Loading...
HomeMy WebLinkAbout291 17TH ST - Building Permits . ., • rr CITY OF COSTA MESA ,6517,1% . BUILDING DIVISION Fi .A.\ 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ra.us �• FOR INSPECTIONS CALL:(714)754-5626 %bmmF PERMIT NUMBER: BC08-00461 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM_ALT DATE ISSUED: 11/25/2008 . ISSUED BY: YH JOB ADDRESS: 291 E 17TH ST CM ;f , ' • Suite/Unit: WORKERS'COMPENSATION DECLARATION: Owner ID verified by driv. A ❑Yes 0 No - - I horeby afftrim under penalty of perjury one of the following declarations: Driver's License No. Expires: 0 I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed): compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. • • c*II have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ' permit is issued. My workers' compensation Insurance carrier and policy 0 I hereby certify that no excavation five(5)or more feet in depth into which a Cnumber are: person is required to descend,will be made in connection with work authorized Cartier (..9000000 2(06"1(.9000000X06 I by this permit,and that no building structure,scaffolding,falsework,a demolition or dismantlin thereof,will be more than thirty-six (This sedon need not be completed Ifthe permit is valued al one hundred dollars($100)or less) g (36)feet high.(Chap.3.2,Grp 1 2,Art 2,Sec.341.Title 8,California Administrative Code). Policy Number: FVE.ees-1 'h7 PA Pa\bla AX Ws. C.0• ❑ As owner-builder, I will not employ anyone to do work which would ❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if I should become subject to the workers'compensation provisions of Section 3700 of applicant's Signature Date the La.. e,I shall forthwith comply with these provisions. = % Division of Industrial Safety Permit Number: 11- 2J r0 `_,Appltont s SigQLe C'ate HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE TO SECI 'E WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to rile and IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑Yes 0 No ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEY'S FEES. Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure). with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file my license is in full force and effect. �p a registration form for acutely hazardous materials? 0 Yes 0 No CLic:*tug 32? Y _Class t/ IS (Section 25533 of the California Health and Safety Code, with some - .SEJ 11,,2,57 Vic exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely "—Contractor's lure L- Dale' hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard CONSTRUCTION LENDING AGENCY: temperature and pressure). ❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work fa which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? 0 Yes 0 No (Section 25534 of the California Health and Safety Code provides that the Lender's Address: Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. Signatures '- ' Date ). — 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS. .... _ ,. Health and Safety Code been fully complied with? 0 Yes 0 No I hereby affirm that under penalty of perjury that I am'p2MPT FROM THE 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish,eor repair anyFstructure, prior to its any other air pollution control district or agency? 0 Yes. 0 No issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Government Code requires that the requested that he or she is licensed pursuant to the'provisions of the Contractors information be fumished on applications fa non-residential building permits). License Law(Chapter 9(commencing with Section;7S0)of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? 0 Yes 0 No applicant for a permit subjects the applicant to a civil penalty of not more than (If'yes", the facility must meet the requirement of Sections 25534 and 42303 five hundred dollars($500).): % of the California Health and Safety Code). O I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other compensation, WILL DO THE WORK, and,JJhe structure is not intended or air pollution control district or agency is required for the work which is the offered for sale(Sec.7044,Business and Ptfessions Code:The Contractors subject of this application,have all of the disclosures prescribed by California License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No thereon,and who does such work himself or herself or through his or her own 8 (If"yes" attach certificate of compliance from the appropriate air pollution employees, provided that such improvements are not intended or offered for - . sale. If, however, the building or improvement is sold within one year of control officer). completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify that,under penalty of perjury the did not build or improve for purpose of sale.). information given above is correct. l'agree to comply with all state'laws and • ❑ I, as owner of the property,am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions. LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code: The contractors License Law does not apply to an owner of Signature Dale property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that ❑ I am exempt under sec.• - the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. . _ g ture of Legal Owner(s) Date 25 Signature Date 11_ -{t 305746(3107) - And/or Authorized App nt—------ ' —Date' CITY OF COSTA MESA • bi%1 �re�. BUILDING DIVISION AOS fU8-00269 k I g ' I 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.0 ".w FOR INSPECTIONS CALL:(714)754-5626 FIRE SUPRESSION PERMIT Job Address: 291 E 17TH ST • Status: ISSUED Suite: - - Applied: 11/0512008 Vicinity: YAS YOGA AND SPINNING Issued: 12/04/2008 Parcel Nunmber: 42522307 . Zoning: Applicant: TREMBLYM - +. • Address: .�' . Phone: ' 714-541-4074 Zip: c"..*:\: Owner: PERLMUTTER, DAN M •Address 36 MISSION BAY OR - , Phone: CORONA DEL MAR,CA - Zip: 92625Contractor: S AND M FIRESYSTEMS INC , - Address: 4702 S TENNESSEE PLACE - - - Phone: 520-624-5066= • - TUCSON,AZ ' Zip: 85714 " License: 838034 SCOPE OF PERMIT FIRE SPRINKLER SYSTEM FOR 20 SPRINKLER HEADS FOR A 3,300 SF INERIOR TI FOR"YAS YOGA AND SPINNING".REF:BC08-00461 FEE SUMMARY Plan Check: $54.11 Calc Valuation: $3,000.00 Permit: $83.25Claimed Valuation: $3,000.00 Other: $0.00 , Total: $137.36 ' ' ' NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. R.00ii INSPECTION TYPE p. IN1mm.