HomeMy WebLinkAbout1775 ANAHEIM AVE - Building Permits CITY OF COSTA MESA
a BUILDING DIVISION
T .rDEVELOPMENT SERVICES DEPARTMENT PE MIT NUMBER
10041 PERMIT 405-00356
bePosig Igoe
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mese.®I ILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
• Job Address: 1775 ANAHEIM AV Status: ISSUED
Suite: B Applied: 03/04/2005
Vicinity: UNIT B Issued: 03/04/2005
Primary Occ: R-3 Dwellings/Cong Res<10 Type of Construction: V-N
Parcel Number: 42426324 Zoning:
Applicant: BOSTANDZIC, DINA '
Address: 1775 ANAHEIM AV
• Phone: 949-254-6798 ISSUED BY: ea/S._
COSTA MESA,CA Zip: 92627-3606 "
Owner: VEJZOVIC; MUSTEDANAGIC; BOSTANDZIC'" _
Address 1773 ANAHEIM AV " . '-' .
COSTA MESA,CA - - • Zip: :92627-3606
Contractor: OWNER-BUILDER ,
Address
Phone:
Zip:` • - License: 000000
Arch_:: •' '; ' `= Eng:
Address: - . Address:
Phone:
Zip. License: , •? License:'
SCOPE OF PERMIT �.
LEGALIZATION OF THECHANGE-OUTOF 7 WINDOWS AND 1 FRENCH COURTYARD DOOR IN EXISTING DWELLING UNIT B.
NO OTHER WORK AUTHORIZED WITH THIS PERMIT.
REF:C05=0309 •. '
_ _. ,,. , _ __ >_ i •
8/19/05:LEGALIZATION OF A LANDING OUTSIDE THE FRENCH DOORSi.' ,t - .
FEE SUMMARY
Plan Check: • $0.00 Calc Valuation ,'. ; $1,200:00
• Permit $44.85 4 n:Claim Valuation $1 200.00
SMIP Res: $0.50
SMIP Com: $0.00
Other: s; $0.00 -
Inspection: $0:00
Total: $45.35•
PLANNING'S,ZONING
SETBACKS
MAIN STRUCTURE(Front .0-.0•- ' Rear 0 0 Left 070 1:. RiRi ght " 0-0
ACCESSORY Front -0-0:- , -- Rear 0 0 :.�; 1.Left. 01'0 Right , 0=0
PARKING Existmq•• -0_ - Required 0 •i - -Proposed ''0'- •
JYr
•
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)754-5628
2448-4a(8/00) -
DECLARATIONS ._
WORIZERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit Is issued.
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance canter and policy number are:
Carrier: Policy Number:
(This section need not be completed I the permit is valued at one hundred dollars($100)or less.)
..0 I certify that in the performer' 1 e wry for whl All Is permit Is issued,I shall not employ any person In any manner so as to become subject to the workers'
compensation laws of Callfoml d act::' that if ryT Id become subject to the workers'compensation provisions of Se I n 3700 r Code,I shall forthwith
comply with these provision
ce_nt.Signature:_r: - - /Date:. 1 l
Appli
WARNING:FAILURE TO SECUR 5'CCM- NSATION.. .• GE IS UNLAWFUL MD SHALL SUBJECT AN EMPLOYER TO CRIMINAL P NALTIE AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE(S100.000),I D TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,I EREST,MD ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is In full
force and effect.Uc.4 Class a
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant fore permit
subjects the applicant to a civil penally of not more than five hundred dollars($500).):
_r-c-y 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 withi 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 own••�of the property. • EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:Th: •ntract•rs Uce -i'w does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license p -1t nt to: e Contr. •rs License Laws.).
❑ 1 am ex: r nder 1• \ Business and Professions Code for this reason:
`Slgnatu I� _rII .�J' (
• G.>7pif lras:--I XI>
Verification of Ow ership by(type of document,I.e.-properly tax bill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five(5)or more feet in depth into which a person Is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(38)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder, I Will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number.
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
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 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 en 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.
y.__.... l_ ...._...
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 Mia the applicant or present or future building occupant require for the work which is the subject of this application a ppermll for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Q Yes ❑No
(Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If 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
�_.__f. . .. ....
