Dale
Division ol Induslnal Safely Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the appliwnt or present or fuWre building occupant need to file antl
certily a Business Plan for emergency response to release or threatened
release of a hazardous material? ❑ Ves ❑ No
(Section 25505 of lhe California Health and Safety Cotle requires, vnlh some
exceptions, thal a Business Plan be filetl with the Costa Mesa Fire
Department by every business which has at any one lime during a reported
year a quantiry of hazardous matenals equal to or greater than a weight of
500 pounds, or a volume ot 55 gallons, or 200 cubic feet of wmpressed gas
at standard temperaWre and pressure).
2. Does or will the applicant or present or future building occupaN need to fle
a registretion form for acutely hazardous materials7 ❑ Yes ❑ No
(Seclion 25533 0l lhe California Heallh and Safety Code, with some
exceptions, requires reqistretion with the Costa Masa Fire Department by
each business which at any one time has on hand a quanlily 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 compresseC gas at stantlartl
temperatwe and pressure).
3. Does or will the applicant or present or future builtling occupant neetl to
prepare an RMPP (Risk Managemem and Prevention Program tor acutely
hazartlous matenals)? ❑ Ves ❑ No
(Seclion 25534 of the Califomia Health and Safery Code provides that the
Costa Mesa Fiie Department may require the preparation, certification and
filing with the Fire Department ot an RMPP by businesses which are requiretl
to register acutely hazardous materials wiM the Fire Depanment.
4. If an RMPP is presently required, has Section 25534 of lhe Califomia
Health antl Safery Code been fully complied with? � Yes ❑ No
5. Dces or will the applicant or present or fuWre building occupant require for
the work which is Ne subject of this application a permit for such construction
or modification from the South Coast Air Quality Management District or from
any other air pollution wntrol tlistrict or aqency7 ❑ Yes ❑ No
(Sectbn 65850.2 of Ihe Califomia Govemment Code requires lhal the requesled
informatbn be fumished on appliwtions fa 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 ❑ No
(If yes", the facility must meet [he requirement of Sections 25534 anC 42303
of the Califomia Health and Safety Code).
7. It a permit from Ihe South Coast Air �ualiry Management District or other
air polWtion control disMct or agency is required for the work which is the
subject of ihis application, have all of the disclosures prescnbe0 Dy California
Health and Safety Code Section 42303 been made? ❑ Yes ❑ No,
8. �(It'yes"; attach certificate of compliance from the appropriate air polNtion
control offcer). � - .
CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury. the
information given above is cortecl. I agree to comply vrith all state laws and
city ordinances regartlinq Hazardous Matenals antl Emissions. " '
Signalure . Oala . ,
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalry of perjury that I have read lhis applicalion and state that
the information given is covect I agree to comply with all state laws and ciry
ortlinances relating lo�building construction, and authorize representatives of
the City ot Costa Mesa �to enter upon the above4escnbetl property for
inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permit until fnal inspection. _
SignaWreol gaiOw eqs) Da
�r»,,� �% ���j d od�
AnOlorAuf onEe0A001iwn1 ate
r
(714) 754-5273 • Faz (714) 754-4656 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626
BUILDING PERMIT
Job Address: 976 W 17TH ST
Suite:
Vicinity: SIDE OF PROPERTY
Parcel Number. 42437110
Applicant: ANDERSON, GARY
Address: 164 E WILSON
COSTA MESA, CA, � ' '
Owner. SALCIDO, DAVID L
Address 954 W 17TH ST �
�
� COSTA MESA, CA �� : -
i , " . i, .
Conuactor: ANDERSON MASONRY
Address: 164 E WILSON ST
� COSTA MESA, CA
Zip: 92626
Arch :
Address:
2oning:
Phone: 949-689-3858
Zip: 92627
Phone: 949-548-0358-
Zip: 92627-4403
Phone: (949) 6893858
License: 739159
Eng:
Address:
Status: ISSUED
Applied: 08/O6/2002
Issued: OB/O6/2002
ISSUED BY: �
� � � " � . . .
�, Phone: � Phone:
Zip: � License: License:
� _ , SCOPE OF PERMIT � � �
� CONSTRUCT 120 LINEAR FEET OF 6-Ff HIGH BLOCK WALL ON RIGHT,PROPERTY LINEPER CITY STANDARDS. WALL
IS SET BACK A MINIMUM OF 20 FEET FROM FRONT P.L. � � �
Plan Check: $54.11
Permit: $83.25
SMIP Res: $0.00
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
Total: $137.36
SETBACKS
MAIN STRUCTURE Front 0. 0
ACCESSORY Front 20. 0
PARKING Existinq: p.
NOTES:
Rear 0. 0
Rear 0- 0
Required: 0
FEE SUMMARY
- Calc Valuation:
� � ' " Claim Valuation
PLANNING 8 ZONING
Left 0- 0 Right 0- 0
Lek 0- 0 Ri9ht 0- 0' �
Proposed: 0 �
s2,aoo.00
$o.00
NOTICE: The work authorized by this permit shall wmply with all applirable handicap access requirements under 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 period of 1 BO days.
INSPECTIONS: In order for ihe work authorized under this pertnit to be considered legal, such work must comply with all applicable codes, and all
requtred Inspectlona and final epproval must be obtained. Failura to obtain inspections and (inal approval will result in the axpiration ol this permit.
FOR INSPECTIONS CALL: (714) 7545626 _
�
WORKERS'COMPENSAnON DECLARAnON: - �
I �ere6y eHirtn under penalry of perj4ry one of the tollowinq declaratlons:
❑ I heve end will meintaln a certlFlcate ol consent lo sell-Insure lor workers' compensetion, es proNded for by section 3700 01 the Lebor Cade, tor Ihe peAortnance of the
work tor wtdch this permi� is issued. .
❑ I heve enG wlll maintein workerg' �mpensatlon Insurence, fls requlred by section 3700 0l tne Lebor Cotla, for the pertortnance of ihe work for which Ihis pertnit is IssueO.
My workers' wmpensation Insurance cerrler end policy number ere:
Cartier.
(7h/s si
In Ihe
WARNINO: FNWRE TO SEWRE
nquSnrvD ooLLARE Rlao.000l.
LICENSED CON7RACT0
I herehy aHirtn thet I em lic
fo[cB.end� Uc.�
contrectots'Stp9eWrA: _
Policy Number.
i rk f r w�lch Ihis permit is issued, I shall not employ eny person in any manner so as lo become suD�ect to ihe workers'
e e het II I shoulC Eecame subJect to ihe workere' compensation provisions oi Sedion 3700 ot (he Lebor Cotle, i s�all torthwlth
/ �t'e.��� � ���/ % �
XM1P NSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECf PN EMROVER TO CWMINAL PENqLTES FND CML FlNES UP TO ONE HUNDRED
TO THE COST OF COMPENSITION, DAMAGES AS PRO��DED FOR IN SECf10N 310fi OF THE UBOR COOE, IMEREST, AND ATiORNEYS FEES.
(crommencing vnih Section 7000) of Division 3�he Bus o'ess �ptl PrqtqS�Code, flnd my license is in full
61ass�#� /� 7/T
�ii oe�e'-6<6 -' G L
CONSTAUCTION LENDING AGElLCy: �
❑ I hereby ettlrtn Ihat there is e constructlon lending agoncy lor Ihe peAormance ot t�e work for which Ihis permlt is issuetl. (Sec. 3097, Civil Code).
Lentlefs Nflme: Lenders Atldress:
Signeture:
OWNER-BUILOER DECLARATION6:
Date:
I hereby amrm t�at unCer penelry of per�ury Ihet I em EXEMPT FROM THE CONTRACTORS LICENSE LAW tor the following reason (Sec. 7031.5, Busineu and Professions
Cotle: Any Gry or counry which requves e permu ro construcl, elter, improve, demolis�, or ropair any sWCNre, prior to its issuance, also repWres t�e epD����t tor such pertnit
to flle e signed stetemen� that he or she Is Ilcensed Dursuant to the D�ovlslons ot tfie Contrecrors lJcense Lew (C�epter 9(commenUnp wit� Section 7000) of Division 3 of ihe
Business end Proteulons Code) or Ihat he or she Is evempt iherefrwn and Ihe besis for Ihe elleged exemptlon. Any violatian af Secllon 7031.5 by eny appllcant for e permit
suDjects Ihe epplicant lo a cNil panelry ol not more than Ilve hunCred dollars ($500) J:
❑ I, es owner of the properry, or my employees with weges es their sole compensation, WILL DO THE WORK, end the structure is not intentled or offered for sele (Sec.
7044, Business and Professions Coda: The Conirectors License Law does not apply �o an owner of property who builds or improves theraon, and who does such work
himself or hersel( or ihrouqh �is or her own employees, pmvidetl that such improvements ere not Intendetl or oNered for sale. If, however, the building or impwvement is
sold vnthin one year ot completion, tha owner-bullder will �ave the burtlen ot proving that he or she tlid not build or improve for purpose of sale.).
❑ I, es owner of tha property, am E%CLUSIVELV CONTAACTING WI7H LICENSED CONTRACTORS to consiruct the project (Sec. 704a, Business end Professions
Cotle: The contractors Llcensa Law does no� appty to en ownar oi property who builds or Improves ihereon, antl who contracts tor suU pm�ect wii� e contractor(s)
license pursuant to the ConiraCtors License Lews.).
❑ I em exempt under sec. Business end Professions Cotle lor ihis reason:
Signeture: Date:
Owner ID vanlied by drivers license. ❑ Yes ❑ No Drivefs License No.
Vedficaffon of Ownarship by (type o( Aocumem, f.e. - property fex bltl or Eeetlj: �
Explres:
DIVISION OF INDUSTRIAL SAFETV pERMIT CER7IFICA710N:
❑ I hereby certily t�at no excavetlon five (5) or more leel In dapth Into which e pereon is require0 to descend, wlll be made in connectlon wlth work euthorized by Ihis
permit, antl ihat no building siNcture, sceHolding, ielsework, or tlemolition or dismentling thereof, wlll ba more then ihirry-si: (36) leet high. (Chep. 32, Grp 2, Art 2, Sec.
341, Tltla 8, Calitomia Administrative Code).
❑ As owner-builder, I will not employ anyone to tlo work w�ich wauld require e permit trom the Dlvision ot Industnel Sefery, as noted ebove, unless such pereon hes e
pertnit to do such work frwn the divlsion.
Signature: Date:
Division of Industrial Safery Pertnit Number:
CEHTIFlCATE OF COMPLIANCE AND AUTHORIZA710N OF EMRV: I certity untler penalry at per�ury Ihet I have read this epplicatlon entl stete that the iniortnation given Is
cortecL I egree to comply with ell stete lews end ciry ordinances relaling to Cuiiding construIXlon, end euthonze representelives ol the Ciry at Coste Mesa to enter upon tha
ebove-descnbed property far insp�ion purpose9. I egree not to occupy or ellow accupenty of eny builtling authorized by tNs pertnil until Mat inspection.
GOUE �,
1616
1268
200
Fi:ed Sysiem Final Fire PrOveniion
Pool Spa Final
Final RaRoot
201 FInaI8lock/Retaining Well
202 Final Fedory Fire Place
203 Final Sign
204 Final Demolition
�.1 J11.
�J � �L /IJ
�
j�QQjj INSPELTIONTYPE
206 Final Mechanical
208 Final Plumbing
210 Final Electrical
2tt Final Fire Prevention
zzo
222
Final Planning Apprwal
Final Site
250 FlnalBullding/Ocapancy
�
PAIF. I�L$
�� r =.
' 1HI5 SKET�I LS FOR tNFORMAT[ONAL PURP066
OMY. APPIJCANi LS RFSPOI�SIBIE FOR PROVIDQJG
AN ACCURATE REPRFSINiAT70N OF Tt�t PROPFRIY
IN CaSE'fliE SHAPE AND 97E DO NOT ODRRffiOND
WCI}i 7HE INPPRMA7ION PROVmID ON 7i� g�Eil'.
�
,
�
�
. `�,-r,•~``r1' V7rJ71'
�:.�_ +�L ,1.'i
GJiTf�i' 0F ��A �h�y
�,�I� ��.
a��e� i� ���. �€$i: �
i . ;
• SOIID WALIS/FENQ�S BEIINFIIV 76' k b' W FffIG7i1' 9iAl.i
BE SELBAIX AT IFASi 10' FROM FROM PIODPEMY lAlE
• 90IID WA1L5/FIIJ�55EUL. NOT ID(� 7 6• IN F�7Qii
WSI}�J lOOF iHE FROM PROPIItTY IAIE �iQf CVRH UNE).
` VERIFY DSI'AN� FROM NRH TO PA�PERIY IQiE
MIDgtOWONPIaN. VERQ7GIIDNFAOMTt�QIY'S
HdGWFBtING D1VffiON LS REQiIOtFD. CAIi QiQ 75/,9U
P�R QdFORMATION.
---�—«-.
a-a�a-
a�
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= r ��,a� �c�iS"��i'�'��' a
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' ---••—
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BLOCK WALL L
:: P
, !,�i
���
�
7,:�,���
��
A
•------•---•••- �
�
--�
� �`��� nAnr��n��
ADDITIO��PROVED 8 Tf{� �� �a� I� �� 5�"`��
BE ,
MMHct�i�tn�� �
�
. I i�:�( �_:, _-
:.•
TYPICAL 6�� CONCRETE BLOCK FENCE
Cemenl CoOing OP�ionat —
CMnnelBbck Wi�h 1�3/B�
Horiiontat Top ol all
FeneH
For Fencn 5' or �eu
Ven. Bari 7/8"� al <' -0" O.C.