$ CODE( INSPECTION TYPE pia IP/TRIALS 1616 Fixed System Final Fire Prevention '21 1 _D A�/ l)-\ 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention • 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS'COMPENSATION DECLARATION: Owner ID verified by driver-...sense. ❑Yes ❑No I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires: ❑ I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document.i.e.-property tax bill or deed): compensation, as provided,for by section 3700 of the Labor Code, for the • performance of the work for which this permit is issued. - . ❑ I have and will maintain workers'compensation insurance, as required by DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: section 3700 of the Labor Code,for the performance of the work for which this ' permit is issued. My workers' compensation Insurance carrier and policy 0 I hereby certify that no excavation five(5)or more feet in depth into which a number are: person is required to descend,will be made in connection with work authorized +� Mby this permit,and that no building structure.scaffdding,falsework,or demolition Carrier: -t or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp (This seodn need nal becanpered0the dental is valued at one hundred dollars($100)orless.) 2,Art 2Sec.341,Title B,California Administrative Code). Policy Number: A t 51 J r`4 4 1 ❑ As owner-builder, I will not employ anyone to do work which would ❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if I should become subject to the workers'compensation provisions of Section 3700 of Applicant's Signature Date the Labor Code,I shall forthwith comply with these provisions. k l i si-r Datebi Division of Industrial Safety Permit Number: s'�"""�(d Tram's Signature L LI HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE TO•SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and IS UNLAWFUL AND SHALE- SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CIVIL FINES UP TO;ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No ($100,000). IN ADDITION TO THE COSMF,COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some PROVIDED FOR Iji.SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEYS FEES? "' - Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas I hereby affirm that I am licensed uriderryrovisions of Chapter 9(commencing at standard temperature and pressure). with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file my license is in full force and effect. r. a registration form for acutely hazardous materials? 0 Yes ❑No Lic.# 'VT 054 ,;7 Class Si C.t to (Section 25533 of the California Health and Safety Code, with some Qiia--- r/ I1I'{Ib,.� exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely Contractor's Sig ure �' Date hazardous materials equal to or greater than a weight of 500 pounds, or a A. volume of 55 gallons. or 200 cubic feet of compressed gas at standard CONSTRUCTION LENDING AGEICY: temperature and pressure). ❑ I hereby affirm that there Is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work for Mich this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? 0 Yes CINo (Section 25534 of the California Health and Safety Code provides that the Lender's Address: Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. Signature Date 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes 0 No I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. the work which is the subject of this application a permit for such construction Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Govemment Code requires that the that he or she is licensed pursuant to the provisions of the Contractorsrequested License Law(Chapter 9(commencing with Section 7000)of Division 3 of the information be furnished on applications for non-residential building permits). Business and Professions Code)or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? 0 Yes 0 No applicant for a permit subjects the applicant to a civil penalty of not more than (If"yes",the facility must meet the requirement of Sections 25534 and 42303 five hundred dollars($500).): of the California Health and Safety Code). o I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the offered for sale(Sec.7044,Business and Professions Code:The Contractors subject of this application, have all of the disclosures prescribed by California License Law does not apply to an owner of properly who builds or improves Health and Safety Code Section 42303 been made? ❑Yes ❑No thereon,and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for 8. (11 yes",attach certificate of compliance from the appropriate air pollution sale. If, however, the building or improvement is sold within one year of control officer). completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE:'I certify that under penalty of perjury the did not build or improve for purpose of sale.). . information given above is correct. I agree to comply with all state laws and 0 I, as owner of the property,am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials-and Emissions. LICENSED CONTRACTORS to construct the project(Sec.7044, Business and Professions Code: The contractors License Law does not apply to an owner of Signature Date property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:'I a cantractor(s)license pursuant to the Contractors License Laws.), certify under penalty of perjury that I have read this application and state that 0 I am exempt under sec. the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. . . '1 Signature of Legal Owner(s) Date Signature Date )A , •tel 1��_ ���� a so5] 61va]) '—^'ta `r""'(�J/ f y And/ thorned Apptreant Date ; CITY OF COSTA MESA ,• I . BUILDING DIVISION • i t �' 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)7544856 • www.ci.costa-mesa,ca.Us f i e. .4 , FOR INSPECTIONS CALL:(714)754-5828 SRnesP PERMIT NUMBER: SB08-00101 PERMIT TYPE B_SIGN STATUS: ISSUED . - DATE ISSUED: 11/12/2008 • - . ISSUED BY: BJK • JOB ADDRESS: 291 E 17TH ST CM .