8 (If yes',attach certificate o1 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 COMP • C: • D • j OR r •TION 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 wi :I -ate I. 5 and • ordinances relating to building construction,and authorize representatives of the ity of C sta Mesa ter upon the
above-described property or n Ir.ction•( ••-i I agQ//r: perms- of to occupy or allow occupancy of any building authorized by this ps Ar ryl i alins On
i
•sinature ei Legal Own6rs) W(s) U�
• d/Or Authorized Applicant Date
CODE 1, INSPECTION TYPE DAIS IMMA LODE( INSPECTION TYPE PEE MOM
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 SIT
204 Final Demolition 250 Final Building/Occupency eft}6%CI "�L^^
•
CITY OF COSTA MESA
BUILDING DIVISION
FSI DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
4 PERMIT
- /805-00416
(714)754-5273 • Fax(714)754-4856 BUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 1775 ANAHEIM AV Status: ISSUED
Suite: A Applied: 03/14/2005
Vicinity: Issued: 03/14/2005
Primary Occ: R Type of Construction: V-N
Parcel Number: 42426324 Zoning:
Applicant: VEJZOVIC, ALISA - ISSUED BY:
Address: 1775 ANAHEIM AV
Phone: 714-317-9465
COSTA MESA,CA Zip: 92627-3606
Owner: VEJZOVIC; MUSTEDANAGIC; BOSTANDZIC
Address 1773 ANAHEIM AV
Phone:
COSTA MESA,CA. . Zip: 92627-3606
Contractor: OWNER-BUILDER
Address:
Phone:
Zip: License: 000000
Arch : - Eng:
Address: Address:
Phone: Phone:
•
Zip: License: • License:
SCOPE OF PERMIT
LEGALIZE WORK DONE WITHOUT A PERMIT.CHANGED OUT 7 WINDOWS AND 1 SLIDING GLASS DOOR THROUGHOUT RESIDENCE TO
MEET 1997 UBC EGRESS REQUIREMENTS.UNIT A.
FEE SUMMARY
Plan Check: $0.00 ---. Calc Valuation: $3,000.00
Permit: $83.25 Claim Valuation: $3,000.00
SMIP Res: $0.50
SMIP Corn: $0.00
Other: $83.25
Inspection: $0.00
•
Total: $167.00
PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0
PARKING Existing: 0 - Required: 0 Proposed: 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)754-5826
244848(8/00)
DECLARATIONS 2 .
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have end will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is Issued.
❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed if the permit is valued of one hundred dollars($100)or less.)
�}Aertify that in the performance of the wo f• which this perffiit is issued,I shall not employ any person In any manner so as to become subject to the workers'
compensation laws ofAAyy'omit!,and agr e at if I should beer bject to the workers'compensation provisions of Sec on 37 of the Labor Code,I shall fdrthwlth
.comp ri tNhese s(6q - r-IT °S
n store: Date:
WARN FAILURE TO SECURE WORKERS'WM-- SATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOI�ERTO CRIMI AL P TIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOL/.ARE(MUM).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.tic.4 Class 4
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097.Civil Code).
Lenders Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve.demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she Is exempt therefrom end the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
u j s the applicanl to a civil penally of not more than live 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(Sac.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)
licensepursuant to the Contractors License Laws.).
L � 4amei.' 2.tynder sec. Business and Professions Code for this reason: �C
Ig�na�turr-e�'_ ., ,t .!� CDi�te:t•R'Iy OS /
ncior ID verified by driver's licenV Yes 0 No ( t is Ucertse No. - "/ / Expires: Q;Wo7
Verification of Ownership by(type of docume L' .-property tax bill or deed)!` ~_v /
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 tiled 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? if 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.
. __ .._.._ _ Heal. .._ly Code
bisio----
__ —.
4 If en RMPP Ls presently required,has Section 25534 of the California Health and Safety Cbeen fully complied with? 0 Yes ❑No
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application appermit for such construction or modification
from the South Coast Air Duality Management District or from any other air pollution control district or agency? ELI Yes Ll No
(Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No
(If yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a pennir from the South Coast Air Duality 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
B (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 AUTHOR •N OF ENTRY:•.-certify ••er penally of perjury that I have road this application and state that the information given is
correct. I agree to comply w all statelaws andordinances relatin• . • •Ing construction,end authorize representatives of the City of Costa Mesa to enter upon the
above-described propegy Bion urpose' 'gr in not .occupy.r a • occupancy of any building authorized by this permit until lin ins �'ion.