For Fenta� Higher Than 5'
Ven.Ban 3JB"� a� 37" O.C. �
F�11 Cells $olid Wi�h Grau�
WAere Steel Occurs
qc�nimcing Sleel Shall
Conlorm lo Sec.A�15�79
A.S.T.M.
All Sleel lo be Lapped
10" or to Code
NATURALGRADE
7W07/0"09Aq5 �
CONi1NU0U5 TOV I
6 BOTTOM _r�
L
NOQ�LSTEEL MUST BE TIEO �N
PLACE 4T TIME OF ipENLN
INSPECTION.
1
0
—NIOTH
SEE CNa
BEIOW
WIDTH . , �q"
iHICKNESS 10��
OEPfH OF EARTNTOOTM� 24�
SPACING OF EARTHTOOTH 12'
FOOTING REQUIREMENTS CHART
14
10"
20"
I4�'
BUILDINC DIVISION
12-
9`
i 6,�
16'
.. . .'� .
:f.
. � '" .
GENERAL- NOTES
MOFtTAR: p�e Part Plasfie Cemenl, and
Three Porft Sand
GHOUT: OnE Port Cemenl Tlvee an0
O�e Halt Ports �and
COPING: One Po�f Cement, Three
Ports Sond
CONCRETE: Well Miaed 1:2- I/2: 3- i/2
Mor of 7-I/2 Golians of '
Waler Per Sack ol Cemenl �
GROU� MAY BE POUREO iROM THE �OP .,
OF TNE FENCE IN LELLS WHERE STEEL �� �
OCCVRS.
CELLS ANO AREASOF HOHIZONTAL REIN
FaRCEMENT SHALI BE CLEAR, CIEAN 6 ,
FHEE OF ALL MOPTAR DEBRIS, ETL.
11 (.�' C4FTHTCO�H
v� h�E NEiGTH Or rEHCE
BE–LOW BOiTOM OF IOG1iNG
SCALE: 1/2° = I�
12'
9"
I 2"
i6'
� :;=* .�n. "a°�'
•..7 ,...
y 1 � 4::
� 'n ;',a�., . .
,.
� ' ° �:i"-� t..
�,
! _ . .. �
• t . .. . .. ".
i /
CITY OF COSTA MESA
BUILDING DIYISION
DEVELOPMENT SERVICES DEPARTMENT
PERMIT
(714) 754-5273 • Fax (714) 754-4856 • www.ci.cosia-mesa.��LDING PERMIT �
Job Address: 97s W � � ���
Suite: A
Vicinity:
Parcel Number: 42437110
Applicant: LIEBHERR,TOM
Address: 17066 PALMDALE ST
HUNINGTON BEACH, CA
Ownec SALCIDO; DAVID AND LAURA
Address 954 W 147TH ST ,
CM, CA
Contractor. PRIMO ROOFING
Address: 17066 PALMDALE ST
HUNINGTON BEACH, CA
Zip: 94627
Arch :
Address:
Zoning:
Phone: (714)841--0456
Zip: 94627
Phone: 949-548-0358
Zip:
Phone:, (714)841-4456
License: 331120
- Eng:
Address:
NUMBER
B00-01464
77 FAIR DRIVE, COSTA MESA, CA 92626
ISSUED BY:
Status: ISSUED
Applied: 09I18/2000
Issued: 09/18/2000
Phone: , , Phone: - �
Zip: License: , License:
SCOPE OF PERMIT
TEAR OFF ROCK ROOF AND INSTALL i-28L8 BAS,E SHEET, 2�F71 �PLY AND 1-75LB FIBERGLASS CAP SHEET.
FEE SUMMARY ' .
Plan Check: $0.00 �,,, Calc Valuation: g2,n2.00
Permit: $83.25 — Claim Valuation: gz,n2.00
SMIP Res: $0.50 � � � �
SMIP Com: $0.00
Other: $0.00
Inspection: $0.00
�,
Total: $83.75 � � � _ � �
� PLANNING & ZONING � �
SETBACKS '� � � ' �" � � �
, ',
MAIN STRUCTURE Front 0�0 ' - Rear 0- 0 Left 0. 0 � . Right �0- 0, ���
- , . . - � - ' / j
ACCESSORY Front 0- 0 Rear 0- 0 Left 0- 0 Right 0- 0 ' �
PARKING Existina: . 0 � Re uired: o � Proposed: 0 � -,,�
NOTES:
NO710E: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. N0. 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 oi 180 days.
INSPEC710NS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspeetlone and final approvel must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. �
POR INSPECTIONS CALL: (714) 754-5648
246646 (NW)
� � .
WORKERS'COMPENSAnONDECLARAnON:
I hereby affirtn untler penalty of perjury one of ihe tollowing declarations: � .
❑ I heve end will main�ain e certiticate ot consent to self-Insure for workers' compensatlon, es providetl for by sectlon 3700 of the Lebor Cotle, tor the peAormance of ihe
wark tor which this permit Is issuetl.
�� I have end will maintain workere' compensatlon insurance, as requiretl Dy section 3700 ot the Lebor Code, for Ihe peAormance ot the woAc for w�ich ihis permit is issuetl.
� My wor/kers' compensation Insurence cartler end policy number are: /'� � C7p?� /
Cartier: �/�L^�%�ti��/f}" PoliryNumber.(ivCG3/p_.yp�cp
(This sect on need not be can0lefed i! the permit is velued at ane hundred tlollero ($100) or /ess.)
❑ I certity Ihat in ihe paAormance ol tha work tor which Ihis pertnit is issuetl, I shell not employ eny person in any menner so as to becane suDjact to the workers'
compensetion laws of Celllomla, end agrea that if I s ould be ome s ���c1 to t�e workers' compenution provisions of Section 3700 of ihe LeDor Code, I shall foMwith
�comply with these E vi ' //k^�5--_� // q //
�AppliceniSigneWre: � �f/i!� d ��� Da19,� / / � �/0�
WARNING: FAILURE TO SECUR WORKERS' COMGENSATI ODVERAGE IS UNLAWFUL ANO SHP1l SUBJECT�AN EMPLO'Y R O CRIMINACPENALTIES AND GVIL FINES UP TO qJE HUNDRED
THOUSFND DOLURE (5100,000), IN ADOITION TO THE COST OF COfdPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3]OB OF THE LABOR CODE, IMEREST, AND ATTORNEV'S fEES.
LICENSED CONTRACTORS DECLARATION:
I�m lice�ed'ntler prQvisions ol Chapter 9(commencing with Section 7000) of DiN51oo-3oL1 ie Business and Pmf ns CoAe, and my license is in full
�f�� - �Cass'a`- t��
�re: �! _ // . i �Dete O }r'i
i I �
CONSTRUCTION LENDING AGENCY:
❑ I hereby aHirtn that there is a consiruction lending agency br ihe peAormance oi the work for which this permit is iuuetl. (Sec. 3097, Civil Code).
LenCer's Neme: Lender's Address:
Signeture:
OWNER-BUILDER DECLAHAiIONS:
Date:
I hereby aHirtn ihat untler Denalty of perjury ihat I em EXEMPT FROM TliE CONTRACTORS LICENSE LAW for Ihe following reason (Sec. 7031.5, Business end Protesslons
Code: My ciry or counry whic� requires e pertnit ta construct, alter, improva, tlemolish. or repair eny slrucWre, D�or ta its issuance, also requires the aD7���ent for such pertnit
lo file e signed statement that �e or she Is Iicensetl pursuent to the pmvisions oi the Coniradors License Lew (Chepter 9(commendng wlth Section 7000) of Division 3 ot �he
Business end Protessions Coda) or I�et he or sha is exempt thereirom and the basis for Ihe alleged exemption. Any violation oi Section 7031.5 by any epplicent for e permit
subjecis ihe epplicant to e civil penalty oi not more ihan five hundred Aollars ($500)J:
❑ I, as owner ol Ihe properry, or my employees wi[h wages as their sole compensalion, WILL DO 7HE WORK, en0 the strucNre is not intentletl or oHeretl for sale (Sec.
7044, Business and Professions Cotle: The Contractors License Lew tloes not epply Io an owner of property who builds or improves Ihereon, end who does such work
himself or herself or Ihrough his or her own employees, provided that such improvements are not Imended or oflered for sale. If, however, Ihe building or improvemem is
sold within one year oi completion, the owner-buiider will heve ihe burden of provinq thet he or she did not build or improve Por purpose of sale.).
❑ I, as owner of Ihe property, em E%CLUSIVELY CONTRACTNG WITH LICENSED CONTRACTORS lo consiruct Ihe project (Sec. 7044, Business anE Professions
Cotle: 71ie contraqors License lew does not epply to en owner of property who builtls or improves thereon, entl w�o contracis tor such proJect with e contractor(s)
license pursuant to the Contradors License LewsJ.
❑ I em e:empt under sec.
Signature:
Owner ID verified by drivers licensa. ❑ Yes ❑ No
Business and Pmfessions Code tor this reason:
Vedficetion ot Ownership by (type ot tlxumem, i.e. - properry tax 6ill or tleeA):
DIVISION OF INDUSTRIAL SAFETY PERMR CER7IFICATION:
DriveYS License No.
Data:
Expires:
❑ I hereby certify that no ezcevatlon five (5) or mora feet in depth into which e person Is required to descantl, will be mede in connection with work euthodzetl by this
permit, and ihat no builtling siructure, stattolding, falsework, or demoli�ion or Uismantling thereof, will be more than ihirty-six (38) leat high. (Chap. 32, Grp 2, Art 2, Sec.
341, 71tle 8, Celifomia AdministreNve Code).
❑ As owner-builder, I will not employ anyone to do work w�ich would require e pertnit trom t�e Division ot Intlustnel Satery, es notetl above, unleu such person has e
pefmi� to tlo such work from Ihe division.
Signature: Date:
Division oi Intlusirial Safery Permit NumGec
CERTIFlCA7E OF COMPLIANCE AND AUTHORVATION OF ENTRV: I certily under penalry of perjury Ihat I have reatl this aDPlication and state Ihat �he inlortnation given is
wrrect I agree �o comply wlth ell stete lews and ciry ortlinances releting to building conswction, and authorize representatives of ihe Clly of Coste Mese to eNer uDon Ihe
ebove-descnbed property for inspactian purposes. I e9ree not ta accupy or allow occupancy of any building authonzed by this permit until finel inspection.
COOE �. INSPECTIONTYPE
1616 Fised System Final Fire Prevention
1266
200
201
202
203
204
Pool Spe Final
Final Re-Roof
Finel Block/Reiaining Well
Final Factory Fire Place
Finel Sign
Final Demolition
PAIE V�69
c '��
COOE 1 INSPECTION TYPE
208
208
210
212
220
Final Mec�anical
Finel Plumbing
Final Electrical
Flnal Flre Prevention
Final Planning Approval
222 Final Site
250 Final Builtling/Occupancy
Date
PR0.IECT AUGHESS: 9 7 6 W 1 7 TH ST
OWNEH'$NAME:CRAIG H, �.J�'E
aooRess:954 W 17TH ST
COSTA MESA
CA 92627
AHCHIENGINEEH:
AOUXESS:
� T UNIT:
�i±���y �
_ ��� . �
' ''. >
PEG.NO.:
UNIT:
PEBMITTEE: CRAIG A. AASE ( 714 ) 548-0358
aoosess: g54 W 17TH 5T
COSTA MESA CA 92627
LICENSEO CONTBACTOB OECLANFTION: I hereby aifirm ��a� I am licensed untler O�ovisions ol ChaD�er 9(cOmmencing with Section
7000� o� �ivision 3 oi Ihe Business and Pm�essions Coae, antl my license is in lull force and e��eci.
CITY LIC.: STATE LIC.: CLASS: .
Daie: SignaNre:
WOPREHS' COMPENSATION OECLAPR710N: I hereby aifirm Ihat I �ave a cehifiwte oi consent to sel4insure or a cetlificate oi Workers'
Compensalion Insurance. or a renifie0 copy ther¢oi (Sec�ion 3800. Lab. C�.
POLICY NO.: E%P. ORTE:
camraNr:
❑ Cerlilietl capy is hereby furnishetl. ❑ C@pi�ietl copy is liled with �he ciiy BuilOinp Oivision.
Jale: ApplicanL
E%EMPTION FBOM WOBNEAS' COMPENSATION UEQppqTION: (This seciion neetl no� �e cam0lelea ilihe permi� is far one hunare0 (S1W) or less�.
I cerlity Iha� in �he per�ormance ol �he work for which this permi� is issued, I shall no� e loy any person in any manner so as Io become
subleq �o t Warkers' Compp� alion Laws of f,alifomia. p
Oate� SignaNre: � � ���
NOTICE: II, afler making Ihis Oeclaration, ypu should Decome SUGIeci � �e Workers' Compensation Omvisian5 0l ��e labor
CoOe. you must lorinwith comDly with such pmvisions or Inis permit shail be deemeU revoke0.
CONSTflUCTION LENUING AGENCY: I here6y dllirm �ha� Ihefe i5 a constmciion IenOing aqenty �of the pehOrmanCe ol Ihe work �or
which Ihis permi� is issued (Section 3097. Crv. f,�.
LENDEfl:
pU0XE5S:
i
OWNEB BUILOEB OELLAflFTION: I here�y affum �Aat I am exempl imm the Contractors' State License Law tor t�e tollowing reason
�Seclion 7031.5 Business antl Pmlessional Code: Any city o� counly which reQuires a permil �o con5�mci, alrer, impmve, tlemolish, or
repair any slmcWre. prior lo its issuance, also �eQuires I�e aDPlicant �ar such permi� lo lile a signe0 s�alement thai he/s�e is licensetl
pursuam m �Ae pmvisions ol Ihe Conlracmrs' S�a�e License Law (Chapter 9(commencing with Sectian 7000) of Oivision 3 0l IAe Business
an� Pmlessions Cotle) or Iha� he/she is exemp� �herelmm and ��e basis lor t�e allegeE exempiion. Nny violation o� Section 7031.5 by
any apDlicant tor a permi� sublec�s Ihe applican� to a civil penally of no� more than �ive �unU�etl tlollars (5500�.