-. . Suite/Unit:- Vicinity: _ SQ. FT: 0 : Valuation: $500.00 SCOPE OF WORK: INSTALLATIONOF A 48 SQ FT NON-ILLUMINATED BUILDING SIGN FOR"YAS FITNESS CENTERS." REF: ZA-05-04 - OWNER: PERLMUTTER',DAN M' Address: ' 36 MISSION BAY DR Unit: PHONE: . City/State/Zip: ' CORONA DEL MAR,CA APPLICANT: SWANSON,.BRIA'N - _ - - Address: • Unit: • PHONE: 949-903-5454 - - City/State/zZip: - CONTRACTOR: A GOOD SIGN INC License No. 805414 • Address: 25801 OBRERO DRUnit: UNIT 1- . . _. ,PHONE: 949-458.6661 City/State: MISSION VIEJO;CA ZipCode: 92691 • . CELL: ARCHITECT: License No. - PHONE: ENGINEER: •- License.No. - . PHONE:- •r - • • 10000000.0000•0, . SIGN PERMIT FEE SUMMARY PLAN CHECK FEE: $15.28 ., HOURLY PC FEE: $0.00 , . '. ' PERMIT FEE: $23.50 - - , ELECTRICAL FEE: .$0.00 • - _ SMIP FEE: ' $0.50 - . OTHER: $0.00 - ' - _ -- INSPECTION: $0.00 . TOTAL FEE: $39.28 - • • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92.28,§1. 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. COaE t. Ifile1098121 QA¢, Mims 000E fIMSYECtON TYPE ME ' INTIML5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention . _ 202 Final Factory Fire Place �'Jt220 Final Planning Approval 203 Final Sign Y/ dri .er 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS'COMPENSATION DECLARATION: • , Owner ID verified by drive, _ .,,ense. 0 Yes 0 No I hereby affirm under penalty of perjury one of the following declarations: .. Driver's License No. Expires: O I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill ordeed): compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 7 I have and will maintain workers'compensation insurance, as required by DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ' • e section 3700 of the Labor Code,for the performance of the work for which this ' permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a number are: ,/ n _ / person is required to descend,will be made in connection with work authorized , vv ,-�fL by this permit,and that no building structure,scaffolding,falsework,cr demolition Camey. or dismantlingthereof,will be more than the frost ween need not be competed/ perm(a vatmd at me nwdreddonars(atoalar lest) thirty-six(Code). high.(Chap.3.2,Grp I , r. G T O I 2,Art 2,Sec.341,Title 8,California Administrative Code). P,WtcgNumber. �-(l 1 0 As owner-builder, I will not employ anyone to do work which would ❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if I should become subject to the workers'compensation provisions of Section 3700 of Applicant's Signature Date the Labor e,I shall forthwith comply with these provisions. ///''' 1 V(7 �/0 [ Division of Industrial Safety Permit Number: L.2.`' HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑Yes 0 No ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEYS FEES. Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of UCENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons,or 200 cubic feet of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure). with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file my license is in full force effect. a registration form for acutely hazardous materials? 0 Yes 0 No #-- Licr )Sti I y Class# CL/ Sr (Section 25533 of the California Health and Safety Code, with some 1�f ar Y exceptions, requires registration with the Costa Mesa Fire Department by Con !` 000�aaa(((/ each business which at any one time has on hand a quantity of acutely vaa`u_igraWrev- ea hazardous materials equal to or greater than a weight of 500 pounds, or a L� volume of 55 gallons, or 200 cubic feet of compressed gas at standard CONSTRUCTION LENDING AGENCY: temperature and pressure). O I hereby affum thatothere is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work fa v.iich this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? 0 Yes ❑ No .-rad (Section 25534 of the California Health and Safety Code provides that the Lender's Address: - Costa Mesa Fire Department may require the preparation, certification and 'e+wcx. 1 filing with the Fire Department of an RMPP by businesses which are required • to register acutely hazardous materials with the Fire Department. Signature tt Date 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS: '�4,4 Health and Safety Code been fully complied with? 0 Yes 0 No I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction Business and Professions Code:Any city or countywhich requires a permit to or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Government Code requires that the requested that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications fa non-residential building permits). License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he o4she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? 0 Yes 0 No applicant for a permit subjects the applicant to a civil penalty of not more than (If yes", the facility must meet the requirement of Sections 25534 and 42303 five hundred dollars($500).): of the California Health and Safety Code). O I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the offered for sale(Sec.7044, Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No thereon,and who does such work himself or herself or through his or her(Se • (If"yes",attach certificate of compliance from the appropriate air pollution employees, provided that such improvements are not intended or offered for control officer). sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I certify'that under penalty of.perjury the did not build or improve for purpose of sale.). information givenabove is correct. I agree to,comply with all;state laws and city ordinances regarding Hazardous Materials and ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH Emissions. UCENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code: The contractors License Law does riot apply to an owner of Signature ' Date • property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I a contracta(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that ❑ I am exempt under sec. • the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described properly for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. . Signature of Legal Owner s) Date Signature Date !/�� /• ,.1 Qj 3057.46(3)07) 'b.+ ris-vV` 0^ \t i/7db- Andlor Aureonzed A man!