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Home My WebLink About1875 ANAHEIM AVE - Building Permits Costa Mesa BilliaingDepartment (Q]C JiPPLICATIUN FOR KG COST FAESA,ST CtAL h STREET FORMA 1_V5 - • —B-U.I.L D_,L KG - -.-- It s' FOR APPLICANT TO FILL IN FOR_OFFICE USE ONLY/n Receipt No. P rP ftlNo. ' Building G •y i - l ! _ 9GO MRi\Y:-hibti • Address O /J �/�T .w �t JedI - - / `� 7A/ A . y, D Rec' Date Issued I Costa Mesa, California 7 / A . •tl iz Mn' 0'1954 Nearest t /y +7r p ./4 T 4 Cross St. t Address / p 7Q ',7/YQ/e i a 7 uC Owner P•L- /t'1 C A n(SCosta Mesa, California ' Mail � Address 44 ( n-3a ,4,.... • Nearest I Nola ` zoCrne St. t City vim- • No./48.1L� Zone pNo.of Type I Group �: Architect or Lic. :(I I Plans I / I Engineer No. Approve by Date Address v city L : CORRECTIONS I ' Contractor Nob( �w • fit /� No. y 1 , Address e��s0 (.)r(,,rL 4n., (;ara.Cq 1(1444. —776 C2o _ ys Legal Lot '/ . i N-•^. r,^%I- - I I Description I No. Y D\occk I Tract-lZa4' , /j�{,, . • (Attach Metes and Bounds) ,'/??A('tie O ` �/ No.of Bldgs. �"• )))...,,,,,, Sizeo?Lot ,7� J< 90 I Now on Lot C (e/,.e-- - '1 ^ ,0 .. ._' . a Use of A, No.of { ..oi ( O 49, _ Existing Bldg. V I FamiltesT �BbMSC)_ T q — __• LI Setback Line from ,.� z Rear Yard 3 (o" .- (, -- •-_- ~- - - 2 • Center of Street J 0 Side Yard S �041',- * B; „_," f., DESCRIPTION OF WORK r New x I Alteration I I Addition I ' I - Repair I I Moving I I Demolish I i' Building No.of ' Size 39X;0 Rooms Stories • Exterior Wall I Covering Covering ,�p Covering � ,APPROVALS. , .. • Use of New ,/1 .. Building _=,U U_ ,,. Foundation Location Inspector Date i """'•n -Forms,Materials,. E .t,4.. t c I Undee-Pinning Y. 1 ° ' _ - • Frame: Fire Stops,-a Bracing,Bolts , _ Lath. frit. . .. . •. I ... ..• . I hereby acknowledge that I have read this Application and state that the above is correct and agree to comply 'Lath. Esti • • ` "` _ C ' with all City Ordinances and State Laws regulating - building constructib ' - - •• - - , Signature of I/s / - -/ Plaster, Int. Permittee — -.:". ' - Plaster,'Ext. • " "' - - . Authorized Agt. - . et Masonry Reinforced Valuation Permit Fee $ ,i4/O a % Plan Check $ .3 D O Bond Beam $ bf Total Fee S .7'7 O d FINAL << .• ai \ •. J C. . 2 a - ,J,a a . ' J r , • Street •• Ne, PLOT PLAN - - Show location and distances from property line and between buildings. Dm youcarryworkman's Compensation Lnsnrance? Yes [ No f • R'ammar e of Provision 3700 of the State Labor Cedewhich requires every employer - • to b8 lured ainst liab• • ))LLy for Fork aA"s coin ation. CAE pigged: • , rii> _ 73"7 . , lo COSTA MESA BUILDING DEPARTMENT FEE RECEIVED • P.O. BOX 317 C�. COSTA MESA. CALIFORNIA ny/��'lJ j�' (I ( {�7=a FOR APPLICANT TO FILL IN APPLF4 N I a PERMIT"�� BUILDING/ 276-1,,a.44 / ._ _ . �I� tttllllllii3FFF . G ADDRESS 9V l.rtiCfL r COSTA MESA. CALIFORNIA FOR OFFICE USE ONLY �� I /1 ` RECEIPT NO. PERMIITT NO. // OWNER'''. 4.�Ps. �/>,I� �. MA)41..4a DC e/lo J 11� MAIL ✓✓ O \ `/ l,, ED BY ,.�(p TE ECEIVs/J DATE ISSUE VV1 ADDRESS/O /L /Ad*/end .e + �J �r S7 3- A3`v ,/a TEL. BUILD NG CIT�j� Spit./1 c.7.5 /f- .- NO. ADDRESS ARCHITECT ['� LIC. OR ENGINEERER +. r.= 5 / iu�� NO. COSTA MESA. CALIFORNIA FIRE ADDRESS/76 r ,J,4. a&r L Q J ZONE II.. � / CITY LIC. ,1 _ 2oNE�/ PLAINS TYPE GROUP CONTRACTORWo yAIAL- GCIz47-e.. NO.•�-f 6 ?, (` 4" j I ADDRESS ') n ��LL TEL APPROVED 1�I Aj �74� <J�I � R.o bw14 Y NO if, K.)311) BAY /��j�y 11Ly�y�/yAy�TryE�p/ DESCRIPTION NO. 0,2-�BLOCK LEGAL LOT TRACT ' �/''(�C•/`7�� A.P.NO. i / G r GI C' -:3 3 �� r v • LI 512E NO.OF LDOS CITY OF COSTA MESA of Lor(P�J, 6 �( C) NOW DNEI LOT ( PLANNING DEPT. USE OF SUBJECT TO 8 G. DEPT. RtG. EXISTING BLDG. p.,ec iA 1.7-4.../p- �%f �/ • SCEi TECH FST FROM 'REAR YARD V /� // By... [,�i 3 .( /�.1 CENTER OF STREET Yl A ,i p PLAN TcCHrAl SIDE YARD RIGHT/1��•(e, LEFT DESCRIPTION OF WORK 6 � ,� "` A R I A N V E NEW ALTERATION ADDITION X REPAIR MOVING DEMOLISH REQUIRED NO.OF SIZE \ L k ROOMS STORIES ( /// ) �� c I EXTERIOR WA1I� ROOF G'�..