I, as owner oi I�e pmpeny or my emplayees wi�h wages as �heir sole comDensation, will tlo Ihe work, antl �he
,� slmcWre is no� in�entletl oro��ereA for sa�¢ (Sec�ion 7044, Business anU Professional Code: The Contractor5' State License Law
tloes no� apply Io an owner o� a pmpetly who �uilds or improves thereon, antl who tloes such work himsel�/herseli o� �Amugh
his or her own employees. provitled �hat such impmvemenls are not intentled or offered �or sale. I�, however Ihe huildinA or
improvemeni is sold wilhin ane year of tompletion, t�e owner will have �he hurden of pmving Ae/she tlitl not build or imDmve
lor the ourpose ol sale�.
I.as ownerofihe p�openy.am exclusively coniracting withlicensed coniractorsta consimcit�e pwle��lSection 706d. Business
❑ antl Pmiessions COUe: The Contrac�ors' State License Law tloes noi aDON �a an ovmer o� pmDeM who builas or impmvu Ihereon
ana who contraQs br Such pmlet�s wi�h a conVacior�s)license pursuan� �0 �he ConVaclorY Sla�e Litense Law),I am aware
�hat proof of ��eir Worker's Compen5ation insurance should be pmvitletl to me.
� I am exempt untler Section�, B. 8 P. C.
br �his reason:
oa,e 2 i�� j f 3 ��e�.
I tlo �ereby cetlity �hat I am aware of antl under9iand the reQuiremenls of Califomia Heallh an0 Safely Code SeC�ions 25505, 25533, and
25530 an0 tha� I or any luture building occupan� WiNwill nol (cucle one) need ta compty wilh saiE Sla�e waes ana �he requiremenis for a
permit lor cons�mction or mo0ilicalion Irom�he pir Oualily Managemen� OiStncL ResiCeniial constm[tion applica�ions are exempt �mm
IheSe pmvision5.
�ale'. ADPlicant:
I hereby cetlify Iha� I have reatl Ihis application and 51aie Iha� Ihe abave in�ormalion is correcL I aA�ee b comply wi�h all city antl county
ortlinances and 5latelawsrelaiinglo builtling cons��uc�ion an0 here6y au�horize represen�a ives o�ihis cirylo en�erupanlhe ahove�mentianea
pmpetly �ar inspecim/n pLurposes. � /�
�a�e: ��L/ � Signa�ure'. � ry �
,
�rive�'s License o� Sociai Securi�y a: '
i6u1-a6 Whi�e—Builtling; Grem—Cotle Enforcemen�; Canary—AOP��canL Pink—Revenue: Goldenrotl—qssessor
CITY OF COSTA MESA — BUILDING PERMIT PERM NO; P 061098
PEkMIT NO: P 061098 PLAN CHECK NO; N GOVT: N SUPP; N
CONSTRUCTION TYPE: 5—N PERMIT TYPE:`PLU PURPOSE; OTH
JOB DESCRIPTION : INSTALL FOUR {q) WATER HEATER5 SQ FT;
CLAIM VALUE; CALC—VALUE: GROUP OCC; R-1 /
COMMENTS; INSTALL FOUR (4) WATER HEATERS IN A FOURPLEX,
+�********��*�r�r�**xx*�r*�r*���***�x*�r��*x*�r**�r�***�r�**���***�*�x x*�***« x��*����**��
Z O N I N G R E Q U I R E M E N T S
S E; T B A C K S
------------ MAIN BUILDING ---------- --------- :9CCESSORY BUTLDING ---------
FRNT; FT ZN REAR; FT IN FRN'f; FT IN REAR; FT IN
LEFT; FT IN RGHT; FT IN LEFT; FT IN RGHT: FT IN
PARKING REO• � PROV; PARCEL; 92437110 ZNE; REF NO:
PLANNING NtST'ES>
i
*�x��*�r�*�������*�*�,«***x�*+�*�*�***�****�*�,��**�`*.x �*���*,�,�**,�*�r��***x�*���*���*�
D E V E L O P M E N T S E R V I C E S';� R E Q U T A E M E N T S
20NING APPROVED BY �% DATE;
BUILDING APPROVED BY ; �� DATE;
APPLICATION ISSUED HY: . ` .��1�L DATE: ��
1E iE iE it iE i! iF jf iE if 1E iElElE 1E if iF 1f if 1F # iE iE iE 3E 3E iE �1l� �E-lF 3F 3FiE iE iE �E iE iF iF iF iE i(� If 9E �! iE �� iE if iE IEif iE if i! iE if i(� iF iE iF if i6 �%iE it if iF iE �F iE it �E 3F if iE �f
LEGALIZATION;N F E E S U M M A R Y STRUCTURAL SEGMENT;N
BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING
PERMIT 28.00
253 SMIP/NON—RES
PLAN
ISSUE FEE 20,00
BUILDING—DIV—> PERMIT ISSUE PI,AN—CHECK TOTAL PAID DUE
TOTALS----> 28.00 20,00 0.00 48.00 48.00 ,00
REVENUE DIVISION TOTALS--> COLLECTED; 48,00 OVER/SHORT; .00
HLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECX
98.00
1E if if ff iE iE iE �E 3E iE iF iF iF iE iE 1F iF iE iE jE if 1E jE iE iE �k if jE iE �k �f iE �t jk if j(� k iE iE 3F if iF 3f iE if 3E �k �E �E iE iE %� iF iF fE �k iE �E iE * dE 3E iE 3f 3E iE iE iE ib ff iE jE iE X-jF 3E iE 3E jf
I N D I V I D U A L F E E P R E A K D O W N
TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST
PLU 4 WATEft HEATER AND/OR VENT 7,00 28,00
END OF FEES
I
.���—.�. � �
��� � ' �� F
FEB 2 Q 19�3 ' �
CfT� e�;;���A �JESA
� "3 �
CONSYRUCTION AND PLANNING POOL 'A '
APPROVALS Permit # Date Inspector APPROVAIS Permix � Date Inspector
1. Tempo�ary Eiecvical Se�vice or Pole 52. Poo� & Equipment Location �'
2. Soil Pipe�Undrgrnd. 53. Steel Reinforcement "
3. Eiectrical Co�du�t Utility�Undrgrnd. � 5A. Forms � ' i
4. E�ectrical Conduit-Und�9�nd. 55. Elect�ical Bonding
5. Steei ReinSorcement � 56. Rough Piumbing & Pressure Test y
��� ElActrical UfEft Gmd, 57. APPROVAL TO COVER-GUNITE
7. Foot�ngs . 58. Electrical Conduit•Undrgrnd.
8. Foundation � 59. Gas Pipe, 0 Undrgrnd., Test
9. VJater Pipe-Undrgrnd, 60. Backwash Lines, P�Trap, � Undrgrnd. .
70. Structural Floor System 67. APPROVAI TO DECK '
11. Property Sewer �ine & House Connection 62. Backwash & Receptor-Final
1?, Sewer Cap � 63. Heater & VenFFinal ' +
13: Roof �rains . 64. Plumbing Syscem • Finat ,
14: Rough Plumbing 65. Electrical-Fina� ' �
15.�Ro�gh ElectriGai-Conduit 68. Solar System-Final . '
}' i6.� Rough Electric Wiring 67. Fencing & Access APprovat . �
17 �Rough Wiring Sign 68. APPRdVED FOR PLASTERiNG
18. Rough ElectricaFT B' � Ceiiing 69. POOL/SPF> SYSTEMS PINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT �
P
20. Rough Factory Fireplace APPROVALS Permit �`r
21. Ducts, in Stsucture ' - 70. Underground Hydro �
22. Ducts, Ventllating � ' 71. Product Piping O Gas ❑ Oil
23. Gas Pipe-Rough & Test " 72. Underground Flush
24. Roof Framing � � 73. Undergmd. Storaye Tark O Gas ❑ Oi!
25. Roof Sfieathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical �
27. Frame and Fiashing 76. Dry Staridpipe
28. Lathing & Siding � � 77. FIXED SYSTEM FINAL
i, Insulation � I , 78. FIRE PREV. FINAL
30. Drywall Nailing � � �� HEALTH DEP7. REQUIREMENT
37. Ptaster Brown Coat � . I � 79. PINAL INSPECTION
i
32. Electrical Power MeterFinal � � � 80. FOOD CEflTIFICATE lSSUED
33. Finai Electric " � Notes:
34. Final Neeting & Air Conditioning - I f
35. Frnal Gas Pipe�Test � �
i
36. Hood or Canopy- t
37. Flnal Factory Fireplace � ����� •� �
38. Final Piumbing � �j�Qj;�(aj/�
��.
39. 4Vater 5ervice�Final � � . , �
4Q. Gas Service-Ffnai - � ' } �
41. Soiar pomesucFinaV � ' { -
42. BackflOW P�eventer � �� �-'�
_ �
43. Backfiow irrigation _ . �
44. Landscape Irripation System - � � - �
45. Sound Attenuation � `
46. Handicap Regulations - - � �
I
47. FIiVAL STRUCTURE & BUILDING I �. "- _
48. FINALPLANNING � ��' � � , �"
49: Electric Release 2o Edison � I.• , �--
50. Gas Release to Southem Caiifomia Gas Co I � 'f
51. GERTIFICATE OF OCCUPANCY
No. Date
LIMITEp STATEMEN . JF RESPONSIBILITY
TO WHOM IT MAY CONCERN:
�
Bldg. Permit #
This Permit � � p
y76� v� /7 f �r '�a�l -37�-�0
Street Address AP Number
I, `��t.A+� ,�'e�Zfv , as Owner in Title of the above referenced
property, do hereby authorize:
�17v�o �C� 0-0
Name -
Streel Address
<S"4-�'-0 3 3 �
Telephone No.
.Z Gi7
to obtain permits in my behalf, as owner/builder, for
at the above reterenced property.
Should gpy oerson become an p,¢�p�py.eE. engaged in the improvement of. the property, I shall
immediately provide Worker's Compensation Insurance coverage and cause a certificate of that coverage
to be fileq with the Building Division of the City of Costa Mesa, as required by State of California laws.
As owner/builder in fact, I understand and accept that my responsibilities do not transfer to any other per-
son, company or corporation.
I agree to indemnify and hold the City of Costa Mesa and its employees or officers harmless from any
claim resulting in damage or personal injury to myself or any other parties.
�c�« (�l. ��—
Printed Name
U �
� Signature ,/���
�1 � /
/y.nr.�v�rv.n, ��
DONNA M.THORDSON
���� NOTAHY PUBUC-MINNESOTA
�� � pAMSEY GOUHTY
My Camm.'cxDbes Pug. �9. 1996
� vvWww�vw�',. .i.�.; ,.�: �Mvvv\NvwVVW •
OT/9d6, rBv. &87
Date
I�tOTAR�ATION
R��[IIRED
li" .� s '
. _. _ . _ Applicant to fill in aU spaces entept tpose within heavy Eortler 1(nes anE signl__._..,_,.T_ _ __ � � -
� CPfY OF COST � S CO I�ST TI � .PE MI P��IT NO_ D _� ' TRACT NO. ' LOT NO. : UNIT.NO:;, �' + � , �' „ � � � , �
. Pro'ect Address - '"� �' /'��C � - � " I' F "�
I TYPEOFCDNSTRUC710N ' NEW ADD. ALTERATION REPAIR - �� � �7'S6 q�2.���] o T�
Applicant's Maili Addreis� � -�- ��Gl `' ❑ CONVERSION� � DEMOCISH � ❑ OTH R � q.p, # ' ' ' ' " ' Zone
Owner'sNamef/��/ • 'Phone�%/� .DESCRI TI OFW�,R N EOFeLDG , •'. . .
Addiess � `� ��`J " .� f ' ' S Main BUilding: � � • Accessory_Buildin9:
' � ' _ . . - E � . . . , - � � . Z �
. Archl�ng: � ' Cicense NO. � ' TYP . HMIT � � GRADING^ � -FO NDATION STRVCTURAL � T Front . - • . , p
� Addre55 ' _ � � = TENANT''n%J_ EL_ECTR��IC//� L ❑ PLUMBING ❑ MECHANICAL . � 6 Reaf ' - .. ' � , .
� ��'��� OTHER, �(/U`7TX. / - � i . --. 'A I�•
Contracto7s Nam � � Phone.ay�c�� ' � � ' ' . �. � , ' • � , '
G.. � S� 7� PROJEC7 DESC IPTION Sa. F7: - OCCUPArvCv C Fll9ht N�
A"ddreu (mailing) ' (� �� ' 'K . . _ r G
� �y.O / � ' CONSTRUCTION�TVPE ' � :VALVATIONS.1"�/'l g L¢ft , . � , , ,
i City�icenseNo. e y � _ • ZONE� ' GRADINGGU.V�S. 'ACRES' ' ' � . � . '.� � R
- Ping. Ref. # . . Parking Req:/Provided ' � E
LICENSED CONTRACTOR �ECLARATION '. ' ' ' �
Irheteby affi�m Ihai I am licensetl untle� provislons ot Chdrter 9�(cOmmencinq � Remarks: �- � - . � � Planning Notes: . � . � , � -' n
with section ]000) of �Division 3 of the Business antl Protessions Cotle, antl � ' � M
' mv �icense is in t�y rorc�5an�p etrect. G i , - , � ' � ! . • . ; ' , _ ' ' � T' '
Licens Class -`� — �y- �fi �nse "��'S/G� ' � � ' ' . . . " S'
oate�—�3- 5'9 t tf(��/� : PWMBING • • � - ,FEES � , . ' ' ' � '
woRKEeS'coMPENSnTION� '�ATOI N � � � � BarSink � i SRowers� � ' , • ' . ECECTRICAL . ' , � , FEES � '
� hereby,affirm that I have a certificate of consent to self-insure or a certificate , �
f WOrkers' Compensation �Insuran[e; o�-a�ce�titie copy'thereOt (5ectian ' gAcktlowPreventer ' ' � - SeiviceSink � � � .