__ ted \7- L • CITY OF COSTA MESA ;�r -c BUILDING DIVISION • 0 r�;',i 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us • Ft 4. o. fl - FOR INSPECTIONS CALL:(714)754-5626 PERMIT NUMBER: •BC08-00466 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM_ALT DATE ISSUED: 09/24/2008 . ISSUED BY: RMD • JOB ADDRESS: 291 E 17TH ST CMX - - 'Suite/Unit',, •.. • APN: 42522307 . - Zoning: , , -• . # Vicinity: INTERIOR Primary Occ: B Const Type: V-B SQ. FT: 0 Valuation: $6000.00 , SCOPE OF WORK: INTERIOR NON-STRUCTURAL DEMO IN PREP FOR TI (REF#: BC08-00461)"YAS YOGA AND SPINING" WITH ELECTRICAL AND PLUMBING CAP. OWNER: PERLMUTTER, DANM Address: 36 MISSION BAY DR Unit: Phone: / City/State/Zip: CORONA DEL MAR, CA - APPLICANT: RAY,BILL • ,' Address: 7152 HAZARD AVE Unit: : Phone: 562-230-0321 City/State/zZip: WESTMINSTER,CA . • CONTRACTOR: TIMBERLINE CONSTRUCTION INC License No. 732308 Phone: 714-903-1185 Address: 7152 HAZARD AVEUnit: Cell: City/State: WESTMINSTER,CA ZipCode 92681 ARCHITECT: License No. - ' . . PHONE: ENGINEER: License No. PHONE: COMBINATION PERMIT FEE SUMMARY Building Plan Check: $81.41 Building Fees: $125.25 Electrical Fees: $41.70 Mechanical Fees: $0.00 1\res#01.°111.11.1e Plumbing Fees: $33.30 SMIP Residential: $0.00 - SMIP Commercial: $0.00 , TOTAL FEES: $281.66 e•Refer to tee receipts for ell fees paid for project • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. . INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. oat INSPEC110NTYPE DAM ItinnAt.4 CODES 1661,80110N TYPE OrlE • lenn"ts 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing • 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention ' 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site �4ryP 204 Final Demolition 250 Final Building/Occupancy 1.25A0 4L7 8(z1 1 WORKERS'COMPENSATION DECLARATION: .. Owner ID verified by drivo..license. ❑Yes ❑No I hereby affirm under penalty of perjury one of the following declarations: Drivers License,No. Expires: ❑ I have and will maintain a certificate of consent to self-Insure for workers' Verification of Ownership by(type of document,i.e.-property tax bill or deed): compensation, as provided for by section 3700 of the Labor Code, for the . performance of the work for which this permit is issued. i ❑ I have and will maintain workers'compensation insurance,as required by , - • section 3700 of the Labor Code,for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:- permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a number are: person is required to descend,will be made in connection with work authorized Carrier > n T by this permit,and that no building structure,scaffolding,falsework,a demolition ` �U 17� �(�� ��J5 or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp (This sect no m be mplgiM the permit is valued at one hundred Oasis(SW or less.) 2 M2 Sec.341,Title B,California Administrative Code). Policy Number: /17G/ >f —q SY 0 As owner-builder, I will not employ anyone to do work which would ❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety,as noted above,unless issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if I should become subject to the workers'compensation provisions of Section 3700 of Applicant's Signature Date the Labor Code,I shall forthwith comply with these provisions. e` 0 6c� /Z ii Jo a, Division of Industrial Safety Permit Number: Applicants Signa a Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? 0 Yes 0 No ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires,with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST.AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEY'S FEES. Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of LICENSED CONTRACTORS DECLARATION: 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9(commencing at standard temperature and pressure). with Section 7000)of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file my license is in full force and effect. a registration form for acutely hazardous materials? 0 Yes ❑ No Li-n-.#T-1--- 7323°X Class#~ // (Section 25533 of the California Health and Safety Code, with some r�.n bi exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one lime has on hand a quantity of acutely uador's gnature Dxte,.- hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard CONSTRUCTION LENDING AGENCY: temperature and pressure). ❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work fa which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? 0 Yes 0 No Lender's Address: (Section 25534 of the Califomia Health and Safety Code provides that the 1 Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. Signature -.;,i - Dale ii- 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? 0 Yes 0 No I hereby affirm that under penalty of perjury,that I am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. the work which is the subject of this application a permit for such construction Business and Professions Code:Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? 0 Yes 0 No issuance,also requires the applicant for such permit to file a signed statement That he or she is licensed pursuant to the provisions of the Contractors (Section 65850.2 of the California Govemment Code requires that the requested License Law(Chapter 9(commencing with Section 7000)of Division 3 of the information be furnished on applications for non-residential building permits). Business and Professions Code) or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any viyylation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑Yes 0 No applicant for a permit subjects the applicant to a civil penalty of not more than (If'yes the facility must meet the requirement of Sections 25534 and 42303 five hundred dollars($500).): of the California Health and Safety Code). ❑ I, as owner of the property, or my employees with wages as their sole 7. If a permit from the South Coast Air Quality Management District or other compensation, WILL DO THE WORK, and the structure is not intended or air pollution control district or agency is required for the work which is the offered for sale(Sec.7044,Business and Professions Code:The Contractors subject of this application,have all of the disclosures prescribed by California License Law does not apply to an owner of property who builds or improves Health and Safety Code Section 42303 been made? 0 Yes 0 No thereon,and who does such work himself or herself or through his or