�`.LLt l-��1+-- • I �V r�'� '.r COVERING (/'�ALv..0 (t COVERING .N Po •-- (- DATE � L USE DI NE ad J _ /J 20 IC ,�/ VAR. No.- APPROVED `�/�ti '• ' BUILDING �hl I/ lJ I HEREBY ACKNOWLEOGtIS CAT 1((Nr AVE READ THIS APPLICAT16N AND/ STATE THAT THE ABOVE IS ORRE AND AGREE TO COMPLY WITH ALL CITY ORDINANCES ANO STATE LAWS REGULATING BUILDING CONSTRUC- TION. VALUATION PERMIT FEE S /.2 PIG MATT RL PERMITTEE 4— ' % $ g 6 CA PLAN CHECK $ AUTHORIZED AGENT TOTAL FEE $ l 1 `Awl Costa Mesa Building Department APPLICATION FOR PERMIT 1116 - 20thSTREET BUILDING1 COSTA „A, CALIFORNIA . f' FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY ata__, � Receipt No. Permit No. Building lig 2� (.1` C�W-�i 78 I A? Address P�Y14-/ %vw Received by Date Rec'd. Date Issued Costa Mesa, California , • Nearest /"' �3 —Cr Cross St. d s.,....- Building Address Owner r eacat Costa Mesa, California Mail \ Address 4,745.— 02.-v--✓ Nearest \ Tel.jot cz 7�p Cross St. City �J No.,/t O / Zone / No.of Type I. Group Architect or Lic. I Plans I I Engineer No. Approved by - Date Address • CORRECTIONS City Lic. Contractor Pli-4&/1/-• l..No. .. Address Lept� Description l I Lo. I0' I Block ot II TTra�ct��...- (Attach es n o da tC/�Z�ZeZZ, rt) -- No, on Lot ,, ^ Size of Lot I Now on Lot /5/A/ �� 0 Use of I No.of I No.of 9 Existing Bldg. Families Rooms G1 Setback Line from Rear Yard t^� Z Center of Street Side Yard ps ___ 'lll,��`�`iiiJJJ,'.ddr'"' n DESCRIPTION OF WORK r New I I Alteration I I Addition I I A pi 1 3 5155- Repair I I Moving I I Demolish I Building No.of Size Rooms Stories CITY OF COSTA MESA Exterior Wall I Roof Covering Covering APPROVALS Use of New Building �hJ� L{/J �� (Jy�f Foundation Location Inspector I Date . 0 /n/ �v"_p Forms,Materials, Under-Pinning ,5—' / .h C- /. /3o' Frame: Fire Stops, W'V Bracing,Bolts r ..'& C ° i r .r � c Lath.Int. I he?' y a t'. edger"`khat I .ve read this A.-. ''cation and state that the above is correct and agree to comply Lath. Ext. with all City Ordinances and State Laws regulating building constructi. Signature of Ala , Plaster,Int. Permittee /i!.e . i ✓ P Plaster, Ext. Authorized Agt. Masonry Reinforced Valuation- ?? Permit Fee $ $ ..:J 01 Tota l • Plan Check $ D 1 Bond Beam Fee $ 4, /0 I FINAL 10Ci(7 - N..)1:?i..) •._- . . .. • - • 1 4 , - _ _ _ :1 _ _ _. __.. _ _ _- . C o -1' • .1... L I-r r-- o . . _ ej - - - - - _ I. t —' - f.' - - - - _` `III- ��' . . , , ' 1 __ : ---- -- - - -Si - .. -.it: - .t",, rc,.Q^9- _ - -a.-'.- • (Street n•r .'r - • PLOT PLAN -- _ Show location 'and distances from 'o• '•' �• - I property line and between buildings. I... • •- Cilie' ilicl.'') ,Ii.t YIP 11^ I . • • . •• - ' 1 S CITY OF COSTA MESA o0"MFS BUILDING DIVISION 4 9 F• -' 77 FAIR DRIVE,COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 41 7"A# FOR INSPEdTIONS dALL:(714)754-5626 '° fi PERMIT NUMBER: B11-00166 • PERMIT TYPE B_ROOF2 STATUS: ISSUED APN: 42421222 DATE ISSUED: 05/31/2011 ISSUED BY: KJB • JOB ADDRESS: 1875.ANAHEIM-AV-CM=_Z7 Suite/Unit: Vicinity: Squares: 3100 - Valuation: $3,500.00 SCOPE OF WORK: RE-ROOF EXISTING DUPLEX AND GARAGE.APPROX 3100 SO FT. ROOF PITCH IS 3:12.COVER WITH CLASS A -30 YEAR COMP SHINGLES.REF:BC11-00192 FOR FIRE DAMAGE REPAIR WORK AT THIS SITE. NOTE:RESIDENTIAL RE-ROOF: Final approval of permit shall not be granted until access to dwelling unit(s)is provided for verification of the installation of smoke and carbon monoxide alarms by the City Inspector. See Attachment w/Inspection Card OWNER: MAC MILLIAN,RODERICK H • Address: 1875 ANAHEIM ST Unit: PHONE: City/State/Zip: COSTA MESA,CA APPLICANT: VALLEJOS,TOM Address: Unit: : PHONE: - City/State/Zip: • CONTRACTOR: BARTWOOD CONSTRUCTION INC License No. 592681 Address: 10840 TALBERT AVUnit: PHONE: 714-965-7900 City/State/Zip: FOUNTAIN VALLEY,CA 92708 CELL: ARCHITECT: License No. PHONE: ENGINEER: License No. PHONE: FEE SUMMARY Reroof Plan Check: $0.00 Reroof Permit Fee: $97.25 Reinspection Fee: $0.00 Bldg Std Admin Fund $1.00 TOTAL