..�C//�> �/ � Automatic Washer 7ransformer ❑ 15-50 KW
Pol��ioy �iv�� ��L� �'✓� �y�rlompSny, � Backflow Irrigation i � Sewer Cap � � � Construction Pole Su6. � ❑ 50�+.KW � '
�Certifietl capY �s hereby furnlsnetl. � , ' , • . � � , � - � : � '
C r'fi r�op �s riled with the city � fitlji �g oiy��iei . . � Bathtubs � Sewer Connection � � Cooking Unit � , Meter ❑up to 100 amps
/�pate '��- r APPIi[aM-�--�,f.G-�// ' - . -
EXE PTION�FROM WORKERS' COMPENSATION DE6C.ARATION �-- - Cldflfi2i5. _ � , S012f C011¢Ct0�5_� � _ _ _ �Di5hw35h¢�- �- � - • -. MELB/ ❑Ov¢� 1003rtip5 -
(Thisg¢ction neetl not be completetl if the permit is tor one huntlretl ($100 or � �
tess). � , . , +) Dishwasher ! � � Solar Piping� Dryers �Gas ❑Electric Sub'Panel ' „ �
I certify that In the performance �of the work (or which this permit is issuetl, I , � ' Y
shall not emo�oY any person in any manner so as to become subject to the • ' Drinking Fountains - Solar Tank - � ' Fan � I Momrs �0-1 HP �1 %�8
Work@�s' Compensation Laws of CaHtovniai j • � - ' - � � . ,
�. Date ' ' ' Si9nature ' � ' ' - Floor Drains ' ; f Swimming Pool w/Spa � F.A'.U. � 1 ,
'NOTICE: If, after making this tlecla�aHon, you shoultl b¢come subject fo the i ' - . I�C 5013� 09=75 HP �16-15+
Wo�k@rs' Compensation' pwvisions Ot,the tabor Cotle, You mu5t torthwith' FI00� Sinl(5 -� � U�inal , � �_ Fixtu�¢5' � '
comply with such provision5� or inls permit shall be tleeTetl revoketl. ' � � ' '
Microwave
\CONSTRUCTION; LENDING-/IGENCV� � :. ; ; -- , ' j A .� � - ' � � GaSService', ��Outlets '. Water.Closet ' � � �- i " _ DeViCeBoxeS � - � , �
I hereby�affirm that there is a construction lentling agency for the pe�fo�mdnce ' POIe Light � �
of the work 'for wtiich. this permit is. issuetl,;(Section: 3097 Civ. CJ ' Inte,rcepfors . � _ �Water Neate� -' ' Outlet5 ' , Ran e � �
` Lentl6r's Name. _ , - , ' � 9 '
Lentl6r's AtlOress � ' • - ' � Kitchen Sink ,: � - 'Water Service . � r Switches� � � Sign . • � � i
\OWNER BUIL�E�R OECLARATION . � � ; , �- - . _ = -
I her¢by affilm that 1 am.exempt fYom the Contractor'S LicenSe Law tor the LdvatOfifS � AutO-WdSh G2lba e Di5 OSdI
follo�ying rea5on (Section 7031.5 Business antl Professional Cotle: Any city or - ' 9 P ; Standing Sections
\mun�y which requires a permlt to const�uct, alter, improve, Oemolish or repair, P-TfaP '�' . LdUndry T�ayS ' G2nC�dtO� �0-5 KW 05-75 KW ' � � . -
any Structure, prior to�.its'issuance, also require5 the applicant for such.pe�mit - ' T�dSh COmp3ct0�
� fo (ile a 5iqnetl•statem¢nt that he/she I5 licensetl pursuant to�the p�ovisions oi � ROOf D�2i05 , � �� -'� ' ' � �
� the Gontractor's License Law (ChaOter 9.(mmmencing witn Section �000) of - ' . .
'Divis�on 3 of [he Business antl Profe55ion5 Cotle) br tnat he/she is eK¢mpt _ -
'herefrom antl tM1e basis for the allegetl exemption. Any violation of Section ' ' - „' _ . , , � -
'031,5 by 5ny applicant Tor a permit subjects'the_applicant to'a civil i� - -
�enalty of not move than five huntlretl tlollSrs ($500). - ' ' - ' �
I, az owner of tha pro0erty or my employees with wages as their sole � . Reinsp¢Ction ,Fee '$15 _; . ISSue Pee� � $ 3' � �
'mmpensation, wi11 qo tne work, antl the sbucture is not intentletl or oHeretl , Reinspection Fee $15 Issue Fee' $ 3
(or sale (Section'�044, Business�anE Protessional Cotle: The Contractor's' _ �- ,: MECHANICAL ' FEES -
Liceqse l.aw tloes not apply'to an oWner of'a prop¢rty who builds or improves � '
thereon�, anG wno does sucn work-himself/nerself-or throu9h nis or her own � DEVELOPMENT SEflVICES REQUIflEMENTS: i �
emplOYees, ptovitletl tltat such'Imp�ovements a�e not infentletl or offeretl fo� BOII¢� � HOOd O� Typ¢ I ❑ . � � +
sale. It, however, the buimin9 or improvement is soltl wilhin one year af com- , , Canopy � Type I I ❑�, '" Zoning Approved By Date
pletiryn, the owner wiil have the burtlen ot proving he/sne tlitl not buiitl or im- , Duct - Under Ground ., . j.. Building ApproVed By � Date
prov0 for the purpose of sale). � - i , ,
❑ i.�az owner ot the property, am exUusively contractin9 with licensetl con- . - Duct -Structural Refrigeration System ', ' i . Application luued By_� � Date- j�%
trac[ors to wnsVuct Ine project (Set[ion 7044, Bu5ine55 antl Arofessions Cotle: , ' I ''
The Contracror's �License Law tloes nol appry ro an owner.oYproperty who __ Duct - Ventilating --� - -, 04100,000 BTU- 0�100,000 BTU _ -- , ' � S MM RV OF FEES ' '
builqs o� improves [he�eon, and who conVactS fOr such Projects with a con- - � � � � �/'�
tractor(s) license pursuant�to the Contractor's License Law). I zm aware tnat ' i '� . ' BUILDING PERMIT �$ � . �� SMIP $�
proo{ of thei� Worker'S Compensafion insu�ance shoultl be provitletl to me.� Exh3uSt $y5t¢m ❑ Multipl¢ ❑ .$y5t2m R¢pai�/AItC�2ti0n , ,
• PLAN CHECK $ � PERMIT ' �
� � am exempt unaer Section , B. & P. C. for this reason � Firepl/FacG BIt. ICBO # Fire Dampers PLUM61 NG ,$ ' ISSUANCE '$
Date �� • Owner, ' ' ' � Heating Sysfem & Ducting � i Registers - , PLqN CHECK 25% 3 ENERGV�P.C. $ �
I-tiereby certify tfiat 1"Fave reatl�this application anE state-Mat'the atiove � ❑6100,OOOBTU �100,0006T ' ' � GRADING ;$ �
information is corretL �I agree to comply with all city antl coun[y ortlinances ' EIECTRICAL ,$� . ,
antl.state laws relating'to buil ing construction, anE nereby authorize repre- ' - � i . , PLAN�CHECK 50%� $�' � MICROFILM ,$� � �
senta�jyes oi t',,' y t ei. er upon the above-rnentionetl�p roperty for � ' ' � , . . �7 �
inspection i se % !L__�3�'� � � MECHANICAL � $ ` � �TOTAL FEE $ � ,�j�' , ,
Signgtu' �ate' ,
ReinspeMion Fee $15 , Issue Fee $ 3 PLAN �CHECK 25% $
Drivprs' icense or 5 � � '
� _ �
CMF OBf�S-46, rev. 10/BO White - Builtling; Ganary - Applicanh Pink - Accounting; Goltlenrotl - Assessor �
� CONSTRUCTION AND PLANNING � POOL .,PA
APPROVALS Permit# Date Inspector p�pPROVALS Permit# Date Inspector
1. Temporary Electrical Service or Pole 52: Pool & Equipment Location -
2. Soil Pipe-Undrgrnd. "- . � 53. Steel Reinforcement .
3. Electrical Conduit Utility-Undrgrnd. - 54. Forms . �
4. Electrical Conduit-Undrgrnd. � 55. Electrical Bonding
5. Steel Reinforcement 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. � 57. APPROVAL TO COVER-GUNITE
7. Footings . � 58. Electrical Conduit-Undrgrnd.
8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test
9. Water Pipe-Undrgerid. 60. Backwash Lines, P-Trap, �-Undrgrnd.
10. Structural Floor System 61.� APPROVAL TO DECK
71. Property Sewer Line & House Connection 62. Backwash & Receptor�Final
12. Sewer Cap . 63. Heater & Vent-Final
13. Roof Drains � - 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit � 66. SolarSystem�Final -
16. Rough Electric Wiring - 67. -Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL �
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit#
I1 21. Ducts, in Structure . 70. Underground Hydro�
)
' 22. Ducts, Ventilating . 71. Product Piping O Gas ❑ Oil �
23. Gas Pipe-Rough & Test -, 72. Underground Flush
24. Roof Framing '- 73. Undergrnd. Storage Tank O Gas ❑ Oil
25. Roof Sheathing � . 74. Overhead Hydro � ,
26. T-Bar Ceiling (Structural) & Monocoat � -� � 75. Dry Chemical .
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding � 77. FIXED SYS7EM FINAL
29. Insulation . � � 78. FIRE�PREV. FINAL
30. Drywall Nailing � HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat � , 79. FINAL INSPECTION �
� 32. Electriral Power Mete�-Final � 80. FOOD CERTIFICATE ISSUED
33. Final Electric Notes:
34. Final Heating�& Air Conditioning
35. Final Gas Pipe-Test ' '
36. Hood or Canopy ' ' �- � ,
37. Final Factory Fireplace . I, . - � � - ' . � -
38. Final Plumbing � -
39. Water Service-Final � •
40. Gas Service-Final � - '
41. Solar pomestic-Final � , •
42. Backflow Preventer • . � '
43. Backflow Irrigation � � � ' ".
44. Landscape Irrigation 5Ystem ,
45. Sound Attenuation �
� 46. Handicap Regulations
47. FINAtSTRIJCTURE&BUI�DING f0 8% Olv
48. Special Requirements Completed . -
49. Electric Release to Edison �-
50. Gas Release to Southern Califomia Gas Co .
51. CERTIFICATEOFOCCUPANCY • -
VO. Date
�
_ _ _ __ . ... . Applicant to.fill in.all soaces eaceot-those witMin heavy bmGer lines anG si9n all appropriate Oeclarations. � �
C���UFCOSTA-�CO STRU TIQ�y�PERMIT � i.� PEr�yir1o. - ` -TRACTNO. ' LOTNO. UNITN6:. ,
Project Address y
Applicant's Mailin ddr ss ���� � ��
Owner's Name � Phone7----dp1l
Atldress `�� �� b'HT/d.�a.�x'� �GeJ/ iV�.
ArcH/Eng. �. . License No.
Address � ' � - �'� // � '
Contractor's Nam�p��✓�f��cLlQr^K— Phone��y� �
Addresslmailin9l -7 � �
n r/O, C
City'License No. �
LICENSED CONTRACTOR DECLARATION � �
1 hereby at(irm that �1 am licensetl untler Orovisions of Chaiter 91(commencing �
with section 7000) of Divislon 3 of the Business antl Professions Cotle, and
my license.is in f�11+'I forsy an0 ett¢ct.
License C15ss `�� � ens Sy � r
Date y ���—�� ,Signature
WORKERS' COMPENSATION bECLARATION `
I he�eby aHi�m [hat 1 have a certificate of cons¢n[ to selt-Insu�e or a certiticate �
>t Workers' Compensation .Insurance, or a� certifie{y/c ooY'th��tion •
3800. Lab, y�J� �� � //� �/� �j/�/{�� .
PolicY �1?�•� `� omPan�r/-�
Certifietl mpy is hereby furnished. �, (T �,
Cer[itie ��� iletl with the city ing isi
ate�..l[= APPlica ' •
EXEMPTION FROM WORKERS'-COMVENSAT�10 DECLA TION �
(This sectian neetl nat be compla,�ytl if the pe�mit is far one huntl�etl ($300) or
less). ' ' - � �
I certify tnat,in tlie perto�manCe of the wo�k tor which this Oevmi{ is iSSUetl, 1
zhall not emDloy any person �n any manner so as to become sub�ect to'tne •
Workers' Compensation Laws of Califomia. � .