her own B (If"yes",attach certificate of compliance from the appropriate air pollution employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of control officer). completion, the owner-builder will have the burden of proving that he or she CERTIFICATE OF COMPLIANCE: I-certify that under penally of perjury the did not build or improve for purpose,of sale.). information given above is correct. I agree to comply,with all state laws and property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions. ❑ I, as owner of the - . - LICENSED CONTRACTORS to construct the project(Sec.7044, Business and Professions Code:The contractus License Law does not apply to an owner of Signature . - Dale . property who builds or improves thereon,and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF'ENTRY: I a contractor(s)license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that ❑ I am exempt under sec. the information given is carted. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building . authorized by this permit until final inspection. • Sig re of Legal er(s) Date Signature Date - y/,// 9J/` /y(�jj,��( • 3057-46(3/07) gybed/ n j �pa{y� f/ n / ul oozed App t G CITY OF COSTA MESA 4• i BUILDING DIVISION >:J"hio r„ !lr/LOr• 1. DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F t ...1.7i..11 I PERMIT �. , B01-01446 • (714)754-5273 • Fax(714)754-4856 • i.costa-mesa.gfl.UILDING PERMIT n FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 291 E 17TH ST BUILDING Status: ISSUED Suite: Applied: 09/17/2001 Vicinity: BEACH N BACKYARDS Issued: 07/12/2002 • Parcel Number: 42522307 Zoning: '/ '�/l Applicant: SANDERS, SHERI _ - .- -- ISSUED BY: - I L/ Address: 14701 MYFORD .<. "-" - SUITE B - ,y! _ -- Phone: 714-508-1900 TUSTIN,CA/(2 1:-.- 'l _ Zip: Owner: PERLMUTfER, DAN_ / M' , ' � Address 36 MISSION BAY DR ., - -J _ -, //,.''/' ).`,, \ ; --- ,- 'Phone: / CORONA DEL MAR;CA' Zip: 92625 iso Contractor. -D M K INC. , /Address: 14701-B MYFORD RD. ,, '-Y Phone:- (714)508-1900 - . _ TUSTIN,CA - - , ' Zip: 927807 License: 659775 - - , • Arch : JULIO.GENER/STUDIO 3 ARCHITECTS ' Eng: Address: 20101,S.W.BIRCH ST .. Address:- _ - Phone: 714-660-7985 - Phone: • NEWPORT BEACH,CA -- - , Zip: 92660 , License: C20599 - License: a - . ,. SCOPE OF PERMIT 3923'SF 1-STORY COMMERCIAL ADDITION TO AN'EXISTING 2-STORY BLDG FOR"BEACH'N BACKYARDS"(3300SF AT FIRST FLOOR PLUS ' 623SF AT MEZZANINE).THIS ADDITIONIS TO BE BUILT AT SITE OF-PREVIOUS GREENHOUSE STRUCTURE. "COMMERCIAL BLDG."ALTERATION"TO EXISTING;GARDEN CENTER(GREENHOUSE)AREA,CURRENTLY ENCLOSED BY WALLS BUT NO 'ROOF. INSTALLING-A PERMANENT ROOF WILL NOT AFFECT PARKING(ADEQUATE.PARKING PROVIDED FOR THIS AREA)„LANDSCAPING, `,P EDESTRIANNEHICLE PATHS OF ;r_ _ ' TRAVEL, FAR.:.BECAUSE CONSTRUCTION OF NEW MEZZANINE IS UNDER THE 2,000 SQ.FT.A.IMIT OS-CODE,NO DR IS REQUIRED. FEE SUMMARY . , -Plan Check: '$1,009.94 Calc Valuation: 5199',319.20 Permit: ' $1;553.75Claim Valuation: $115,000.00 SMTP Res: $0.00 a 1 - _ SMTP Com: $41.86 , ' vOther: $0.00 :.: 1-.” - .- , , Inspection: ,$0:00 . ' ' Total: /$2,605.55" - _ N N. - PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 -�- C Rear 0=0 , , ;,Left. 0-0 ' -Right,- "0-0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. • INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(6/e0) DECLARATIONS WORKERS'COMPENSATION DECLARATION: • ' .1 hereby affirm under penalty of perjury one of the following declarations: ' O I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the ork for which this permit is issued. I have and will maintain workers'compensation Insurance,as required by sey1 ior,3700 of the Labor Cod),for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier end policy number are: S r}C' C.rny! inert- `^I 0 eft 0 Carrier: `G'.- 77 Policy Number: 6pS (This section ne not be completed i/the permit is valued at one hundred dollars $100)or less.) ❑ I certify that In the performance of the work for which this permit Is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Caltfo ia,end agree that 111yyyI shout tl become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisi AppllcantSignature:—. p-/ *I1♦A/i7...i✓J Date: s//d WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Llc.4 'S Z 7 / Class x TContracto7ssignatu7e:v, r .1 ®C,a 8{(.12 Date: /moi/n T-o CONSTRUCTION LENDING AGENCY: O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: • Signature: - '. Date: OWNER-BUILDER DECLARATIONS: —.1. I hereby affirm that under penalty of perjury that lam EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Cade)or that he or sho is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of nutrnore than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet In depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes U No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6 Will any part of the facility to be constructed Under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No • (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and cityordinances regarding Hazardous Materials and Emissions, Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes,I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. `Signature Oi Legal Owner(s) l0( 5-i„U ate ate pAnd/Or:Authorized Applicant--., CODE 6 INSPECTIONTYPF PATE. Itl)1TleJP COOS! INSPECTION TYPE PATE ti nt'{ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site �""`Y-'� � 204 Final Demolition 250 Final Building/Occupancy 7740,1 • • • CITY OF COSTA MESA 011l- BUILDING DIVISION y°;j Iii,• "�b• I I1.11”.•Thili 1) DEVELOPMENT SERVICES DEPARTMENT P MIT NUMBER PERMIT F03-00014 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-maREASUPRESSION PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 291 E 17TH ST Status: ISSUED Suite: Applied: 02/04/2003 Vicinity: Issued: 02/11/2003 Parcel Number: 42522307 Zoning: i(c2_ _ ISSUED BY: Applicant: MARQUEZ, DAVID, . Address: 1424 S ALLEC ST-', ",i _i; - :ii-^ Phone: 714-776-6395 X 231 ANAHEIM,CA'" , Zip: 92805 Owner: /PERLMUTTER, DAN M" . - _ - Address " 36 MISSION BAY DR - Phone: / CORONA/D ELMAR,'CA Zip: 92625 N Contractor GUARDIAN/FIRE PROTECTION • Address: 14245 'ALLEC ST Phone:. 714-776-6395 ANAHEIM,CA Zip: t 92805 , \ Lice nse; 500330 1, N --=•,• .:—SCOPE OF-PERMIT - HADD OVERHEAD FIRE SPRINKLERS FOR TENANT IMPROVEMENT FOR"BEACH AND , ii __ BACKYARDS'. REF: . - " _ B01-01446. v v .