•
Si etuus.O1. =•afOrior(e)'ffC-, L-L•ti+ - 4. 11 Data-�-
And/Or Authorized Applicant Date
ODE I INSPECTION TYPE gen INTITIAL6 BODE E INSPECTION TYPE DALE IMID1SL9
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1268 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 7
204 Final Demolition 250 Final Building/Occupancy 1!1-mom .
t L' CITY OF COSTA MESA
4 atBUILDING DIVISION
F�:' ) DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER
: j PERMIT B05-01560
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.c$UILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 1775 ANAHEIM AV Status: ISSUED
Suite: B Applied: 09/09/2005
Vicinity: UNIT B Issued: 09/09/2005
Primary Occ: R-3 Dwellings/Cong Res<10 Type of Construction: V-N
Parcel Number: 42426324 Zoning:
Applicant: BOSTANDZIC, DINA 401,
Address: 1773 ANAHEIM AV .,1
Phone: 949-642-7105 ISSUED BY: Sa
COSTA MESA,CA Zip: 92627-3606 �
Owner: VEJZOVIC; MUSTEDANAGIC; BOSTANDZIC
Address 1773 ANAHEIM AV
Phone:
COSTA MESA,CA Zip: 92627-3606 ( e
Contractor: OWNER-BUILDER. Ire
Address: -
Phone:
Zip: License: 000000
Arch : Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
•
SCOPE OF PERMIT
RESTUCCO AN EXISTING 2-STORY SFD,UNIT B.
REF:B05-00556
•
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $1,000.00
Permit: $38.75 Claim Valuation: st,000.00
SMIP Res: $0.50
SMIP Com: $0.50
Other: $0.00
Inspection: $0.00
Total: $39.75
PLANNING & ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0
PARKING Existing: 0 Required: 0 Proposed: 0
•
•
REt,
Ip .
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
2446-48(WOO)
DECLARATIONS
WORKERS'COMPENSATION DECLARATION: •
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to sell-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workers'compensation Insurance carrier and policy number are:
Carder. Policy Number.
(This section need not be completed if r :permit is valued at one hundred dollars($100)or less.)
r I certify that In the performance• j wo 1 or which permit is Issued,I shall not employ any person In any manner so as to become subject to the workers'
^ compensation laws of California {. gre.that If I s d become subject to the workers'compensation provisions of Section 3700 f the Labor Code,I shall forthwith
((( comply with these provisions. /� �/1
..----
Applicant y t Date"OLABO �ll
_.`/Y[
OrFAILURETO SECURE• •- R ••M- •TION COVE• GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TOCNNTHE LABOENALTI AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOU ARE PM 00,000),IN ADDRI•' TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE R CODE,INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force end effect:Llc.a l Class 4
T
Contractor's Signature: _ Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which glyuires 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 shojis 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).):
74. 1,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 a_Jter 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•ropery,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contr'Il•rs License Law d•:s not appy to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)license pursuan(�wr{7 he Qntractors inset Laws.).
❑ I am exempt un. lee. and Professions Code for this reason: /,�
arm
Signature:_ - .2 i '_ t',' 1
1 �Expi as: 122/0/701Owner ID verifi:•b d. ars I :rise. ❑ es ❑No ibiNers`License,No.-
Verification of Ow • -h p 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,faisework,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:
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? ❑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
s or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutelyhazardous 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 a phcatlon apermit for such construction or modification
from the South Coast Air(Duality Management District or from any other air pollution control district or agency? Li Yes U No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Wit any part of the facility to be constructed under this permit be within WOO feet from the outer boundaries of a school? 0 Yes 0 No
(If yes",the faciliyryasl meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code).
7 If a permit from thfte��•tile bCoast escri :.• ;,merit District or other airpollution ooncontrol district03be or agency is required for the work which is the subject of this
application,have aII LN4}ie disciosur rescdb,," � .. le Health and Safety Code Section 42303 been made? 0 Yes 0 No
8 (If"yes',attach certificate of comet( a from t "� •^•ate air 1,7,:t._ �d� •ntrol officer).
CERTIFICATE OF COMPLIANCE:Irbertify the pn ('1•onatty•.• +Y e information given above is correct.1 agree to comply with all state laws and city ordinances
regarding Hazardous Materials and Emissiona:u LLL qtr n.,
Signature: ,. Date:
CERTIFICATE OF COMPLIANCE ' r t OR TON •:MIRY: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 s.: �jls an city ordi .5 relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property •r inspect T••s a! e: .o •occupy or allow occupancy of any building authorized by this permit until fi al i tion.
g : -=Of Lege • ner(s) — • Date ^.