�ate � Signdture • �
'NOTICE: If. dite� maki�ng tM1is q¢claration, you shoultl become subjett tO�the
'Workers' Compensation O�ovision5 of'the L'abor'Cotle,'you-must forthwith'�
comply with such Orovisions., pr. tnis 'permit shall be tleemetl revoketl. �
CONSTRUCTIOM LENDING AGENCV ' •�• �
I hereby�af9�m thdt theie is a mnitruction lentling agency for the pe�to�rtlante �
of the work .-for •which this permit is' Issuetl (Sectian -.309] Civ. CJ ',
Lentler's Name -
Lentler2 Atltlress - � � ,
OWNER BUILOER �ECLARATION � � ' '
I hereby affirm�.that 1 am exerrypt irom the ConVactor'S License Law (Or the
following'reason (Section 7031.5 Business and Professional Cotle: Any city or �
county which require5 �a permit to ConStruct, alter, ImPrOve, tlemolish ot �epair
-any sVucture, prior [o its issuanc¢, also requires the applicant for such permit
to ti�e a siqnetl statement tnaLne/sne is licensetl pursuant to the provisiOns of
'the Contractor's License Law (ChaO�er 9(commencinq with Sectlon �000) of '
Olvision 3 of the Business and Professions Cotle) or that ne/she is eXempt
-;:theretrom'antl the basis for tne allegetl exemption. A�Y �iolationA! Section
�ic'9031.5 by� any applicant for. a permit subjec[s the applicant to'a civil
" enalty of not more Ihan tive huntlre0 doilar5.($500)., 1 �
� I, as owner of the p�op¢rty o�. my,employee5 with wages as their sole
com0ensation, will tlo the work, antl the'structure is not intentletl or oFferetl
tor sale (Section',7044, Business antl Professional Gotle: The Contrat[or's'
LicenSe Law tloes not apply to an owner of,a property who builtls Or improves
thereon, antl who tloes SucM1 Work,himselt/herselt oLlM1rough his or her own
¢mployees, provitletl that such imp�ovements are not inte0tletl or otferptl to�
sale. If„however, the builtling pr improvement Is soltl wi[hin one year of com�
pletioq the owner wiil have the burden ot proving'he/she tlitl not builtl or im-
prove for the purpose of sale). , ,' . �
❑ 1, ai owne� of •the properiy, am exclusively cont�acting with licensetl con-
tractors to construct tbe Orojec� (Section �064, Business antl Professions Cotle:
. TM1e Contractor'S License Law tloe5 mt apply to an owne[ ot p�operty who._
builtls or improves thereon, aptl wh6 contracts tor sucb projects with a con-
tracto�(s) license pursuan[ [o tne Contrac[o�'S License Law). I am aware that
proof of their Worker's Comp¢risation insurance shoultl be pwvitlea to me.
❑ I am'exempt untler Section- B. & P. C. for this reason �
Date � Owqer
I hereby certify'that I-have reaalhis applicati�on znd state that�the above '
information is mriecL I agree to comply with all citY antl munty ortlinances
antl.state laws relatin9 to buil ing mnsVuction, and,hereby autnorize repre-
sentatives ofr thi city to e � up the above-mentionetl property io�
inspectlon pur es. . .
Dat�—�6 —��
TYPE OF CONSTRUCTION. ' LI NEW .0 ADD U ALTERATION L�iREPAI R" �
O CONVERSION.'� DEMOLISH ❑ OTH R � � Ap #
DESCRIPTIONOFWO�K/USE FBLDG' �'�m-�!l��y �, `�
/�}�f�y' �t" s �5 � ,� �k . _ S Mam Buildin9: ''
TYPEOF RMIT ' GRA�ING FOUNDATION - STRUCTVRAL �: T Frout
' ❑ TENANT� � ELECTRICAI 0 PLUMBING � MECHANICAI.� � �B Rear ' ' �
��OTHER �� � � ' ' - �_ ; I A ' .
� C Pi9ht
PROJECT DESCRIPTION 5� T. � nr�uanNcv K
�CONSTRUCTIONTVPE ' � � �^VALVATION$ ��� 'g Left .•
' 20NE - � " � GRADING CU. VDS. � ACRES � pjng. Ref. �r` �
Remarks: , - � ' , � . � Planning Notes:
. � � I . ' ' - ' , ' ' .
Sink �
cflow Preventer � .
cflow Irrigati0n �
rtubs •
ifieFs __ ... .,
iwasher �, - ,
Floor Drains �
Floor SinkS" �� �
3as Service � ' Outlets
Inreiceptors' i '
Kitchen Sink . ' �
Lavatories "' . '
P-Trap �
Rnnf.flrainc ' -� .
.c - s '
Reinspection .,Fee
Boiler
$15
Duct�-UnderGround . . �
� Duct-Structural �
� Duct--Ventilating ' -
ExhaustSystem ❑ MWtiple❑
Firepl/Fact. Bit. ICBO # '
Heating System & Ducting
- 00-100,OOOBTU �100,OOOBT
Siqnatur
Drivers' License or 55 I � Heinspectian Fee � $15
CMF 0865-46, rev. 10/84 White - gulltling; Canary - ApP���ant Pink - Accounting; Goltlenrotl - Assessor
Showers .
Service 6ink ' � '
Sewer Cap ' �
Sewer Connection , �
Solar Collecrors � ' � �
Solar Piping �
Solar Tank � '
Swimming Pool w/Spa+ �
Urinal � �
Water Close{ � �' �
�
.Water Heater ' � � �
Warer Service � - - �
Auto=Wash . '
LaundryTrays � �
Issue Fee $ 3
Hood or Type 1' ❑ � � : �
Canopy' Type I I ❑ '
4efrigeration System '
❑0-100,000 67U �0700,000 BTl
System Repair/Alteration � �
1
Fire Dampers � � ,
Registers , � � �
1
laue Fee �
9237 4/16%66 `
' _ ' . , Zone :
� Accessorv�8wldma: . �� � �
• ' - � . _
. . T _ _ . , . y. _'
'
' Parking Aeq./Provided� �
AutomaticWasher, �
Construction PoleSuh.
Cooking Unit, � .
Dishwasher - --
Dryers ❑Gas ❑Electric
Fan �
F.A.U. ,
FiztureSl
Device Boxes . �
Outlets , , . �
Switches
Garbage Disposal ,
G'enerator 00.5 KW �5-15
�
ELECTHICAL ' '
Traosformer ❑ 15-50KW I
❑ 50 +�+KW
- ,.,r i
Meter ❑up m 100 amps '
- � Meter-�over 100amps - -
Su6 Panel
Momrs �0-7 HP �1 % -'8 .
Inc.Solar �9-15 HP �76-15+
' Microwave . � -.
Pole Light � �
Range
Sign
; Standing Sections , ,
� � Trash Comoactor .
�
_ _ �.
j�n:C TL
• Z
Ni
��
N'
G'
R '
E•
_ Q
��' M
T
' S-
�
FEES �
i
� Reinspection Fee � $15 Issue Fee " $ 3
DEVELOPMENTSERVICESREQUIREMENTS: '
Zoning�Approved By Date
Building APProved BY � Date��
APPlica'tion.lssued 8y . . Date__ �'���lCfrfrQ
(,1 i. � �� � , .SUM V FEES �
^ ��BUILDING,PERMIT � $ � SMIP � $ � S�
� ,?P�LAN CHECK . ' $ ' PERMIT � �
(�'S �PLUMBING $ ' ISSUANCE $ .
�� ' � ENERGV;P.C. $ �
ij �PLANCHECK 25%• S � ,
'ELECTRICAL � , $ �GRADING $ �
�, i
PLAN•CHECK 150°,6� $ � - MICROFI.LM $ �
: �� �MECHANICAL � f $ � TOTAL FEE � $ IS S�
. 'P,LANCHECK .25% $ � . �
.,
-r.
, �CONSTRUCTION AND PLANNING
,; APPROVALS Permit#�
'1. Temporary Electrical Service or Pole
2. Soil Pipe-Undrgrnd. �
3. Electrical Conduit Utility-Undrgrnd.
4. Electrical Conduit-Undrgrnd:
5. Steel Reinforcement - '
6� Electrical UFER Grnd. -
.7. Footings . �
8. Foundation �
9. Water Pipe-Undrgrnd. �
10. Structural Floor System �
17. Property Sewer Line & House Connection
72. Sewer Cap
13. Roof Drains
14. Rough Plumbing
15. Rough Electrical-Conduit�
16. Rough Electric Wiring .
17. Rough Wiring Sign . -
18. Rough Electriral-T Bar Ceiling �
19. Rough Heating & Air Conditioning '
20. Rough FactorV Fireplace '
21. Ducts, in Structure
22. Ducts, Ventilating '
23. Gas Pipe-Rough & Test ,
24. Roof Framing , ,
25. Roof Sheathing
26. T-Bar Ceiling (Structural) & Monocoat
27. Frame and Flashing
28. Lathing & Siding
29. Insulation � �
30. Drywall Nailing
31 . Plaster Brown Coat ,
32. Electrical Power Meter-Final
33. Final Electric
34. Final�Heating & Air Conditioning
35. Final Gas Pipe-Test , .
36. Hood or Canopy
37. Final Factory Fireplace �
38. Final Plumbing
39. Water Service-Final �
40. Gas Service-Final. ' �
41. Solar pomesticFinal � ,,
i -
42. Backflow Breventer
43. Backflow Irrigation �
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations
47. FINALSTRUCTURE&.BUILDING
48. Special �Requirements Completed �
49. Electric Release to Edison .. -
50. Gas Release to Southern California Gas Co
`51 ;CERTIFICATE OF OCCUPANCY
Date
Date
n
POOL _ �PA
Inspector qppROVALS Permit#
52. Pool & Equipment Location
53. Steel Reinforcement �
54: Forms
55. Electrical Bonding
56. Rough Plumbing & Pressure Test
57. APPROVAL TO COVER-GUNITE
58.� Electrical Conduit-Undrgrnd.
59. Gas Pipe, O Undrgrnd., Test
60. Backwash Lines, P-Trap, O Undrgrnd.
. 61. APPROVAL TO DECK
62.�Backwash & Receptor-Final�
63. Heater & Vent-Final � � -
64. Plumbing SYstem - Final
65. Electrical-Final
66. Solar System-Final
67. Fencing & Access Approval
68. APPROVED FOR PLASTERING
69. POOL/SPASYSTEMSFINAL
� FIRE DEPT. REQUIREMENT
� APPROVALS Perrtiit#
70. Underground Hydro �
71. Product Piping OGas ❑Oil �
72. Underground Flush �
73. Undergrnd. Storage Tank O Gas ❑ Oil
74. Overhead Hydro
, 75. Dry Chemical
76. Dry Standpipe
77. FIXED SYSTEM FINAL '
78. FIRE PREV. FINAL
HEALTH DEPT. REQUIREMENT
79. FINAL INSPECTION
80. FOOD CERTIFICATE ISSUED
Nates: �,jo�- .�,p�an.. y>G ��0.
r
Date � Inspector
I
AOP��cant to flll In all spatts except tnosn witnin heavy bortler Ilnas antl sign all aoo�opriate tleelantlom.
CITY OF COSTA iv]gsA CONS� U TION PERMIT P�,AMIT NO. _ � TRACT NO. LOT NO. UNIT NO.
t
ProjecLAddress ��
Applicant's Mailin drou ' � ''� '� �,^
Owner's Name �Phone SL�L-//
Address � �l� '�.i-� ..-...{t� �� . �I.-�--. /
Arch/Eng. License No.
Address `
Contracmr'sNam ,� /. _Phone Sy>/l%�
Address'Imailingl�CL� 7
City LicenseNo. ��'D fi � ' ' �
LICENSED CONTRACTpR'DECLARATION
I hereby aHirm Iha[ I am p�¢nsetl untler provi5ion5 ot, Cbarter 9'(commencing '
with sectlon 7000)'ot Divislon 3 ot the Business antl Protessions Cotle, ana ,
my Iiconse.is in iv}I�force a oHect. . '
L:Ican�Clas�� � -l.ice fVd ytj'�5�
Date� 519 t n �s�v
WORKERS'COMPENSATIpN CLARATION� � �
I hereby aitirm that I nave a certlticate oi consent to seH-Insure or a certificate .
oi Workers' Compensation Insurance,-or a�ertifie coOY lnar ot (Section ,
�00, lab. ) �� � /�
IicY IV�`S" ���l���pan, �
�F ertifietl copY is hereby fumishetl.
C�Ce tili tl c s filetl witn the ciry Byyt n4 ivi "�'
tiatc � APPliwnt �
EXEMVTION F OM WORKERS' COMPENSATION OECL RATION
(This sectian neetl no[ be CompleteE il the 0?rmit iz far One puntlratl ($100) or
less).
I ttrtlty that In the pertormanca ol tne work for which tnls permR is Issuetl, I
shall not employ any person in any manner so as to become subjec[ to the �
Wo�kers' Compensatlon Lyws ot CalilOmia. �
, Dala ' SI9�aWre '
'NOTICE: 11, ditet making this tleClardtiOn, you Shoultl become Subject to the
' WorkCrs'�COmpensation' ptovlsion5 of Ihe CabOr Cotle, you must fortnwl[h
camO�Y'w��h suth provlsion5 Or th15 plrmit shall be tleomotl revoked.
CONSTRUCTION LENDING AGENCV.
� 1 M1ereby aHirm that tnere is a coMtructlon lenaln9 agency for the pertormance
of lh0 work tor which this p¢rmil is issu¢tl (SeCtlon 3097 Civ. C.)
l.entler's Name �
LonGer's Aatlress _
OWNER BUILOEH OECLARATION
I hnreby.a!(irm [hal 1 ertl ozomOl from Iha Canfractor'S License Law /or the
followin9 reason (SCction ]031.5 BuSlnGis antl P�o1aSSiOna1 Catle: Any cltY o�
county whlch requires a permit lo conztruct, altar, improve, demo�lsn or repair
anY strucWra, prior to its Issuance, also requires tne applicant lor such permit
to lilo a si9netl slatemOnt lhat n0/Sho Is IICfnSeC putsudnt to Ihe pwvlsions of
(hu Contractor's License �aw (C�apler 9(commencing wllh 5attion 7000) of
, Divlslon 3 af lhe Business antl Prolessions Cotla) or tM1at ho/she is exempt
'I theretwm antl the baiis for t�o all¢g9tl axempUOn. Any violdtlan of Setllon
'�31.5 by any applicant tor a permit subjec[s the �apD���ant to a civll
�ally ol not more Ihan five huntlretl tlollars (5500).
