HomeMy WebLinkAbout1379 BAKER ST - Building Permits re,,,,, CITY OF COSTA MESA
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DECLARATIONS (
•
WORKERS'COMPENSATION DECLARATION: 0 •
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 layhave and will maintal orkers'compensation' urance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is iced led.
My wore pen tion Insur carrier policy number are:
tar—S.,
�/r POIIcy.Number ?BEV•- 3
.-(Th(s section need not be comp/et if the.emelt is valued et one hundred d ars($100)or less.)
❑ I certify that in the perfo ,nce of t ii work for Ich this permit is I d,I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of J omia,aagree tha 1 I shout become ject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with these prov i r s. r `
Applicant'Sipnaiurei - Date:
\ iN'ARNING:FAILURE TO SEC •-I RS'COMPENSATI ERAOE UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOl1ARE($100,000).IN ADDn1ON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION roe OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATI•I :
��'ry _I.hereby,affirm.that�license.�I,- r�Pj 5si •hapter 9(corn•:ncing with Section 7000)of Division 3 of.the.Business and Professi$ns Code,and my license is in full
`® ;force and effect.Lia.N._ r �1 7 :'<`GIa54.Y..�--1�� S
Contractor's Signature: I a Date:---
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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 for a permit
subjects the applicant to a civil penalty of not more then five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,end 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 properly 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. 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 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 an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health end 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 Eermlt 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 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 partof 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 ENTRY:I certify under penalty of perjury that I have read this application and state that the information given Is
correct. I agr to comp) with all state laws and city or ' ances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-descri d prope for i spection purposes.I agr not to occupy or allow occupancy of any building authorized by this permit until final inspection.
Si natur f Legal er(s) t -"C.) /Date
Warr - OF n pplicant._ -- Data ._
;ODE if INSPECTION TYPE Dale REMAI5 CODE if IBSPECTIDNTYPE ;Ale IIf
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final /p L_ '/� 206 Final Plumbing
200 Final Re-Roof Q LC �� (6Y 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
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. —
CITY OSTA MESA. _ • PERMIT NO. ' TRACT NO. • LOT NO., BLDG.NO. ' •
1• 779 - • ,.
CONST • UCTION PERI)AIT /
Applicant's Meiling Addr -s - • • - • ` �' TYPE OF CONSTRUCTION ' NEW U ADD U ALTERATION U REPAIR •
1• /�4t �_,
/� BRIC'h/ '❑ CONVERSION '❑ DEMOLISH 0 OTHER - `- •
• i��st►•SalpiCi-�
Project Address n , -
K2 ry R D SS Phone DESCRIPTION OF WORK
Owner's'NameZONING REGULATION• .-A- y�_(�-610,19c3
Address: " 'j,D: ti 19 . N..3 N 4 - . . - - - { a7'<ip--Yettitrl Y 't
.
\' TYPE OF PERMIT ❑ GRADING rU FF,0UNDATION 0 STRUCTURAL A.P.Mi•' ZONE 1
1V1` Arch/Eng. License NO. ❑'TENANT ❑ ELECTRICAL Bd'PLUMBING 0 MECHANICAL PLNG.REF,W. - • r-BUILDING• __
�O Address) - ❑,OTHER gPrg&Cr r•rl 9 CITY-.00()FLOW
F MCL p
rr q - TO BUILDING , • REAR YARD •(TO P/L), 1 1 !1 LaJ1
Contractor's Name 5th �p/Rl—bS PI nor Phone ��R•S.7p PROJECT DESCRIPTION SQ. FT.• ' OCCUPANCY PROPERTY LINE
Address(mailing) I TS -J'1� 'Rib -� {r� CONSTRUCTION TYPE ' VALUATIONS LEFT SIDE YARD RIGHT SIDE YARD:
�, D , QI g < I I • ZONE ' - ' ' GRADING CU.YDS. •' �ACRF% •• PKG.SPACE REG. 1 , PROVIDED I
License No; '_ ..- - - — - -.
\ LICENSED CONTRACTOR DECLARATION I Remarks: _ I ` - STREET WIDTH , t PARK FEE.S _-
I'.heieby,affirm that l'am licensed under provisions of Charter.9 (commenting • _ • -
with lection 7000) of Division 3 of the Business and Professions Code,and j f 1 • _ SPECIAL CONDITIONS: I • 7 • I
my license is in full force . •'effect. , - - - -
License Class' C - •—
License N ' 15 � i -II PLUMBING ' -
Date Signature - /'• . , : •
(....t." : Bar Sink ` • Sewer Cap ELECTRICAL - I
�x reby S'COMPENSATION D' ' •TION - • - - '
F i^bi reby affirm trot I have a certifl - e •1 a certito self-Insure era certificate..tion • Backflow Preventer '' • Sewer Connection - - --• - . -- . Automatic Washer i_ - t_ - - :Metro Clover 100 amps' - - _ _ •
'Workers' Compensation Insuranc,•or a certified cppy thereof (Se tion - _ -
3800, Lab. CJ ' 2 / F_ 1-" A" J Backflow Irrigation , Solar Collectors • , •, •
Construction Pole Sub Panel 4,
Policy No, C• O Company c/1-LlX.7.C. 'r ' I — _ - - - Cooking Unit ' Sub Pole , I
Certified copy is hereby furnished I ' I Bathtubs 1 • Solar Piping I
r5rti 24;5,s/tiled led with the city B • ng Divlslo Dishwasher 'Motors ❑41 HP ❑1X$ i - '
; Date !!``�� .Applicant J•r ' i��•/- "1: Clarifiers ; _ Solar Tank ' -
•
' EXEM ION ROM WORKERS'C. •PENSATION DECL-RA ION • • Diyers '❑Gas "❑Electric - ;Inc$olar 0945-HP ❑16-15+ i
(This section need not be completed'f the permit is for one hundred($100)or Dish, iNNSher , • - I , Swimming Pool w/Spa ' ,
less). I Fan; 'Microwave . I i
• I certify!that in the performance of the work for which this permit is issued I 1 I Drinking Fountains - Urinal. , - t .
shall•not employ any person In any manner so as to become subject to the , - F.A.U. Pole.Light i I i
Workers':Compensation'Laws of California. I Floor Drains. ' Water notal. - -
Date • - ' Signature Fixtures Ran e ' _
, NOTICE:if,after making this declaration,you should become subject to-the' , Floor Sinks- . -- a - - -- • Water Heater - - - - . . . . - - - --- . - - - g -! - . ._ - - . . .
Workers' Compensation provisions of the Labor Code,-you-must forthwith DeVICa BO%e3 , ' 4
comply :with such provisions'or this _permit shall be'deemed' revoked, 1 ' Gas Service- 1Z :Outlets• Water_Service ' ' c- 2 a e a 'Sign , ,
CONSTRUCTION LENDING AGENCY ' 1 . ( • • ' • I - 1
i hereby affirm that there Is a constructlon.lending agency for the performance- i • Interceptors; ? I , OU els 1 I Standing Sections
of the work for, which- this permit is,issued r(Section .3097 Civ: C:) - - — - ' - -
Lender's' Name - I i ' - , - • I - _ Switches : Trash Com actor
- • r _ I - _ r KitcheriSink __ _- _ - - i P
Lender's AOoress - , - Garbage Disposal • I
OWNER BUILDER DECLARATION - • ' • • lavatories . • -
I hereby:affirm that I am'exempt from the-Contractor'i,License Lave for the ' - - - - ' Generator 00-5 KW ❑5.15 KW •
following reason (Section.7031:5 Business and Professional Code: Any city or P-Trap, v i- , ' i i, _ ' '
:county which requires a permit to construct,alter improve;demolish:or repair - -. { - ._ _ - Transformer 015-50 KW ' - • •
any structure, prior to Its'issuance,also requires the applicant for such permit' I Roof Drains) ,- I . ' ' _ - - .