And/Or • thorized Applicant Date
CODE!, INSPECTION TYPE PATE Immo CODE t INSPECTION TYPE 25.3 1NTmNL9
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 '1
204 Final Demolition • 250• Final Building/Occupancy +1 -PLT Q(A
F CITY OF COSTA MESA
BUILDING DIVISION
DEVELOPMENT SERVICES DEPARTMENT PER NUMBER
IFI4. IMO
PERMIT
` f,+ B05"00355
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
BUILDING PERMIT
Job Address: 1775 ANAHEIM AV Status: ISSUED
Suite: B Applied: 03/04/2005
Vicinity: UNIT B LAUNDRY ROOM AREA Issued: 03/04/2005
Parcel Number: 42426324 Zoning:
Applicant: BOSTANDZIC, DINA ISSUED BY: Ae
Address: 1775 ANAHEIM AV
Phone: 949-642-7105
COSTA MESA,CA Zip: 92627-3606
Owner: VEJZOVIC; MUSTEDANAGIC; BOSTANDZIC
Address 1773 ANAHEIM AV
Phone:
COSTA MESA,CA Zip: 92627-3606
Contractor: OWNER-BUILDER
Address:
Phone:
Zip: License: 000000
Arch : - Eng:
Address: Address:
Phone: Phone:
Zip: License: License:
SCOPE OF PERMIT
DEMOLITION OF AN ILLEGAL"LAUNDRY ROOM AND AWNING"IN EXISTING DWELLING UNIT B.
NO OTHER WORK AUTHORIZED WITH THIS PERMIT. - -
REF:C05-0309
FEE SUMMARY
Plan Check: $0.00 Calc Valuation: $300.00
Permit: $23.50 Claim Valuation: $300.00
SMIP Res: $0.50 _ -
SMIP Corn: $0.00
Other: $0.00
Inspection: $0.00 . .
Total: $24.00
PLANNING &ZONING_
SETBACKS
MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 / ,
ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right -0-0
PARKING Existing: 0 Required: 0 Proposed: • 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
2448-46(6✓00)
DECLARATIONS 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.
❑ 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 carder and policy number are:
Cartier: Policy Number:
(This section need not be completed 11 the permit is valued at one hundred dollars($700)or less.)
OI certify that in the pertormanc f he ork for whi• his permit is issued,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of Catfom d::r ree that if ould become subject to the workers'compensation provisions of Section 3700 of he Labor Code,I shall fdrthwith
comply with
e:these pr ns. CYO
NI
WARNG:FAILURE TO SECURE OR RS'•' -ENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL ENALTIE AND CML FINES UP TO ONE HUNDRED
THOUSAND DOUARE($100,000).IN ADDIRON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE,INTEREST,MD 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 lull
force and effect.Lic.p Class a
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant fore permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
A. I,as owner of the property,or my employees with wages es their sole compensation,WILL DO THE WORK,and the structure is not Intended or offered for sale(Sec.
7044,Business and Professions Cade: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• •perty,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contra •rs Lice se Law does••f apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant •de Co tractors Lice.so Laws.).
❑��I am exempt un.,:/ec. /-1 _y Business and Professions Code for Nis reason:
I�-. JfS •- -. t 7111,:fe
Owner ID verifi:• .y. 'vets 1,i 1nse. 24 Yes 0 No Drivr ea No. ' Expiries'siL., O' O
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 live(5)or more feet In depth into which a person Is required to descend,will be made in connection with work authorized by this
permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(38)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,California Administrative Code).
❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a
permit to do such work from the division.
Signature: Date:
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
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 end 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 end 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
....._.._ i_ . ..._..__. li_...___ Department.
4an RMPP is presently requirod_hes Section 25534 of theCalifomia Health and SafetyCode 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 appermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes 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? 0 Ves 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: //1 Date:
CERTIFICATE OF COMPLIANCE 41.11 •RIZATION • -Y:I certify under penalty of perjury that I have read this application and state that the information given is
correct.I agree to co ply with : . : e la and city ordi . :s relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described pro.: for ins..c on pu 4 :s.I agree n. o occupy or allow occupancy of any building authorized by this permit find ns
o
Sig ature a IT. w :r(s) O0' 77//--/
And/Or Authorized Applicant Date
;ODE• INSPEC110N TYPE PATE =1A65 c0ot• INSPECTIONTYPE QAIF RnmALfl
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
204 Final Demolition NY-�11�()j 250 Final Building/Occupancy
• On CITY OF COSTA MESA
t BUILDING DIVISION
• .,a\ DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
l;I r PERMIT
J -`"Moannwee IX05-00183
(714)754-5273 • Fax(714)754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 1775 ANAHEIM AV Status: ISSUED
Suite No B Applied: 03/04/2005
Vicinity: UNIT B GARAGE Issued: 03/04/2005
Parcel Nunmber: 42426324
i
Applicant: BOSTANDZIC, DINA ISSUED BY: �j
Address: 1773 ANAHEIM AV
Phone: 949-642-7105
COSTA MESA,CA Zip 92627-3606
Owner: VEJZOVIC; MUSTEDANAGIC; BOSTANDZIC
Address 1773 ANAHEIM AV
Phone:
COSTA MESA,CA Zip: 92627-3606
Contractor OWNER-BUILDER
Address:
Phone:
Zip:
License:000000 •
SCOPE OF PERMIT
LEGALIZATION 4 CEILING FLOOD LIGHT AND 2 SWITCHES IN AN EXISTING GARAGE FOR UNIT
B.