FEES $98.25 HOURS FOR CONSTRUCTION ACTIVITY; EFFECTIVE 3/18/2010-PER CMMC Sec. 13-279 Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibitied all hours-Sundays and the following Federal holidays New Years Day, Memorial Day, Independence Day, Labor Day,Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia 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. CODE N. INSPECTION TYPE DATE INTITIALS CODES INSPECTION TYPE DATE INTITIAt,S 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final y 208 Final Plumbing /r 200 Final Re-Roof 6-' -fl mP 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 driv�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 or deed): compensation, as provided for by section 3700 of the Labor Code, for the ormance of the work for which this permit is issued. • I have and will maintain workers'compensation insurance, as required by • • Con 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 i urance carrier and policy ❑ I hereby certify that no excavation five(5)or more feet in depth into which a number are: ,/Q �/ ��,n D person is required to descend,will be made in connection with work authorized Carrier: �`� ' -r .A/f$(1/"Y "`1.— by this permit,and that no building structure,scaffolding,falsework,or demolition (This sedan nee67/149-14-- be completed it the permit is--w-�eAd at one hundred dollars(8100)or less.) or dismantling thereof,will be more than thirty-six(36)feet high. (Chap.3.2,Gm 33o QC7�� '[Sir� 2,Art 2,Sec.341,Title 8,Califomia Administrative Code). Policy Number _l 0 As owner-builder, I will not employ anyone to do work which would O 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 orthwith comply these provisions. //// T Division of Industrial Safety Permit Number: Apo' m's'S`i9nawre Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: AILURE 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? 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? ❑Yes 0 No Lic.# 06 fr/ Class# . (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by „ems/ •® each business which at any one time has on hand a quantity of acutely a /tors sirialure Late 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). O 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 which this permit is issued.(Sec.3097,Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? 0 Yes 0 No Lender's Name: (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 Dale 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 requested that he or she is licensed pursuant to the provisions of the Contractors information be fumished on applications for non-residential building permits). 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 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). ❑ 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 Califomia 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 purpoge 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 contractor(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. • ego • . Is) Datoma Signature Date /� 3057-46(3/07) J / Andlor Autper -. 'pPlirant Date • CITY OF COSTA MESA os¢ ,y BUILDING DIVISION Fi '.!,CMB 77 FAIR DRIVE.COSTA MESA,CA 92626 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714)754-5626 V'%Veen ° PERMIT NUMBER: BC11-00192 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: RES_ALT DATE ISSUED: 05/03/2011 ISSUED BY: RMD JOB ADDRESS: 1875 ANAHEIM AV CM Suite/Unit: APN: 42421222 Zoning: , , Vicinity: GARAGE AREA - Primary Occ: Const Type: V-B . SQ. FT: 550 Valuation: $10,000.00 SCOPE OF WORK: FIRE DAMAGE REPAIR TO AN EXISTING GARAGE AND HOUSE RAFTERS FOR UNIT"E".WORK TO INCLUDE REMOVAL AND REPLACEMENT OF AN EXISTING EXTERIOR GARAGE WALL AND REPLACEMENT OF RAFTERS AT GARAGE AREA AND PORTION OF HOUSE WITH 7 LIGHT FIXTS, 10 OUTLETS,3 SWITCHES AND UPGRADE SVC TO 100A. SQUARE FOOTAGE OF GARAGE TO REMAIN 550 SF. . OWNER: MAC MILLIAN,RODERICK H Address: 1875 ANAHEIM ST • - Unit: Phone: 949-642-6248 City/State/Zip: ' COSTA MESA,CA APPLICANT: VALLEJOS,TOM Address: , Unit: : , Phone: 714-727-7322 ' City/State/zZip: • CONTRACTOR: BARTWOOD CONSTRUCTION INC . License No. 592681 Phone: 714-965-7900 Address: 10840 TALBERT AVUnit: Cell: City/State: FOUNTAIN VALLEY,CA ZipCode 92708 ARCHITECT: License No. PHONE: ENGINEER: HANSEN HOKAMA STRUCTURAL ENGINEERING License No.S4505 PHONE:714-573-0073 • COMBINATION PERMIT FEE SUMMARY Building Plan Check: $117.81 Building Fees: $181.25 Electrical Fees: $76.00 Mechanical Fees: . $0.00 Plumbing Fees: $0.00 SMIP Residential: $1.00 SMIP Commercial: $0.00 Bldg Std Admin Fund $1.00 TOTAL FEES: $377.06 "Refer to fee receipts for all fees paid for project HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010- PER CMMC Sec. 13-279 Monday thru Friday-7:00 am thru 7:00 pm. Saturdays-9:00 am thru 6:00 pm. Prohibited all hours-Sundays and the following Federal holidays: New Years Day,Memorial Day, Independence Day,Labor Day,Thanksgiving Day and Christmas Day 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. CODE If. INSPECTION TYPE DATE INi1TIALS CODEC INSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention _ 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical X S-3- II /NP b y oL. 201 Final Block/Retaining Wall 212 Final Fire Prevention _ 202 Final Factory Fire Place _ 220 Final Planning Approval 203 Final Sign 222 Final Site `/ p ��n/n{l- 204 • Final Demolition 250 Final Building/Occupancy y B 5-» r�" "'/ "`' WORKERS'COMPENSATION DECLARATION• Owner ID verified by driv ense. ❑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 erformance of the work for which this permit is issued. I have and will maintain workers'compensation insurance,as required by tion 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 number are: person is required to descend,will be made in connection with work authorized CartierCarrier" [/w'n rrie i ee4-� /j g ¢, Ct, Q� by this permit,and that no building structure,scaffdding,falsework,or demolition or dismantling thereof,will be more than thirty-sixx(36)feet high.(Chap.3.2.Grp (This sector need not peredd the pemM is valued at one hundredhdollars($100)or tess.) 2,Art 2,Sec.341,Title 8,California Administrative Code). Policy Number: 33 0 00 Sir fl ip ❑ 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 t. - ers' compensation pr visions of Section 3700 of Applicant's Signature Date the Lab. vie,I shall fort 't .mply with th a provisions. �/•3 //r Division of Industrial Safety Permit Number: Apph, Slgnaw7e Pa!e�/- - 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? 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-iGn�full force/ and effect. /� a registration form for acutely hazardous materials? 0 Yes 0 No Lic_#'- J- /210�/ Cl s#--- b (Section 25533 of the California Health and Safety Code, with some _ __ exceptions, requires registration with the Costa Mesa Fire Department by r/f f each business which at any one time has on hand a quantity of acutely actors Signa ure .ro - 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 for 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. Signature Dale 4. If an RMPP is presently required, has Section 25534 of the California OWNER-BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑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? ❑Yes 0 No issuance,also requires the applicant for such permit to file a signed statement (Section 65850.2 of the Califomia Govemment Code requires that the requested that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits). 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 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). ❑ 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? ❑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. I 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 Date 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 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. -I O+mer(s) Date Signature Date r/3% 3057-46(3/07) A • •uthorized'Applicani Dat