I, as owner o/ the proporty or my empioyees wltn wa9os as iheir sole
�omponsatlon, wi11 ao the work, an0 the structure is nol intentletl or otferea
IOf Sala (SCGtion ]044, BUSIne55 antl PrOlGisional COtlU: ThG COn[racto!'S
Liconse Law tloes not apbry to an ownor oi a property wbo bulltls orimproves
lhareOn, and who tloe5 Euch wo�k himself/h¢rzeH or throUgh hii or hBr own
employocs, provitletl tha� su<h Improvements are not intenEeO or oHeretl tor
sdle. I�, howevtq [he builtlin9 or ImprOvemenl i5 zoitl withln ona yea� ol COm-
plellon, the owner will have tno buraen ot proving he/sno tlitl not builtl or Im-
prov0 lor the purpOse ot;ale). � �
❑ I, as owner ot tne prbperty, am exclusively contracting with licensetl con-
l�actOrs lo construct the broject ($OCfI00 %044. BUSII185T dOC PfO/C55I0O5 COdB: �
Tha Contraclor's License �w does nOl apply to an own2r ol property who
bulltls or Improves ther0on, untl wbo mniracts tor SUGh projacts with a con-
Vactor(51 license pursuant'to the Contractor's Licanse Law). I am awar¢�that
proof O( thair Worket's CompanSaHon InSurdnGe ihaultl ba provitletl lo me.
❑ I am ezempt untler Se��ion B. & P. C. for this reason
Date Owner _
1 hereby cer[ify Mat I hav¢ reatl lhi5
IMormatlon is correci. I agr¢n to comp
antl state iaws rela(ing to builtlin9 con
SenlallvGs o/ lhiz city o 2ntef fp0
. inspection ur s
51 natur
tat¢ that the above
tl county ortlinances
•qy au�norize repre-
lonea prooerty tor
�ate ' �' �
TYPE OF CONSTRUC710N LJ NEW . U ADD LJ AL
❑ CONVERS�ON ❑ DEMOLISH � O OT}AF.R
DESCRIPTION OF WORK/l1SE QF BLDS'i.ji.�i"r.ycf i�•�-
TVP ��P8ICMIT LI GRAOING LV'FQHNDATION LJ STRUCTURAL
� TENANT ❑ IECTRIC�AL/ .�' PLUMBING ❑ MECHANICHL ,
I�,-OTHER �/I �YC'� h . �
PROJEC7DESCRIPiION Sa.F. /%� oCCVPary(��v�
CONSTRUCTIONSVPE - VALUATIONS�//U,
ZONE GRADING CU.YDS. ' � ACHES__
Remarks: ' . . � � .
i
3ar Sink � � �
3ackflow Preve'nier �
Beckflow Irrigation
9athtubs '
Clari(iers __ �
Dishwasher ` �
Drinking Fountains �
Floor Draina
Floor Sinks ' - �- " -
Gas Service �. �Outlets
Interceptors ' �
Kitchen Sink -
Lavatories ..
P-Tra{i '
Roof.Drains � �
Reinspection Fee
oiier
luct � Under Ground
Showers '
-� � Service Sink� �
$ewer Cap
Sewer Cqnnettion
Solar Collectors
Solar Piping�
Solar Tank �
Swimming Pool w/Spa
Urinal� '
Wacer Closet � � �
Water Heater '
� Water Service
$15 laue Fae �
Duct-Ventilating�- � �
Ezhaust System ❑ Multiple �
Firepl/Fact.8lt. ICBO #
Heating System & Ducting
❑ 6100,000 BTU O 7 00,000 BT
9 I I
Drivers' Licens¢ or 55 q/ ' ' ReinSpBttion Fea
CMF 0865-46, rev. 10/84 Wnito - Builtling; Canary - Appltcanh Pink - Acwuntin9: Goltlenrotl - Assessor
$15
�
A.P. •/p
S Main Buildin�
— E
T Front
B Rear _
.A
— C Right
— K Left
— S
— Ping. Ref. #
Planning Notes:
FEES
Automatic Washer �
Construction PoleSub.
Cookirg Unit
_ Dishwasher � . _ r..
Fan
F.A.U. '
- Device Boxes •
Outlets
� - Switches
Garbage Disposal -
Generator �0.5 KW
Hoodar Typel ❑
Canopy Type I I ❑ "
Refrigeration System i �
❑o-ioo,000sTu ❑ioo,oaoe
System Repair/Alteration ' �
Fire Dampers
Registers
Issue Fee
9754 �i/29/8G
Zone
Accessory Bui�ding:'
Parkin9 Req./Provided
r . �
ELECTRICAL ' �
Transformer � 15-50 KW
• ❑50+KW
Meter Qup to 100 amps
Meter ❑over 100 amps _
8
5KW
Sub Panel •
Momrs �61 HP �i'h-'8 '
Inc. Solar �9-15 HP �76-15+
Microwave
Pole Li9ht
Range
Standing Seciions
Trash Compactor
S 3 , �
Reinspection Fae $15 luue Fen
FEES
DEVELOPMENT SERVICES REdUIREMENTS:
ZoninB Approved 6y
Building Approved By
Appliption Issued 6y '
1
$ 3
" "` T�.
2
O
N
1
N
G
R'
E
Q
M
T
S
FEES
$ 3
SU�M9RV OF FEES , .C71
BUILDING PERMIT � $ � �� SMIP $ J��
PLAN CHECK ' S PERMIT �
PWMBING � , $ �ISSUANCE � $
PLAN CHECK •25% 5� � ENERGV P.C. S�
ELECTRICAL ' $ ' GRADING S
PLANCHECK 50%� $ MICROFILM � S '
MECHANICAL. $ TOTALFEE 5 �• �
PLAN CHECK 25%� $ . • . �
�
,
'i CONSTRUCTION AND PLANNING - POOL &
APPROVALS Permit# Date Inspector p�ppROVALS Permit# Date Inspector
1. Temporary Electrical Service or"Po�e - � 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. � 53. Steel Reinforcement
3. Electrical CondUit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement � - 56. Rough Plumbing & Pressure Test �
6. Electrical UFER Grnd. 57. APPROVAL TO COVER�GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
8. Foundation - 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, O Undrgrnd.
10. Structural Floor System 67. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
72. Sewer Cap 63. Heater & Vent-Final
13. Roof Drains 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final
i 6. Rough Electric Wiring - 67. Fencing & Access Approval
17. Rough Wiring Sign ' 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOUSPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit #
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping O Gas O Oil _
23. Gas Pipe-Rough & Test 72. Underground Flush �
24. RoofFraming 73. Undergrnd.StorageTank�Gas ❑Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation . 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION �
32. Electrical Power MeterFinal 80. FOOD CERTIFICATE ISSUED
33. Final Electric ' Notes:
34. Final Heating & Air Conditioning
35. Final Gas Pipe-Test ,
36. Hood or Canopy
37. Final Factory Fireplace � �
38. Final Piumbing
39. Water Service-Final -
40. Gas Service-Final
41. $olar pomestic-Final ,
42. Backflow Preventer .
43. Backflow Irrigation � �
44. Landscape Irrigation System �
45. Sound Attenuation .
46. Handicap Regulations �
47. FINAL STRUCTURE & BUILDING 6 f�(�-
48. Special Requi�ements Completed � ' •
49. Electric Release to Edison ' � �
50. Gas Release to Southern California Gas Co � .
51. CERTIFICATE OF OCCUPANCY , � -
No. Date
„/4�
Applicanl to fill in all spaces excev� ehose within heavy eoraer Ilnes ana sign all aoo�aoriate tleclarations.
CITY OF COSTA 7SA CO II�TR C.I9� N�P�E�R�y1T.� PF�RMIT NO. _ _ TRACT NO. LOT NO. . UNI7 NO.
Project Address �/ ` ' � � � �^�✓'��/ V
Applicant's Maili A��dre�ss-a -�/�,/J(17G -� 7� '
Owner's N/a/ e`�'Z�N �"h � vhn�ni�1 ��-S�i 7
Address 7�1.c.��a���1""-�� ”
Arch/Eng' � '� � License No.
Address ' - ' �l
Contractor'sNam��l'�" � ho���� V
Address.lmailing) � � ^ '
Ciry License No. � �'�G �
LICENSEO CONTRACTOR DECLARATION .
I hereby affirm thati am Iicensetl untler provislonsof Charter 9(commencing
with section �7000) ot DivisiOn 3 of tne Bu5ine55 antl Professlon5 Cotl¢, antl
my license is in t II farc}e qtl eifect. s.6 E� ,
License Class �—✓ U�g s A'! /' p
Date �3 59 t vA�
WORKERS' COMPENSATION DECLARATI N
I hereby atfirm that I have a certificate of consent to self-insure or a certlflcate
ot Workers' Compensation-insurance, or a certlHe cooY thareot (Section
3800, Lab G
PolicY � _ �� ComPdny
�Certifietl copy Is nereby (umishetl. � �
Ce�rp _fie copy IS tiletl with lhe U[y � i on.
Date Y ��—�l-. Applitan� �
EXEMPTION FROM WORKERS' COMPENSA 10/ CL ATION
(This section neetl nol be mmpleteU ii the permit iz tor one huntlretl (5100) or
less). �
I certify tnal in tM1e Oe�formance ot Ine wo�k fOr whlcn Inis pe�m�t i5 i55ueQ I
snall not employ any person in any manner soi as to bemme suDject ro the
Workers,' Comvensation Laws ot Caiifornia. '
oate � Si9nature -
'NOTICE: If, afler making thiz tleclaratlon, you shoulC become subject to the
/� . Workers"Compensation provisions of the Laboi Cotle, you musf forNwlth
1— comply with such prOvisions or thi5 Permit shall .be tleematl �evoketl.
CONSTRUCTION LENOING.AGENCV �
'` 1 hereby a(firm that there is a conztrutt(on lentling agency tor tne performance
V� of the work for w�ich tnis pormlt is issuetl (Section 309] Civ. C.)
\Lentler's Name " _ '� .
Lentler's AdUress '
OWNER BUILOER �ECLARATION '
`� I hereby aftirm [hat I am-exampt from the Conlractor'z License Law for the
followin9 reason (Section 7031.5 Buslness antl Professional Code: Any city or
`
counry whicb requires a permil to construc[, alter, ImOrova, tlemollsh or repalr
any structure, P/ior to It5 i55uanCe, also �equires IM1e apP��cant fo� suth pe�mit
to file a signetl statement that he/sne is Iicensetl vursuant to the provisions ot
the Coniractor's UGense Law (Chapt¢r 9(commoncing with 5ection 7000) Of
'Division 3 of Ihe Bu5ine55 and Profe5son5 Cotla) or that he/sh¢ is ezemp[ �
theretrom antl tne basis tor tne allegetl exempHon. Any violation o! Section
7031.5 by any applicant for a permit subjects [ne apP��cant to d civil
� enalty of not more tM1an five huntlretl tlollars ($500). �" � �
.� I, as owner of the property� or my employoes with wa9es as ihair sole
compensation, will Oo the work, and the'sVucture Is not Intentletl or ofteretl �
for sale (Section ]044, Buziness antl Profe55ional Cotle: The Con[ractor'S'
Lic¢nse ldw tlOes�not appry to an owner Of a prop¢rty who bulltls or improves
thereon, antl who tloes such work himself/nerseli or tnrough hls or her own
employees, provltletl that such improvemenis aro not intentlea or oHeretl tor
sa1e. If, M1owever, tM1e builtling or improvement I5 SoIA within one year of com- .
pletion,'the owner will have the buraen ot proving he/she dltl not builtl or Im-
��ov¢ tor the purpose of saie). '
I, as owner oF the proper[y, am ex[lusively Contracting with Ilcen50tl COn-'
tractorsto cons[ruct the prqect (SeCHon 7044, Bu51nes5 antl ProfoS510ns Cotle:
The Contractor'S License Law tloes nOt apply to.dn owner of property who'_
builtls or improves lhereon, antl who contracts./or sucn projects with a con-
tractor(si license pursuant to tne Contracfor's License Law). I am aware [hat
proof o( their WorkeCs Compensation inzuranca shoultl be provltletl to me.
❑,I am'exempt untler Section B. & P. C. tor tFiis reason
I I
Date ' Owner
certify t
m is con
�pplic5tion antl state-that the above �
witn all <Ity antl county ortlinances �
�uc[iOn, antl he�eby authorize r¢pre-
the above�mentionea property,to
Date�
TYPE OF CONSTRUCTION - L1 ivew �LJ Aoo L.� ALT.ERATION D�'F
❑ CONVERSION� ❑�DEMOLISH ❑ OT ER
SCRIPTI NQp,WOFJG/y�1S LDG. '
.{ ) /
TYPE E IT � GRADING• FOUNDATION ❑ STRVCTURAL
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL
❑ �OTHER - • � •
PR0.IECT DESCRIPTION Sa. FT. ocCUaANCv'_
� CONSTRVCTIONTVPE ' ' VALUATIONS -
, 20NE � GRADING CU. VOS. ' � ACRES—
Remarks: � . _
Sink
<flow Preventer
<flow Irrigation
Drinking Fountains
Floor Drains � �
Floor Sinks "" - - '; "-
Gas Service " Outlets� -
Interceptors� . -
Kilchen Sink ' �
Lavamries � �
P—Trap
Roof Drains �
_ � ' .