4 LIGHT FIXTURES,2 SWITCHES
NO OTHER WORK AUTHORIZED WITH THIS PERMIT.
-FEE SUMMARY
QuantityQuantity
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 $0.00 0 -up to 10 kva/kw $0.00 - 0
Lighting Fixts $4.40 4 up to 50 kva/kw $0.00 0
Recept Outlets $0.00 0 up to 100 kva/kw - $0.00 0
Switches $2.20 2 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 $0.00 0 Misc.Conduit - $0.00 0
Service to 1000a $0.00 0 ' - Misc.Conductor - - - • $0.00 -0
Service over 1000a $0.00 0 • Circus(gen or ride) - $0.00 0 •
Motors to 1hp $0.00 0 Circus(mech ride or lights) . $0.00 ' -0
Motors to 10hp $0.00 - 0 Christmas Tree Stand -$0.00 0
Motors to 50hp $0.00 0 Fireworks Stand . - $0.00 0
Motors to 100hp $0.00 0 . ' -Other Electrical Fee - - $0.00
Motors over 100hp $0.00 0 • - _ _-
Communicationdrops $0.00 0 - Investigation 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 end final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5826 .
24413-46(WOO)
DECLARATIONS a •
•
WORKERS'COMPENSATION DECLARATION:
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑ I have and will maintain workers'compensation Insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued.
My workers'compensation Insure e carrier and policy number are:
Carrier: Policy Number:
(This section need not be completed/ go permit s valued et e hundred dollars($100)or less.)
* I certify that In the pe ormance•U,•wo for which t is rmit Is Issued,I shall not employ any person in any manner so as to a subject to the workers'
(� compensation laws o Callfoml•, :y•ag that if h 'become subject to the workers'compensation provisions of Secti n 1300 1 the Labor Code,I shall fdrthwith
Sig
comply with these Previsions. r 0� X1 [ �1)
store: Sf /v7 /v>
WARNING:FAILURE TO SECUR- ••• •RS' ENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIM1 PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOGARE(VOODOO,IN ADDI ON TO E COST 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 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.Uc.# Class 0
Contractors Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lenders Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant fore permit
sublets the applicant to a civil penalty of not more than five hundred dollars($500).):
I,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 Profess') s 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 throug 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 corn*lotion,the owner-builder wit have the burden of proving that he or she did not build or improve for purpose of sale.). •
❑ I,as owner of the property a 1 XCL i SIVELY•• TRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors Lis:n•: :w•.es not ap ly to an owner of property who builds or improves thereon,end who contracts for such project with a contractor(s)
license ursuant to the • /:•tors cense Law L,
❑ I am axe pt under se / Business and Professions Code for this reason: 03 t r��(/�� y
,Swremy F1�Va�1% r
E4 es: `i T n
Verification of Owner ip 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 Ls 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,wit be more than thirty-six(38)feet high.(Chap.3.2,Grp 2,Art 2,Sec.
341,Title 8,Califomia 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 hes 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 ❑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 Califomia 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.
.____ ._.___..._ ___._ ___._.._ s_.-_.. No .__..._..
4 If an AMP;is presently required,has Section 25534 of the 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 apermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes Ll No
(Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential any building permits).
._.._.._._ _t._ _ __ _ __.____.......__._.__.._.........
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If'yes',the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code).
7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by 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:
I
CERTIFICATE OF COMPLIANCE • A ORIZATI• •F 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 allI •os:s.I agr.•not to occupy or allow occupancy of any building authorized by this perm un it f el ins ction.
e la s and city.. • ances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described prop: for In 1, rt•r p //_n
Si. :Iu• iOCvner s) d3 �
(IOat
And/•r Authorized Applicant Date
NODE I INSPECTION TYPE RATE 0=M$ CODE( INSPECTION TYPE PATE INTRIAL.S
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Fool Spa Final 208 Final Plumbingr.(1.0
200 Final Re-Roof 210 Final Electricalal
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