-1 ,_ .u. - FEE'SUMMARY-'• . .- v. Plan Check: $72.31 Calc Valuation: $4;800.00 . permit: .$111.25 ; Claimed Valuation: $4,800.00 Other: $0.00 , . • Total:• . $183.56 • . • r_'' , r • . ! a " \' " , , • • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(6/00) DECLARATIONS 1 _ 1 WORKERS'COMPENSATION DECLARATION: ' I hereby affirm under penalty of perjury one of the following declarations: ' ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 1 have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: ZEM(rN • bus.� . (Q. Policy Number: 2094/761929/ (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) . . . . O I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,end agree that if I should become subject to the workers'compensation provisions of Section 37 of thLabor Code,I shall forthwith comply with these•rovislons.u .'t I/ � .Applicant Signature: - . Date: U ./M�--7 i WARNING:FAILURE TO SECURE WOR.,--'COMPENSATION COVE-• IS UNLAWFUL AND SHALL SUBIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN AD•TION TO THE COST OF COM• NSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under rovisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# 5 4/.50 Class N C•/G 1 / Contractors Signature: Date: � // / cir CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: • I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the property,em EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ l am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. 0 Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: O I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 6,California Administrative Code). . ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greeter than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a_Lermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes 0 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑No I (If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). I 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is thel subject of this application,have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If'yes",attach certificate of compliance from the appropriate air pollution control officer). ' CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) • 2//l I I U • r s�aA �/dd��TT�� And/Or Authorize Tin icant CODE t INSPECTION TYPE 2IE =AU CODE r INSPECTION TYPE PATE, JNTmAL$ 1616 Fixed System Final Fire Prevention _ 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall . 212 Final Fire Prevention - 15.x- 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site . - 204' Final Demolition - ' ' 250 Final Building/Occupancy ' ' CITY OF COSTA MESA , a9 BUILDING DIVISION >:e .. , DEVELOPMENT SERVICES DEPARTMENT PERMIT N BER � . 1��Citi PERMIT h . 3-00024 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 FIRE SUPRESSION PERMIT Job Address: 291 E 17TH ST Status: ISSUED Suite: Applied: 02/18/2003 Vicinity: Issued: 02/24/2003 Parcel Number: 42522307 Zoning: ISSUED BY: Applicant O'MAHONY, ROBERT E Address: 1725 MONROVIA ST SUITE D3 Phone: 949-631-7576 COSTA MESA,-CA Zip: 92627 - - Owner: PERLMUTTER, DAN M Address 36 MISSION BAY DR Phone: CORONA DEL MAR,CA Zip: 92625 Contractor: , D&E FIRE PROTECTION INC Address: 1725 MONROVIA ST :faH SUITE D3 • Phone:. 949-631-7576 COSTA MESA,CA ' Zip: 92627 • License: 812329 SCOPE OF PERMIT_. - , FADD-52-FIRE SPRINKLERS TO "BEACH N BACKYARD" REF.: B01.01446 r -.- - FEE SUMMARY - Plan Check: $136.01 _ - - _ Calc Valuation: $12,000.00 Permit: $209.25 Claimed Valuation: $12,000.00 Other: $0.00 Total: $345.26 • • • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446.46(6/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: • I hereby affirm under penalty of perjury one of the following declarations: • ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. r ❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ' My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed it the permit is valued at one hundred dollars($100)or less.) _ , dg I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provision provisIsss Applicant Signanature: � /,,�I� Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE I'r-^I• WFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED G THOUSAND DOARE($100000),IN ADDITION TO THE COST OF COMPENSA�7 AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Pro �slons Code,and my license Is in full force and effect.Lie.• . $/ 2 3 2_'t Class a G Ei Contractor's Signature: _,/r 57 "f Il Date: Z- Z 4,4- .� CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior toffs issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ 1,as owner of the properly,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the properly,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person Is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safely,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3—Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of ihe California Health end Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apgermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? r0 Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescnbed by Califomla Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: • CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ‘01ure Of Leal • 019 Date And/• Authorized Applicant Date RODE I INSPFCTION TYPE DATE CODE I INSPECTION TYPE. PATE INRTIAL$ • 1616 Fixed System Final Fire Prevention 206 Final Mechanical • 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention P ) IS J O2> ‘t-a 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition - 250 Final Building/Occupancy • _ • •� T CITY OF COSTA MESA " 4 . BUILDING DIVISION �1 DEVELOPMENT SERVICES DEPARTMENT P MIT NUMBER t;1 writ .� t PERMIT ti. ircik • E03-00599 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 291 E 17TH ST Status: ISSUED Suite No Applied: 07/02/2003 Vicinity: Issued: 07/02/2003 Parcel Nunmber: 42522307 Applicant: SHELBY VAN WICKLE ISSUED BY: Address: �, Phone: (949)646-5062 , - - _ - , ,�� Zip. � � Owner:�PERLMUTTER,,DAN M Address;��36 MISSION BAY DR- - Phone: CORONA DEL MAR,CA Zip: 92625 " Contractor. , JETTY ELECTRIC Address: P.O.BOX 3033 ' .