Reinspection Fea i , $75
Duct � Under Ground :
Duct-Svuctural ,
Ouct - Ventilating
Ezhauit System ❑ MWtiple �
Firepl/Fact. Blt. ICBO #
Heating System & Ducting
❑0-100,000 BTU 0100,OOOBT
I"""'" t-�If"y""� � _ I I Reinspection Fee
Drivers' License or �
CMF OBfiS-46, rev. 10/04 White - Builtling: Ganary - APPlicanq Pink - Accounting; Goltlenrotl - Assessor
Showers
Service Sink
Sewer Cap
Sewer Connection
.Solar_Col lec[ors
Solar Piping
Solar Tank
Swimming Pool w/Spa
Water Closet - .
Water Heater
Water Service � �
Auto-Wash � �
launtlry Trays - �
, luue Fee�� ,
�Hood or Type I; ❑ �
Canopy Type II ❑' '
Refrigeration System �', _
❑0 100,000 BTU �❑�100,000 Bl
System Repair/Alteration
Fire Dampers
Registers ; '
.
$15 laue Fee
$ 3
FEES
$ 3
�
/1.P. #
S Main Buildin9:
E
T Front
A Rear
C Right �
SLeft
Ping. Ref. #
Planning Notes:
`9Z5M 4/
� Atcessory Bi
Parking Req.
� , '
0
'"' TI.
� � _.,
2
- ^ O
N
I
N
� G
R
� . : E
_ Q
M
• T
S
, ELECTRICAL
Automatic Washer - Transtormer � 15-50 KW �
ConstructionPoleSub. ' � ❑50�+'KW .
Codking Unit' ' Meter ❑up to 100 amps
Dishwasher . . . . . Meter �over..100amps _ '
Dryers �Gas ❑Electric Sub Panel .
Fan � Motors �Ui HP O7X � 8 '
F.A.U. � Inc.Solar 09-75 HP �16_75+
Fiztures, Microwave �
Device Baxes . � Pole Light �
Outlets . Range
Switches i Sign .
Garbage Disposal ' � ; Standing Sections '
Generator �0-5 KW 05-15 KW Trash Compactor
� Reinspection Fee �$15 � �. luue
DEVELOPMENT SERVICES REQUIREMENTS:
2oning Approved By
Building APProved By �
Application Issued Bv �
A
FEES
$ 3
' SUMMARV OF FEES �
� BUILOING PERMIT $ �- 0� SMIP . $ � �
PLAN CHECK $ �PERMIT
• PLUMBING • $ ISSUANCE S
- PLAN CHECK 25% $� ENERGV P.C. $
ELECTRICAL ' $ GRADING ' $
PLAN CHECK 50% $ MICROFILM $ _�
, MECHANICAL � 5 TOTAL FEE $ �
PLAN CHECK 25%� $ �
;�
CONSTRUCTION AND PLANNING POOL & SPA
APPROVALS Permit # Date Inspector qppROVALS Permit # Date Inspector
1. TemporarY Electrical Service or Pole , 52. Pool & Equipment Location
2. Soif Pipe-Undrgmd. . � 53. Steel Reinforcement
3. Elecvical Conduit Utility�Undrgrnd. � 54. Forms -
4. Electrical Conduit-Undrgrnd. , 55. Electrical Bonding _ '
5. Steel Reinforcement . 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE
7. Footings 58. Electrical Conduit-Undrgrnd.
�8. Foundation � 59. Gas Pipe,�O Undrgrnd., Test
9. Water Pipe-Undrgrnd. � 60. Backwash Lines, P-Trap, 0 Undrgrnd. _
10. Structural Floor System 61. APPROVAL TO DECK �
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final � .
12. Sewer Cap � 63. Heater & Vent-Final -
13. Roof Drains 64. Plumbing System - Final .
14. Rough Plumbing 65. Electrical-Final
J5. Rough Electrical-Conduit 66. Solar System-Final �
16. Rough Electric Wiring 67. Fencing & Access Appcoval
17. Rough Wiring Sign ' 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory fireplace � , APPROVALS Permit # '
21. DucTs, in Structure � 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping � Gas ❑ Oil
23. Gas Pipe-Rough & Test � 72. Underground Flush
24. Roof Framing � - 73. Undergrnd.StorageTank OGas ❑Oil
25. Roof Sheathing -74. Overhead Hydro '
26. T-Bar Ceiling (Structural�.& Monocoat . � 75. Dry Chemical . �
27. Frame and Flashing 76. Dry Standpipe � '
28. Lathing & Siding ' � 77. FIXED SYSTEM FINAL � ��
29. Insulation ' 78. FIRE PREV. FINAL
30. Drywall Nailing � HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat � , , 79. FINAL INSPECTION
32. Electriral Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Elect�ic ' Notes: . �
34. Final Heating & Air Conditioning
35. Final Gas Pipe-Test � � �
36. Hood or Canopy '
37. Final Factory Fireplace '
38. Final PlumUing � ' . � �
39. Water Service-Final � � '� �
40. Gas Service-Final • , �
41. Solar pomestic-Final
42. Backflow Preventer _
43. Backflow Irrigation .
i
44. Landscape Irrigation System � �
45. Sound Attenuation � � ' � , � � � � �� � '
46. Handicap Regulations � �
47. FINALSTRUCTURE & BUILDING 6 g� D� ' �
48. Special Requirements Completed ,
49. Electric Release to Edison - �
50: Gas Release to Southern California Gas Co
51. CERTIFICATEOFOCCUPANCY . . � . ,
No. - Date
�
1
.
,_ Applicant to fill in atl spaces axcept t�osa wit�in heavy Dortler lines antl Si9n all a0p�epriate tleclarations.
�CI:�oF COSTapMESa CONSTRUC710N PERMIT
. Project Address 1 � �'1 �7gJ C-j� �1/ (1 �� 5T 2
ApplicanYsMailingAddreu p � l3D`� iya� i�FWk`(�t.
Owner's Neme �� �= T i4 (�,laa�. �Rl Phone �ab- 11c+Di q
Aildress �}q N1(�� HA'U�K ' `1R�11NE
Arch/Eng. � License No.
Address
Contracror's , y� Phone
Address (mailing)
City LicenSe No.
LICENSED CONTRACTOR �ECLARATION
1 hereby affirm that I am IicenSetl untler provi5ion5 of Chart¢r 9(commenCing
wit� S¢CliOn 7000j of Division 3 of the Busine55 antl PfO�C55IOf15 COdB� dflC
my Iicense is in �ull torce and eftect. �
IJcense Class U�ense No.
Date Signature
WORKERS' COMPENSATION DECLARATION
1 hereby aHlrm tnat I have a certiticate ot consen� to selt-insure or a cerNfi<ate
at Workers' Compensation Insurance, or a certl(ietl covY thereot (Settion
3800, Lab. C.) I
Polity No. Company '
�C¢rti/ietl Copy iz h¢reby fumishftl.
Ce�tifietl copy IS flletl with the city Builtling O���zion.
Date Applicant
EXEMVTION GROM WORKERSICOMPENSATION DECLA0.ATION
(ThisSeClion neetl no[ bC cOmpletotl if the permit Is for one,huntlretl ($100) or
lessl'- ' . ' .
I certify that in the p¢rlormance Of t {{{k fo� �+nich this e� � 5 issuetl, I
snall not pl ny person in any ma YYY¢�g so b yy s ject to'tha
Worke tlon Laws ot Cali o�f���11 �T _
Da[e Si9nature
'NOT : I, aiter making this tl¢Clar t on, you ShOW� become sub�ect [o the
Work 5' ompensation provisions of tne labo/ Cotle, you must fortnwlth
compty with suc� provisions or this- pe�mit Shall be tleemetl revOketl.
CONSTRUCTION LEN�ING AGENCV� �
1 he�eby affirm tltat tM1e�e is a con5t�uction IentlinQ ag¢nty for Ihe per(ormdnte
of [he work io� whiCh this p¢rmi[ i5 iSSUCtl (SectiOn 309] Clv. C.)
Lentler's Name -
Lenaer's Aaaress
OWNER BUIL�ER OECLARATIOfJ -
1 herebY atfbm that I dm exempt lrom the ConVacto�'s LlcenSe Law fo� ine
[a
5 hy any eppi
:y of mt more b
as owner of tf
ensation, will ac
�le (Section ]0�
ce Law tloes nat
m, antl wno tla
ryeei, provitletl
f, howeve�, the
n, the owner wl
to�fhe purpose
a5 owner ot the
builas ar
tra<tor(sl
proof o/
❑ I. am e
such
for a permit subjeCts tne appiiwni [o a ovu
ve huntlretl tlollars (5500). ' �
>perty�or my employees with wages as their sole
wo�k, antl the'st�uctUre i5 no[ intentletl o� off¢r¢tl
usine55 and Pro/e55iO�al Cotle: Tha Cont�acto�'S
I to an owner of a prOPer[y who builas Or iTprOvez
cn work himselt/hers9lt or throu9n hls or'her own
uch imp�ovemen[5 a�B nOt intentletl or offe�ed to�
ing or improvement IS soltl within one year of com-
e tba Durtlen ot proving he/she tlltl nOt builtl a6 im-
e).
erty, am exclusively contracting with licensetl con-
�ject (Section 7044, Business antl Profeszionz Cotla:
�w aoes not apply to.an owner ot pro0erty wno
�, antl wno contracts �or such proje<is with a con-
ta [he;�Con[ractor's Utense Law). I am aware that
ompensatlon insuranLo sM1oultl be provitletl to� me.
'ion �� .r Qr�,C. for this reason
Date �d/Q(G_ OwnqF/�yQ(�L
I �erel�y �ertify that I have r� m�: a
iMormation is m�reGt. 1 agree to comply
antl state laws to builtling co st
sentaHves of �i5 c' . O e e p
inspectlon ourp
Signa W re
Drivers' Lic or 55 �
1F OB65-46, rev. 30/84 :
TVPE OF CPNSTRUCTION LI NEW LI ADD LI ALTERATION LJ RECAIR
�� � CONVERSION ❑ DEMOLISH ❑ OTHER q,p. #
�
DESCRIPTIONOFWORK/U8E"'C'FB'CVC. S MainBuilding:
TVPE OF PERMIT �O GRADING ❑ FOUNDATION STRVCTURAL T Front
❑ TENANT ❑ ELECTRICAL ❑ PLVMBING ❑ MECHANICAL B Rear
❑ �OTHER � � %� .
C Right
PROJECT DESCRIPTION 5ci. FT. • OCCUPANCV K
CONSTRUCTIONTVPE VALUATION$ g LCft
ZONE ' G OING CU. VD A ES p�ng. Rei. `�
Remarks: ' Planning Notes:
Backflow I
Dishmrasher '
Drinking Fo�
Floor Drains
Floor Sinks �
Gas Service �
Interceptors
Ki[chen Sink
Lavatories '
P-Trap
Root.Dreins
Reinspection Fee 4 $15
oiler
luc[ - Under Ground .
Duct � Ventilating
Exhaus[ System ❑ Multiple ❑
Fiiepl/Fact. Blt. ICBO #
Heating System & Ducting
❑aioo,000-sTu Oioo,oaosri
Reinspection Fee � $15
APPlicant: Pink - AccoUnting; GoltlenrOtl - Assesso�
Sewer Cap
Sewer Connection
Solar.Collecrors
Solar Piping,
Solar Tank
Swimming Pool w/Spa
Water Closet
Water Heater
Water Service
A uto-W ash
Issue Fee
Hood or Typel ❑
Canopy Typell ❑
Refrigeration System .
❑aioo,000 eTu- Oioo,000
System Repai�/AI[eration
Fire Dampers
Registers
Isiue Fee
�
FEES
A
§ 3
Automatic Washer
Construction Pole Sub.
Cooking Unit •
Dishwasher -- -
Dryers �Gas�, ❑Eleci
Fan
F.A.U.
Fixtures
Device Boxes
OuNets
Switches
Garbage Disposal
Generator �0.5 KW C
Fee
i�%38 5/Ot3/':6
- I Zone
Accessory Building:
Parking Req./Provided
ELECTRICAL �
Transformer ❑ 15-50 KW
❑ 50+KW
Meter up to 100 amps
Meter ❑over100amps� �-
Sub Panel
Motors�0.1 HP �7X-�8 �
� Ina Solar �9-15 HP �16-15+
Microwave
Pole Light '
Range
; Standing Sections
5�15 KW � Trash Compactor
$75 Issue Fee
FEES
�DEVELOPMENTSERVICESREQUIREMENTS:
2oning Approved By
� Building Approved By �_/��
Appliqtian laued By ' � /
S 3
$ 3
� SUMMARY OF FEES
BUILDING PERMIT � $ SMIP $
PLAN CHECK � $ PERMIT
PLUMBING S ' ,ISSUANCE $ ,
PLAN CHECK 25% S �����jj' ENEflGY P.C. $�
ELECTRICAL $ �p..l%V GRADING $
PLAN CHECK 50% $ MICROFILM $ �
MECHANICAL �$ TOTALFEE $ �
PLAN CHECK 25% $ � ' �
0
0
`� T� i'. . . . . � ' . . � -
-R
� CONSTRUCTION ANDPLANNING POOL&SPA
��' �1PPROVALS Permit # - Date Inspector pppROVALS Permit # ` Date Inspector
�� �1. Temporary Electrical Service or Pole 52. Pool & Equipment Location ,
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement � ��
3. Electrical Conduit-Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding -
5. Steel Reinforcement , 56. Rough Plumbing & Pressure Test
6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE ,
7. Footings .. � 58. Electrical Conduit-Undrgrnd. -
8. Foundation 59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgmd. _ 60. Backwash Lines, P-Trep, O Undrgrnd. '
10. Structural Floor System . 61. APPROVA� TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap 63. Heater & Vent-Final ,
13. Roof Drains 64. Plumbing System - Final .
14. Rough Plumbing 65. Electrical-Final •
15. Rough Electrical-Conduit � 66. Solar System-Final -
16. Rough Electric Wiring 67. Fencing & Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Firepiace APPROVALS Permit #
21. Ducts, in Struaure 70. �Underground Hydro
22. Ducts, Ventilating 71. Product Piping O Gas ❑ Oil
23. Gas Pipe-Rough & Test 72, Underground Flush
24. Roof Framing 73. Undergrnd.StorageTank OGas ❑Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical .
27. Frame and Flashing 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29: Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED
33. Final Electric n Notes:
34. Final Heating & Air Conditioning `
35. Final Gas Pipe-Test �
36. Hood or Canopy ,
37. Final Factory Fireplace _
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final
41. Solar pomestic-Final
42. Backflow Preventer
43. Backflow Irrigation
44. Landscape Irrigation System ,
45. Sound Attenuation � �
46. Handicap Regulations
47. FINALSTRUCTURE&BUILDING
48. Special Requirements Completed
49. Electric Release to Edison
i
50. Gas Release to Southern California Gas Co '
51. CERTIFICATE OF OCCUPANCY �
���. No: Date �
\ � � .
/
J
. :
. •-� ' 9�6`,Z' � �� -,:�'�"'9��,
COSTA MESA BUILDING-SAFETY DEPARTMENT �j -`a.- S'=( �j U
P.O. BOX 317 COSTA MESA, CALIFORNIA ;-11� ���CE DEPT.
fOR APPI/CANT TO f/[[ /N COMPCETELY APPLICATION�FOR�PERMIT
TYPE OR PRINT BUILDING
BUILDIN� � � �/ 1 /� '
AODRESS / �/1p w` r A �V
COSTA MESA. CALIFORNIA ryn OFFI{.G USL VN(.l
I '�1 � flECE1PT NO. P/C/RMI /NO,
OWNER � �/ C O�` I I 7�(!� ��
3 � � 1 t, RECEIVED BY I CATE qECE1VED I �AT�85UED�
ADDRESS/ �� L '��� �r -r _s — g s •�� -
��T / 7 T/ �/Z �S� 2-% BUILDING
ADORE55
nrecr+�-ecr ��c. COSTA MESA. CALIFORNIA
OR' VEER NO.
FIRE
ADDRE55 ZONE T011 �
/� w. � /�(] �/J�
IS'1'R ���% " F/��'L�- CT NO Z%� APPROVED'/
OR gy �/IdYCi DATE
ADDRE5�2O� � LL-��ST/�Y%//fJ�TG' ZONING
LEGAL ILOT I � r A ZONE INO.OF �6E OF NEW � J^
OESCRIPTION NO D� BLOCK $wGTl� � PLPNS � BUILOING r.l rR
V�� �
A.P. NO. / F� � �1 �C D � D,� APP VE _\
BV DATE V
SIZE Ga'�'4C� v V� �O � I NO.OF BLO65. /"� yqRDS EVES
OF LOTJ��c•/N /\ NOW ON LOT �� REOUIRED ALLOWED
USE OF O /t'9 ICENTEft LINE 6T.) •
FXISTING BLDG. �"�
FRONT J FT. IN.
SETBiILK LINE FROM (/X/�
CENTER OF STREET � REAR YA�Tr R. SIDE F. IN.
c / 1�
91DE YARD ILEFT /�� S RIGHT `� L.SIDE IN.
DESC�IPTION OF WORK
REAR q/� OOFT. IIN.
NEW I II ALTERATION I II ADDITION I /L/�{..Gd" � .Q�{L1(/^�
REPAIR
I II MOVING I II DEMOLISM I � `/
5=1E DING r%Q �J� . ROOMS � STORIES / �
C� Ur�v _ J.f�
EXTERIOR W L ROOF �%��nq -
COVERING ICOVERIN(7 /''K � G<. :-� �
USE.OF BUILDINy� AND WORK TO BE PERFORMED
S /�/ / �P /�-- /YI . � �
�s ``J r � %s� i� T yo�
6� —
I MEREB wCN�LE GE TH 1 HAVE R D THI6 APPLICqT10N
AND BT TE THA T ABOV 18 CORpECT ND qGPEE TO COM- THE AMOUNT 6MOWN UNO VALUITION 18 FOR THE
� pLY WITH ALL IT O ND STA WS FEGULATING PURPOSE OF EST/�BLISHIN6 • PEflMIT FEE ONLY.
�,BUILDINGCO OCTION. C yqLUATION
\
?NATUR� PERMIT FEE $ �Q � -
'�11TTEE
� P4AN CHECK $ � O -
' $ ����-
%"��.' 2ED AGENT TOTAL FEE S .3� � /'/-,
/ \ —
� ' 9��3 : •
• _,._ ��ti'v;t.������1
COSTA MESA BUILDING•SAFETY DEPARTMENT Co-o"1. ^a � V �,D�
P.O. BOX 31� COSTA MESA. CALIFORNIA ; INA(�CE DEPT.
FOR APPL/CANT TO F/LL /N COMPIETELY APPLIG�ATION� FOR4 PERMIT
TYPE OR PRINT BUILDING
BUILDING _ / �J� /
ADDRE55 � —
COSTA MESA. CALIFORNIA FOR OFF/Cf USE ONIY
q G O� I NECEIPT NO. I P MI O.
OWNER / i U � _
ADDRE55/�` qL D/,�-/y� AECEIV¢D BY D TE RECEIVED DATE e UEI
�( �r � -1- � G %�_�
CITY /7 � C� ' —V �Z� BUILDING
ADDRESS
nRc���—ECT ���� COSTA MESA, CALIFORNIA
OR NEER NO.
FIRE
AODRESS 20NE � Grou �
OR �A� ( `�✓ C NO./ l� BYPROVED � �� rq�.r�"�� DATE �
!/�
aoo ess�-2o.2 Gr%!�-S'?/1qi��sTff ZONING
C� 2 NO.OF �) ��118E OF NEW ,'//� ^ �
DESCRIPTION I NO' �� I LOCR I PL�NS /�BUILDING /�
!/ I
A.P. NO. /� b� �� D ���� BVPROVE ��� DATE � 1
OF LOT �.� "� ��J I�O.OF eLOGe. � ypRDS EV
now oH �oi REOUIRED ALLOWED
USE OF O Q (CENTER LINE BT.)
EXISTING BLDG. e� FRONT � FT. � IN.
SETBACK LINE FHOM /03�
CENTER OF 6TNEET r� HEAR YARo— R. SIDE FT. IN.
SIDE VARD LEFT /J~S I RIGHT �^ L. SIDE , IN.
DESCR TION OF WORK
REAR / O .Ff. IN.
NE\' ( ALTERATION I II ADDITION I �� /
�BUILDING�DO J^� NO.OF `
SIZE ROOMS STORIES
EXTERI A ` IROOF T K�Q �
COVERI� UG � COVERINd � C
US�OF BUILDING P�J� WORK TO BE PERFORMED � �
J � �
�-s w !� — �i-�c' fi 6� Q —
o�-�
A�-
1 NEHEBY AGtFOWCCI
•ND ST�TE TH�T THF
PlY WITH qLL TY C
OUIL�ING CON RU
SIGNATUR
PERMITT
AUTHORIZED AGENT
f I H�VE RE�D THIB �PPLIC�TION THE �MOUNT BHOWN UN VALUITION 18 FOR THE
18 CORRECT I/�ND AGN6E TO COM- pUPPO6C OF ESTABLIB G• PERMIT PE8 ONLY.
,G$ /�I�D STAY LAW9 REOULATINfi
`/� VALUATION �J
�4 � PERMIT FEE $ p��O v
_ $� 9D� PLAN CHEGK S � � �
/ / TOTAL FEE $ � �
, . � 9�64
COSTA MESA BUILDING-SAFETY DEPARTMENT
P.O. BOX 31� COSTA MESA, CALIFORNIA
fOR APPC/CANT TO F/LL /N COMPLETELY
TyPE OR PRINT
BUILDING �� � � ` _ <�
ADDRESS � .J7
COSTA MESA. CALIFORNIA
OWNE _ .♦ �� �v/�cry�o�-
AODRESS/�+ � / / / �� `� � � V �
� r r�
��� �ti;�.���k�
�o - a- - -�' \ � l.).
fINANCE DEPT.
APPLICATI ON'TFOR S PERM IT
BUILDING
FOR OFF/CE USE ONCY
I FECEIPT NO. I PE{IMIT NO
�1/// �
/ l`'4�l
RECEIV6U BY �I DAT6 RECENED DATE 185UE
��.f/ � .� � .� f � I � _ �� _ .
FIRE
COSTA MESA, CALIFORNIA
TRACTOR \ CJf7S' O LIGNO. «�`�L BV i��G�T�� DATE
A�DRES� L'� �S � I��%� (�� � L ZONING
LEGAL I LOT// /p I G� ��A ZONE I NO.OF I OSE OF NEW
oescrtiviioH NO. �" BLOCK/r• Rvr PLANS euaowc
�f � APP
A.P.NO. �•/C7 ��� b y r+ BY � ATE
SRE ��'� f y�CT�INO.OF e�oGB. Q ypRDS EVES
OF LOT \[ /� t� rvow oH �oi REqU1RED ALLOWED
usp nc /rY (CENTER LINE 9T.) �/j
SETBACK LINE FROM
CENTEF OF STHEET
�^ f
LEFT /V � S RIGHT
DESCRIPTION OF WORK
�
/
9UILDINGPLJ'� �� NO.OF �
SIZE o IROOMS STORIES
EXTERIORWALC UF�^�COVERING���� C_'
COVERING v
USE.OF BUILDIN/G AND WORK TO BE PERFORMED
� / Q ��i / �
�s ``'�r�. C��h'p �t'r- 0� —
o-a —
1 HEFEBY KNO LEOGE �XAT I HAVE NERD THIS APPLICATION
THE AMOUNT 6HOWN UN[
�ND 6TAT T!f AT HE AB E I6 COA T AND AGAE� TO COM� pURPOSE OF QBTABLISHI
PLY WITM'RLL QTY AM S AND $ TE LAW9 flEGULATING ,
eWLOINc'cOFS UCTION' ! VALUATION
l
SIGNATUR F — �.L/J/j.� PER
PERMIITEE �/> /q —
' $ // / O� LA
�AUTHORIZED AGENT
�
:@/��ALUATION IB FOR THE
G A PERMIT FEE ONLY.
11T FEE $ � O �
I CHECK $ /O '
AL FEE $ � Q
• ' �^ 9�6�
C057A MESA BUILQING-SAFETY DEPARTMEN7 �' "'I � �q � 1y. �� C� `�1
P.O. BOX 317 COSTA MESA, CALIFORNIA lO ' d-� '`� � v�
FINANCE UEPT.
fOR APPUCANT TO f/C[ /N COMPIETELY APPLICA'TION� FOR PERMIT
TYPE OR PRINT �`IT UBUILDIfVG
BUILDIN � � f �_
ADDRES � '
COSTA MESA. CALIFORNIA foR officE usF� oNcy
'�� � �� ^ Q I RECEIPT NO. I P pM�T
OWNER �. 2 :�
. �,_�
MAIL �[�p/� � / Y�� RECEIVED BY D TE HECQIVE UPTE I6:
AODRES�V / ]� � G.. // .r� /�-�/I `2-J � /., �
C�7y /(� � � p� a� t 3 BUILDING
ADDRE55
ARC"'�ECT ��a COSTA MESA. CALIFORNIA
OR NEpR NO. '
FIRE
ADDRE55 ZONE Q /'1 Grou "`
�
^ STATE APPROVED
TRA Q D'f � /✓ LIC. NO �� gy Jl a� pATE �
ADDRES �d.Z �%+T/✓i �iy S T��j� ZONING
LEGAL I LOT I/� r% I � �� � tf �� I NO.OF I USE OF NEW
OESCRIPTION /NO.�/ Y ocK tbwtq\
PlwNS BUILUING
A.P. NO. //(�J T� Of 3 L/ D� BYP ��/\/ � �v � OATE C9 ���
OF LOT (^����' I How oH LOT8 � YARDS
�f� REOUIR
USE OF � v O (CENTEH
EXISTING LDG. FRONT
SETBACK LINE FNOM �
c[Nica ov sTqEEr L REAR VARO/� R. SIDE
� l � c
SIDE YARD LEFT �, ,�J RIGHT I.�y_ L. SIDE�
DESCRIPTION OF WORK
BUILDING
SIZE
EXTERIOR
COYERING
U�E OF 81
J i A
I1 HENEBY
•ND 6TAl
PLY WITH
BUILDING
. AUTHOR12ep AGENT
�
t
l
[�
�
.�
-/K �i�3 � I
/iL �o /� �- �t�
�
� _
f I HAVE /�D THIS /�PPLICATION THE AMOUNT 9HOWN fIND VALUM1T�ON �S FOR THE
I6 COFNE .�NO AGREE TO COM� pVRPOSE OF ESTABL�SHING A PENMIT FEE ONLY.
£S AND STA jLA�,WS RE6ULATING
� C �/„ ^ _ ` VALUATION �
/� U'^�/ 4 PERMIT FEE E O�
//)�D� PLAN CHECK $ �Q —
$ /�'
TOTAL FEE S 3D