to file a signed statement that he/she Is licensed pursuant to the provisions of , - - - - ' ' - - '' DSO+KW
_,Contractor's License Law(Chapter 9(commencing with Section-7000)of - ' ! , i ' - 'Reinspection Foe ,•I".•;.....-Isioni3 of the:Business and Professions $15 i
. eirom end the basis for the alleged exemption.�Any,r that
ion of Serhe/she IS mon • I. Showers n• - j Reinspection Fee $15 Meter
>`31.5 by, any applicant for:a permit subjects the-•applicant to a:civil ' ' - - r ' ❑up to 100amps Issue Fee $ 3
anally of not more than five hundred dollars($500). - Service Sink' " Issue Fee $ '3 1
LI i; as owner of the.property 'or'my employees-with wages as their sole 1 - -" '- - -• _ _ - Zoning Approved BY i Data
compensation' will,do the work,and the-structure is not intended or offered , i : �. I , MECHANICAL I• - i Application Approved By Date' / '
for sale'(Sec/Ion 7044, Business and.Professional Code:'The•Contractor's _ - r . /7? /�
' Ucense Law does not apply to an owner of a property:who builds or improves , Bolles Refrigeration System •: - 1J/ (p l{/
thereon es, pro,who does such work himself/hsrseit or through his or her own �• - I Application Issued By - Data ,
employees, provided that such'improvements is sol not Intended or offered for ' 4 ❑0100,000 BTU ❑100,00087U . •
sale. If, however, the building or Improvement Is sold within One year of com- 1 Duct' Under,Ground 1 I • I SUMMARY OF FEES
Motion, the owner will have the burden of proving he/she did not build or Im- . - - - -- - -- -- ---
rove for the purpose Of sale): Duct-Structural ' System Repair)Alteration ,BUILDING PERMIT $ ' SMIP : • $ •
U I,as Owner of the property,am exclusively contracting:with licensed con- - - . • , . -.
',tractors to construct the project (Section 7044,Business.and Professions Code: Duct.Ventilating_ _/.,,�, _ -'__, ,- _ ,PLAN CHECK - $ PERMIT '
The Contractor's License Law does not apply to an owner of property who . - , {{(La ISSUANCE f •
$ '•
builds or improves thereon,and who contracts for such projects.with a•con- Exhaust System 0 Multiple❑' 1 i ,PLUMBING - 1 $ Is/•
tractor(s) license pursuant to the Contractor's License Law). - - - PLAN CHECK ' $ GRADING i , $ ! -❑ I am exempt under Section ' B.& P.C.for this reason Firepl/Fact.Bit. ICBG 5N• - , I •
i t -. • . ,
f i r -ELECTRICAL, $ •
Date . ' t ' ', Owner I I Heating System&Ducting :. ,.
•PLAN CHECK' $' MICROFILM $ '
' •-hereby certify-that i-have read this application and-state that the above '• ❑0.100,000BTU 0100,000 BTL— - - - - -
information is correct. I agree to comply with all city and county ordinances ' 1. TOTALFEE $ I • '
and.state laws relating to benter- .construction,and hereby authorize repro- - 4 - -- •MECHANICAL I $ - I I I '
somal Ives • s city,to enter. upon the •ova-mentioned property for Hood Or Type I 0- Reinspection Fee. $15 - LESS '
inspection'ourp•ses, Canopy Type 11 ❑ ,PLAN •CHECK; I $ ' • 'ADVANCED PC ? $
Signature, /rii - Date • - - I 1
Drivers' -rise or'SS 3X , , Registers Issue Fee $ 3 _ _ I, _• _ • _FINAL FEE ' ' $
CMF 0:65-46 rev.12/82 White-Building:Canary-Applicant:Pink-Accounting;_Goldenrod-Assessor - - . . . ca.-0
4 .- .
POO PA RCONSTRUCTIONAND,PLANNING
rnspector • ' Date In ecmr. 'APPROVALS , P°ermit#` °-F7�q�z :.Date, APPROVALS - Permit# _
-
Temporary Electrical Service&P-Ole •� - - _ 52: Pool &.Equipment Location - -
!_� 2: •Soil Pipe-Undrgrnd_' .4., r f."..! - ' i :71 :. 4-> z >y - _ , ' 53.' Steel Reinforcement _ - - •
. •
316lectrical Conduit Utiliiv-Undrgrnd I : ; T`, : >- .'54.' Forms '- • • - - - -
I` 4. Electrical Conduit-Undrgrnd z 1 '. ' ,•, 55: Electrical Bonding ' '
5:.Steel Reinforcement r f',,-;17., c.. •t. .- - .56.- Rough Plumbing& Pressure Test - e. _ '
6: Electrical UFER Grnd.' ° - - _ . - 57. APPROVAL'TO COVER-GUNITE-
7. Footings I ,• • - E - 5= - 58.Electrical Conduit•Undrornil:
8. Foundation Ia_' ' - ,
I z, _ 59. Pas;Pipe,,O.Undrgrnd.,Test'
9. Water Pipe-Undrgrnd: 80. Backwash Lines,.P•Trap, 0 Undrgrnd.
10. Structural Floor System ! g.,;" ;‘...: 61. APPROVAL TO DECK =
11. Property Sewer Line& HouseConnection, c ° !r..
62. Backwashs'& Receptor-Final
12. Sewer Cap i " r4 ' • 63. Heater& Vent-Final- -
rr
13. Roof Drains l - 64. Plumb ng.System • Final - -
ii
14. Rough Plumbing ! • � � ' _ = - 65. ElectricarFinil •- - -
, 15.'ROugh'ElectricaRConduit'fl:-'- -T' r-- -- - ,- - - - •• --
R I I : � 86. Solar Systi:m-Final ,
16. trough-Electric Wiring, y ! E I - -f : - - • -
• " �r`� , ` i � 67 , Fencing&�Aceess Approval . -
_ 17. `.Rough Wiring Signt3 .. i - 1 1! I. . l , V I i P :. • :68.• APPROVED FOR PLASTERING
4. 18.•' lj'B
Rough ElectricaSr Ceiling ; I ' - "4 _, ' ; 69. POOL/SPA SYSTEMS FINAL ' •
19. Rough_Heating& Air:Conditidning ! : I 0 _ ' . •FIRE DEPT. REQUIREMENT- - ' '
I .
'' 20. iRough•.Factory Fireplace I . . i , , APPROVALS] Permit;#
- i 21.,Ducts, in SOucture2 t ( !• i; i I I I / i 70. Underground Hydro - .
4 22. Ducts, Ventilating ; I ; !" 1 i 71.' Product Piping D Gals D Oil '
:'23. Gas:Pipe-Ro ,
ugh&Test j I ,.- ' I l I ' II 72.. Underground Flush i
24. Roof Framing- ' ! • I - 1 , i - !• :73.! Undergrnd.Storage Tank D Gas 0 Oil. .
-, 25. .Roof Sheathing ,. ' -
•
l - 'j.: ' '- I 74 , Overhead Hydro ,
--26:T-Bar Ceiling (Structural),& Monocoat• ! • ,I _ ! .1 : ! ' '75. Dry Chemical ' . - - ' '
' 27. 'Frame and Flashing, : i l !l . , i I ; . ' I 76.: Dry Standpipe
28. 1,ILathing& Siding' 1 I ii :1 I ! I 77. FIXED SYSTEM FINAL. ..
y29._..Insulation jz ; 1 ' • I I ; I i I I l I 78. FIRE PREV. FINAL '
,
-30. ;Drywall Nailing ' i• , '`! Ii i Notes:
y 31.,Plaster Brown Coat • : - 1 ii i___ 1 r --_ - ---
• .32. Electrical Power Meter,Final I 1I � � ! -
33. Final Electric ' ! i ' 1 i! i , { I ; . 1 4 ' I
34. Final Heating& Air Conditioning G ; ' ' I I ,
35. Final Gas Pipe-Test , ' II I .. a !ai - I I- Ir , > ' j'' IT .
' . • '
36. Hood or 1Canopy., - '` ,! : 1 ` l: - H . - -
37. Final Factory Firetr places _ I ^I " ' - .
38. Final Plumbing 1- . •., 1, . , - , -
•
39. Water•Service-Final! i I •"
40. Gas Service-Final ' 1 ! ! i 0 4/?0/47-1, / : „ t. , . . _.
41. Solar Domestic-Final 1 l I ,1 _-L . _J- _ I L .) I, .' _ -_ -_-_ •_ _i- l -
42. Backflow;Preventer -1 I ' i - _ ' Il 1 , i ! ; l
r.
43. Backflow Irrigation 1 ' r 1 Fr - _ , 1 , '-, - , , -
• I
44. landscape Irrigation;System ! I - ' - -
45. Sound:Attenuation . I t .. I . I • I i I° _
46. Handicap Regulations '-
47.'FINAL STRUCTURE& BUILDING l': - I T, I i , , ,
48. Special'Require'nents Completed - 1 .
49. Electric ReleaseltoEdison: I ' ` j 1 1
50. Gas Release to Southern California Gas Cn .. i i I '
51. CERTIFICATEIOF OCCUPANCY ;i _ ,r_ _ �" ,_ _t. -l_
No - ' I:. ' Date I , li i -, - , I