- -Phone: (949)646-5062 NEWPORT BEACH,CA I Zip: 92659 • , License: 677322 N SCOPE OF PERMIT 3923 SF 1-STORY COMMERCIAL ADDITION TO AN EXISTING 2-STORY BLDG FOR"BEACH'N BACKYARDS'(3300SF AT FIRST FLOOR PLUS 623SF AT MEZZANINE).THIS ADDITION IS TO BE BUILT AT SITE OF PREVIOUS GREENHOUSE STRUCTURE. • "COMMERCIAL BLDG."ALTERATION".TO EXISTING,GARDEN CENTER(GREENHOUSE)AREA, CURRENTLY ENCLOSED'BY•WALLS BUT NO ROOF. INSTALLING A PERMANENT ROOF WILL NOT AFFECT PARKING(ADEQUATE PARKING PROVIDED FOR THIS AREA),LANDSCAPING,PEDESTRIANNEHICLE PATHS OF TRAVEL,FAR...BECAUSE CONSTRUCTION OF NEW MEZZANINE IS UNDER THE 2,000 SQ.FT.LIMIT OF pODE,NO DR IS REQUIRED.REF.:B01-01446 ; ELECTRICAL TO INCLUDE:65 LIGHT FIXTURES,30 OUTLETS, 18 SWITCHES, 1 SERVICE TO 200 � AMPS, 1 SERVICE TO 1000 AMPS,2 COMMUNICATION DROPS,AND 1 SIGN CIRCUIT. , " . v • . - FEE SUMMARY Quantity - Quantity ISSUE FEE- / $23.50 / / , Temp Dist System/Lighting $0.00 ,0 Temp service test.' - $0.00` Busway/100 ft $0.00 0 Res.a/c package,`. . $0.00 ' . Standing Section / $0.00 0 New Res(1-2 units) \ $0 00 ' ' ' 0 Misc Electrical Equipment $0.00 0 New Res(3+units) - $0.00 , , 0 . Transformers up to 1 kva/kw - .$0.00', ' 0' Pool/Spa N, $0.00 0 up to 10 kva/kw _$0.00 -' 0 Lighting Fixts $54.85 , 65 ' ' - up to 50 kva/kw - $0.00 ' 0 Recept Outlets $29.30 30 up to 100 kva/kw . " $0.00 0 Switches $19.80 " - 18 -_ over 100 kva/kw., $0.00 0 Non Res Appl $0.00 0— - , " . Low Voltage Equipment' $0.00 0 Res Appl $0.00 0 " Low Volt Wiring System/Ckt $0.00 0 Service to 200a $30.50 1 Misc. Conduit $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days,or if work Is suspended or abandoned for a period of 180 days. • INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(6/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 0 I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: �y N_T /� Carrier: 1YyV tzV & Policy Number. HQv .1 -I' 5'75-6 / (This section need not be completed it the permit is valued at one hundred dollars($100)or less.) ❑ I certify that In the performance of the work for which this permit Is Issued,I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these pro (�O / Applicant Signature: 1,6)11'1 Date: WARNING:FAILURE TO SECURE WORKERS'COMP SATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND OVIL FINES UP TO ONE HUNDRED THd SAND DOLLARE($100,000),IN ADDMON TO WST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am IIcensed u gov4 io,p of Chapter 9(commenting with Section 7000)of Division 3 of the Buslnag9$nd Professions Code,and my license is N full force end effect.Lk.a G fY �.,L& (� ,, Class a l-_—r C/ Contractors Signature: /1Y �+(x71LArt 'v..^--�.,..�,.-1LX� Date: '7 iR/U CONSTRUCTION LENDING AGENCY: /y ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued.(Sec.3097.Civil Code). Lenders Name: Lenders Address: Signature: Date: r-. OWNER-BUILDER DECLARATIONS: _ iy I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Lew does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth Into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: -_ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for ecetety hazardous materials)? ❑yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or willo the applicant orpresent aor future b District occupant other for the work which isi the sor age c this a plication eppermii for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? �Yes LJ Na (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the lacility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No (If yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South C.aSt Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescnbed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes',attach certificate of compliance from the appropriate-jai-pollution—control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the Information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. motor@ _Legal n r(s) �,^ 7te_j And/Or Alfa d Applicant oC Date CODE}, INSPECTION TYPE DATE ILLS CODE! INSPECTION TYPE gAIE 9EALE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing / 200 Final Re-Roof 210 Final Electrical v 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy I rims CITY OF COSTA MESA NC? BUILDING DIVISION > • 4„,,.,4,,,.,,, i DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER :�. • PERMIT M03-00336 (714)754-5273 • Pax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 291 E 17TH ST Status: ISSUED Suite No Applied: 07/18/2003 Issued: 07/18/2003 Vicinity: BEACH N BACKYARDS Parcel Number: 42522307 ISSUED BY: Applicant: SANDERS, SHERI,, Address: 14701-B MYFORD RD. Phone: (714)508-1900 • TUSTIN,CA Zip: 92780 Owner PERLMUTTER, DAN M Address: 36 MISSION BAY DR Phone: CORONA DEL MAR,CA Zip: 92625 Contractor: D M K INC. Address: 14701-B MYFORD RD. Phone: (714)508-1900 TUSTIN,CA Zip: 92780 License:659775 SCOPE OF PERMIT 3923 SF 1-STORY COMMERCIAL ADDITION TO AN EXISTING 2-STORY BLDG FOR"BEACH'N BACKYARDS"(3300SF AT FIRST FLOOR PLUS 623SF AT MEZZANINE).THIS ADDITION IS TO BE BUILT AT SITE OF PREVIOUS GREENHOUSE STRUCTURE. 2 VENT FANS/SINGLE DUCT REF:B01-01446 FEE SUMMARY 'Quantity Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0 Inst FAU <100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 Inst/Rep.Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys<100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems Gas Piping $0.00 .0 Up to 3 hp/100 k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp/500 k BTU $0.00 0 Hood w/Mech Exhaust $0.00 . 0 15 To 30 hp/1,000 k BTU $0.00 0 VAV Box $0.00 .0- 30 To 50 hp/1,750 k BTU $0.00 0 Vent Fan/Single Duct $14.50 2 • Over 50 hp/Over 1,750 BTU $0.00 0 Appliance $0.00 0 - Boilers Fire Dampers $0.00 0 Up to 3 hp" $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers< 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§1,12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-46(WOO) DECLARATIONS (1 WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations:, - ❑ eve and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 4I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: (// y Carrier: �, .e.,,.7:.tf+bY1 5,7x5, f�mo� Policy Number: -/C�7 — 1( G 0 -O 3 (This section need not be completed it the permit is valued at one hundred dollars($100)or less.) ❑ I certify that In the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if 1 should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these p slo ,/ ,,/ Applicant Signature: :rC /LL..Lt� Date: tI(i /4 3 WARNING:FNLURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS(5100,000),IN ADOr1ON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECRON 3706 OF THE LABOR CODE,INTEREST,MID ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensedrovls��hster(commencing with Section 7000)of Division 3 of the Business and rofesslons Code,and my license is In full force and effect.Lie.a) J I-.) Class# Contractor's Signature: 7 Date: ' 03 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: 1 hereby affirm that under penalty of perjury that Gam EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit.to construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,end who does such work himself or herself or through his or.her own employees,provided that such Improvements are not intended or offered for sale.If,however,the building or improvement Is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person Is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feel high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has e permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑No . (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Flre Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire partment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this,a,ppplication aPermil for such construction or modification from the South r'+rast Air Quality Management District or from any other air pollution control district or agency? U Yes 0 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No (If yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or othic air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescnbed by California Health and Safety Code Section 42303 been made? 0 Yes ❑No — 8 (If'yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application end state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. itan Sign /Legal nun Pat And/Or Authorized Applicant Date CODE L INSPECBONTYPE PAIS Mall conn- INSPECTION TYPE - • ' ME (1t1�n/L5 1616 Fixed System Final Fire Prevention 206 Final Mechanical • (�'1 18-03 U I V 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof ' 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval - 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy • CITY OF COSTA MESA • 4 .' BUILDING DIVISION r/ . > • ,,,,,.,,,,r,,, r : DEVELOPMENT SERVICES DEPARTMENT PERMI UMBER PERMIT J . pica 44" P02-00560 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 291 E 17TH ST Status: ISSUED Suite No Applied: 09/04/2002 Issued: 09/04/2002 Vicinity: RESTROOMS sat/44_, Parcel Nunmber: 42522307 ISSUED BY: Applicant: SANDERS, SHERI Address: 24726 FREEPORT DR ' Phone: 909-662-7620 MORENO VALLEY,CA Zip: 92551 Owner: PERLMUTTER, DAN M Address 36 MISSION BAY DR Phone: CORONA DEL MAR,CA Zip: 92625 Contractor: D M K INC. Address: 14701-B MYFORD RD. Phone: (714)508-1900 TUSTIN,CA Zip: 92780 License: 659775 • Arch / Eng: _ Address: Phone: • Zip: License: SCOPE OF PERMIT 6/18/02:PERMIT WITHDRAWN PER LETTER FROM CONTRACTOR(B&J PLUMBING)ATTACHED TO PERMIT. • PLUMBING TO INCLUDE:2 WASH BASINS,2 WATER CLOSETS,AND 2 ROOF DRAINS."BEACH N BACKYARDS"REF.:B01-01446 FEE SUMMARY AMTQTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 Sump Pump 50.00 0 Backflow imgation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool 50.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $19.60 2 Dishwasher $0.00 0 Sewer Cap for Demo - $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void II work is not commenced within 180 days,or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: to order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 244646(6/00) N DECLARATIONS ' g ` WORKERS'COMPENSATION DECLARATION: �/ I hereby affirm under penalty of perjury one of the following declarations: ❑ I ve and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the- ark for which this permit is issued. • Clra have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is I«ted. My workers'compensation Insurance canier and policy number are: C t/ Carrier: r�� ��wy�� r�,��J.4ryx Vet' . Policy Number: — IO€SO ' 0? (This section n rid net dpmplered it the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit Is Issued,I shell not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions Applicant Signature: n-3 071 I Date: 7/I PI 6 3 WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOU.ARE(S100,c00),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect.Lk.D z , y' Class C Contractor's Signature: -4‘ 1--14-2) Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or County which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement That he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she Is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not Intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,em EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. 0 Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,I.e.-property tax bill or deed): - _ DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title B.California Administrative Code). ❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ._....._. __.___ _.._ __._._............_...._... _....__..—_.... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Ves ❑No -- ..-5 Does or will the appllcant or present or future building occupant require for the work which Is the subject of this application apermit for suchconstruction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for nonresidential building permits). 8 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution-control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: ' CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. �nature egoC r( / Da te % / a .. 7/1110-7 — d/or Authorized Apt:WeanDa te ' con IN J'ECTION TYPE MALE !MALS ;ODEI INSPECTION TYPE PIE Mai 1616 Fixed System Final Fire Prevention 206 Final Mechanical O . • 1266 Pool Spa Final 208 Final Plumbing B`)R —03 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval - 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy