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HomeMy WebLinkAbout2390 ELDEN AVE - Building Permits • 1_0850 • COSTA MESA BUILDING-SAFETY DEPARTMENT FEE RECEWED P.O.BOX 317 COSTA MESA. CALIFORNIA c TOR APPLICANT TO flit /N COMPLETELY APPLICAMAk$6441 IT TYPE OR PRINT t'l'abiige 9 . BUILDING n ADDRESS 2790 ELDEN AVENUE FOR MESA. CALIFORNIA FOR Off/Cr USE ONLY I RECEIPT NO. I / OPERMIT NO. OWNER ERNE S T D. REASON Y..5 . MAIL RECEIV�EDy9—Y DATE RECEIVED DATE ISSU ADDRESS 211 E. ADAMS �N ii—ii•- ///p2 /5 TEL. BUILDING CITY ALHAMBRAS CALI F• NO. ADDRESS • AR' -ECT LIC. COSTA MESA. CALIFORNIA OR (NEER NO. ADDRESS FIRE 11 ZONE TYPE GROUP CONTRACTOR ROMAR BLDRS• LIC.NO. 160614 APPROVED DATE COSTA ADDRESS 21430 NEWPORT BLVD.MESA ZONING LEGAL LOT Z ZONE �J IP-LOAN-SF UUI OF NEW,.IaiQ I_ DESCRIPTION I NO. 91 BLOCK TRACT-l00 Yl I PLANE BUILDING A.P.NO. (l f / 1/-OS �-OAPPROVED 6 BV (AA_ J/ DATE - ///�'7 -), SIZE NO.OF OF LOT 59.75X179.25. NOW ON LOTS 1A YARDS E REQUIRED LOWED USE OF 0WELLING (CENTER LINE ST.) EXISTING BLDG. FRONT Q FT. IN. SETBACK LINE FROM (/ CENTER OF STREET C REAR YARD R.SIDE )/ FT. .3 (/ IN. SIDE YARD I LEFT 571 I RIGHT 261 L.SIDE 5-2. IN. DESCRIPTION OF WORK REAR 6 -FT. IN. NI X I ALTERATION I II ADDITION �4 p E/l. / j. R. 5 • MOVING DEMOLISH J` (r (ilkiy, REPAIR / BUILDINGZ975/p NO.OF ROOMS 5 STORIES ASPHALT T7 & / / EXTERIOR WALL ROOF V COVERING WALL,. C COCOVERING ROCK / USE OF BUILDING AND WORK TO BE PERFORMED. - / DWELLING - SINGLE_ _ .. _. I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PLY WITH ALL CITY ORD ANCES • STATE AWS EGULATING COM- PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. BUILDING CONSTRUC / VALUATION SIGNATURE OF �/-,� PERMIT FEE $ tomq -- PERMITTEE / $ PLAN CHECK $ //•-- • AUTHORIZED AGENT 3, N- TOTAL FEE S • 10853 FEE RE, n COSTA MESA BUILDING-SAFETY DEPARTMENT &) /� / P.O.BOX 317 COSTA MESA.CALIFORNIA 7 -cr., FlNANCE � // fOR APPLICANT TO FILL IN COMPLETELY APPLICA7Q V1 ANC IT I TYPE OR PRINT /I BUILDING €SA BUILDING .Fi 1` 8I. ADDRESS 2390 ELDEN AVENUE iY COSTA MESA. CALIFORNIA FOR OFF/CE USE ONLY PERM / S OWNER ERNEST DP REASON I RECEIPT NO. MAIL RECEIVED BY DATE RECEIVED DAT IB9U):D ADDRESS 2 E. ADAMS /�- I //-/,--57 #//1 L/'Y////5y • TEL. , BUILDING !^ / ' CITY IL. • - C 1 F NO. • ^ ADDRESS AR 'ECT LIC. COSTA MESA. CALIFORNIA • OR INEER NO. FIRE /� J • ADDRESS 6r�� 1 ZONE TYPE GROUP �}C ]f-9-- .• CONTRACTOR ROMAR BLDRS• L CTNO160614 - APPROVED DATE COSTA ADDRESS Q�430 NFWPORT BLVD. MESA ZONING ESCR LOT �I- - ZONE - NO. O USE OF NEUyM DESCRIPTION I NO. 9' 1 BLOCK ITRACT DO PLANE I BUILDING ^, A.P.NO. 11 O'1,--/ Q BYPROVE•- 0 DATE 1` SIZE / 111777 NO.OF SLOGS. AI OF LOT59.75)(179.25 I NOW ON LOT REQUIRED �A LOWED USE OF `I (CENTER LINE ST.) //,I EXISTING BLDG. DWELLING FRONT (0 FT. IN. SETBACK LINE FROM CENTER OF STREET 27 1 REAR YARD 3 R.SIDE A/ FT. • 3 IN. SIDE YARD I LEFT L 1 I RIGHT 261 L.SIDE .7�. IN. DESCRIPTION OF WORK • REAR / 0 FT.4 (I(. REPAIR MOVING BUILDING " F3%a • ���; SIZE • . / ROOMS� .i / EXTERIOR WALL IROOF '1i.. . COVERING STU C COCOVERING RO CK ' -- ��,/• 7 ��� / j � II/'/� USE OF BUILDING AND WORK TO BE PERFORMED - (/ h®FELT NG DUPLE /pJ • I I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION • ' AND STATE THAT THE ABOVE IS CORRECT AND GREE TO COM- THE AM•UNT SHOWN UNDER VALUATION IS FOR THE PLY WITH ALL CITY ORDI ANCES AND�;y ATE WS REGULATING _ PURPOSE OP ESTABLISHING A PERMIT FEE ONLY. BUILDING CONSTRUCT! , , VALUATION �J • SIGNATURE OF / i/ ` '/^- PERMIT FEE $ 3 d PERMITTEE /� / //�y `�L- Y / i. / 9' . $ I ^ PLAN CHECK S / / AUTHORIZED AGENT TOTAL FEE $ 57- • • • 1:0854 FEE RECEIfED COSTA MESA BUILDING-SAFETY DEPARTMENT 4-g-c) 1/_ 7 - (-5 P.O.BOX 317 COSTA MESA. CALIFORNIA FINANCEDER € FOR APPLICANT TO NIL IN COMPLETELY APARCM't2 OTk lfERMIT TYPE OR PRINT BUILDING BUILDINADDRESS 2390 EL DEN AVENUE CFO COSTA MESA, CALIFORNIA FOR OFFICE USE ONLY • OWNER ERNEST D• REASON RECEIPT NO. PERMIT NO. MAIL RECEIVEDLBY DATE RECEIVED DAT ISSU D ADDRESS 224 E. ADAMS CAST //.-/7- ' // jg Vy2 TEL. BUILDING /�' J/ CITY ALHAMBRA, CALIF. NO. ADDRESS AR' 'ECT LIG. COSTA MESA, CALIFORNIA OF INEER NO. • FIRE ADDRESS ZONE TYPE 1 GROUP CONTRACTOR ROMAR BL DRS• LCS.ANO. o061 lIBYPROVED DATE • I CO STA • ADDRESS 2430 NEWPORT BLVD. MESA ZONING LEGAL I LOT 91 I ZONE I NO.OF I USE OF NEW DESCRIPTION NO. BLOCK TRACT 00 Purvs BUILDING / Q /1 L l O b APPROVED 1 1 \ 1/_ /1 �-(% A.P.NO. ' 7�V J J- BY (j/ v tJ DATE • 1 / -s SIZENOO . YARDS OF LOT 5q .7 5 g � I NOW OnN LOT Loi 1 REQUIRED ALL WED USE OF D W E L L I N G (CENTER LINE ST.) I �//�J-Af j/lJ EXISTING BLDG. - FRONT (V FT. IN. SETBACK LINE FROM a.I CENTER OF STREET REAR YARD R.SIDE /9 FT. a IN. SIDE YARD I LEFT 4f I RIGHT 261 L.SIDE fir". IN. DESCRIPTION OF WORK REAR I /f, RT. IN. IX II ALTERATION I II ADDITION I �rd 7 e/ f.C9 REPAIR I LOVING I II DEMOLISH I if ff f BUILDING a2 a;1 '. O S OF SIZE )I 1 20/ ROOMS IA STORIES '1 zle ',Le {'-/may X11 / /I I V EXTERIOR WALL r. 1 ROOF SPH AL T ��� "' � fC 11'Y '1 COVERING °TU GG COVERING POCK �' {I/ wl USE OF BUILDING AND WORK TO BE PERFORMED C./(375 � DWELLING - DUPLEX �l� �,� I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT, SHOWN UNDER VALUATION IS FOR THE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PLY WITH ALL CITY ORD ANCES AND STAT LAW EGULATING PURPOSE OP ESTABLISHING A PERMIT FEE ONLY. BUILDING CONSTRU 1 VALUATION SIGNATURE OF PERMIT FEE $ ?cli:1.— PERMITTEE A /! $ /gee PLAN CHECK $ /9--- AUTHORIZED AGENT TOTAL FEE $ S 7�� 10855 FEE RECE1Vt�, COSTA MESA BUILDING-SAFETY DEPARTMENTeiA) //_/7-J 7 P.O.BOX 317 COSTA MESA. CALIFORNIA FINANCE CEP,,t�,.� FOR APPLICANT TO FILL IN COMPLETELY APPLIcJ�tiorN A IFR MMIT TYPE OR PRINT BUILDING BUILDING ADDRESS 2390 ELDEN AVENUE t� • COSTA MESA. CALIFORNIA MR OFFICE�t USE ONLY I RECEIPT NO. I 14�5_r OWNER ERNE BT D. REASON MAIL RECEIVED BY DATE RECEIVED DATE I§SED ADDRESS 2h. E• ADAMS AY- ,�-�,.J� �� $� - TEL. BUILDING` CITY ALHAMBRA. CAL , Fe NO. ADDRESS AR ECT LIC. COSTA MESA, CALIFORNIA OR !NEER NO. A• DDRESS FIRE FONE TYPE U GROUP STATE APPROVED CONTRACTOR ROMAR RI FIRS_ LIC.NO.1 6961), _ BY DATE • CDs T a ADDRESS 21 30 NE ttPO RT BLVD* MOST ZONING LEGAL LOT Z ZONE NO.OF USE OF NEW DESCRIPTION INO 91 I BLOCK I TRACT 300 A !PLANS � SUILDINc I/�/) ,/I-`A�{�/.(y�/�7i A.P.NO. n •�Com. 3 _v6 ABY PPROVED ` . DATE • • " / _ ! ' SIZE OF LOT 59 . 7 5X179.25 I NOW.O FONB LLOT 1 REQUI , ALLOWED ALLOWED USE OF IVE LLI AO (CENTER LINE ST.) D EXISTING BLDG, FRONT G FT. IN. SETBACK LINE FROM � IIIIYYYY` CENTER OF STREET REAR YARD R.SIDE FT. IN. S• IDE YARD I LEFT 5j 1 I RIGHT 141 / L.SIDE .5 yFT. IN. DESCRIPTION OF WORK REAR FT. /';.f� w. I X II ALTERATION I II ADDITION I 5_(� -b R./ • , REPAIR I II MOVING I II DEMOLISH I // I I BUILDING NO.OF IP SIZE 20 X 20 ROOMS STORIES 1 — )/00EXTERIOR WALJT I ROOF ROCK ' L Y 1 COVERING OTUCCO COVERING A SPH A I T k P I USE OF BUILDING AND WORK TO BE PERFORMED / GARAGE �� • I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE AND STATE THAT THE ABOVE IS CORRECT AN• AGREE TO COM- PLY WITH ALL CITY OR NANCES AND STAT 70.;EGULATING PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. BUILDING CONSTRUCT! N. VALUATION SIGNATURE OF 4 /n) PERMIT FEE S 9:---- PERMITTEE / i 0 U / $ / JE PLAN CHECK $ '�' A• UTHORIZED AGENT / TOTAL FEE $ /a • �r-+t. CITY OF COSTA MESA u? "� BUILDING DIVISION p RMIT NUMBER tel "� ' ' DEVELOPMENT SERVICES DEPARTMENT, Jd�' PERMIT . 4tbibenmsDP00-00165 (714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT ' Job Address: 2390 ELDEN AV Status: ISSUED Suite No Applied: 04/05/2000 Issued: 04/05/2000 Vicinity: KITCHEN/BATHROOM �^ ISSUED BY: �- -/ Parcel Nunmber: 43926213 Applicant: PAT SANDBERG Address: 18832 WINNWOOD LN . Phone: (714)288-9376 ' SANTA ANA,CA Zip: 92705-1233 ' Owner: SANDBERG R W TRUST PT Address 16832 WINNWOOD LN Phone: • SANTA ANA,CA Zip: 92705-1233 Contractor: OWNER-BUILDER - Address: • - - - ' Phone: Zip: License: 0 Arch/Eng: - " - ' Address: , - • Phone: _ , , - License:-- SCOPE OF PERMIT INSTALL 1 SHOWER,1 KITCHEN SINK, 1 WASH BASIN AND 1 WATER HTR. REF:B00-00435 • FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 - Sump Pump $0.00 0 Backflow irrigation $0.00 - 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 ' Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00" • 0 Septic Tank $0.00 0 Wash Basin $9.80 1 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain,Floor $0.00 0 _ Sewer Connect • $0.00 0 - Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 ' Water Closet(Toilet) $0.00 0 Drain,Roof $0.00 0 Shower - - $9.80 1 Water Heater/vent $12.30 1 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Ins(or Rep.) $0.000 Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 - 0 Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $0.00 0 Sink,kitchen $9.80 1 Water Softener $0.00 0 Gas(Over 4 outlets) $0.00 0 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $65.20 rnnnnMCrurc I °E'r ' `' CGNDITIGMB 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 / DECLARATIONS WORKERS'COMPENSATION DECLARATION: . I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ 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 nor be completed it the permit Is valued at one hundred dollars(5100)or less.) ❑ I certify that In the performance of the work for which this permit Is issued, I shell not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,1 shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE(Si 00,000).IN ADOfRON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST.AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is In full force and effect.Lic.# Class# 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). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penally 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 , Busi ess 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 su acts 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 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 UCENSED CONTRACTORS to construct the project(Sec. 7044, Business and Professions Code. a .. rectors 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) lic se pu uan,to the Contractors License Laws.). ❑ m exam.t ger - Business and Professions Code for this reason: ✓y/�J Signe /> 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 Califomia 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 or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management end 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 end 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? ❑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 U 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? ❑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: CERTI ATE OF COM LANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is corr .I agree to m y with ap state laws an ity o 'minces relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the abov described pn r for iinnssppe�cttien pu s I agr not to occupy pr allow occupancy of any building authorized by this perm gntl��a�rnLlspectiol. Signature Of Lege ner(s) // F/ Date And/Or Authorized Applicant Date CODE 0 INSPECTION TYPE ME giIjjiia5 Mr( INSPECTIONTYPE QM MALI 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing .&/tf00 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy 2448-46 t4,.,."---"Xicp. CITY OF COSTA MESA it llitr..► BUILDING DIVISION V/ MIT NUMBER ' ""^ ' DEVELOPMENT SERVICES DEPARTMENT. PERMIT B00-00435 (714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 2390 ELDEN AV Status: ISSUED Suite: Applied: 04/04/2000 Vicinity: Issued: 04/04/2000 Parcel Number: 43926213 Zoning: y�� Applicant: PAT SANDBERG ISSUED BY: 0 r/ Address: 18832 WINNWOOD LN Phone: (714)288-9376 - SANTA ANA,CA Zip: 92705-1233 Owner: SANDBERG R W TRUST PT ' Address 18832 WINNWOOD LN i - . Phone: (714)288-9376 SANTA ANA,CA Zip: 92705-1233 Contractor: OWNER-BUILDER Address: _ Phone: Zip: License: 0 Arch : . - Eng: Address: - Address:- " 7. • Phone: - Phone: Zip: License: License: SCOPE OF PERMIT REPLACE SUB-FLOOR IN BATHROOM AND UNDER WATER HTR IN LAUNDRY ROOM.ENLARGE DOOR OPENING(NON BEARING WALL)FROM DINING ROOM TO LIVING ROOM TO APPROXIMATELY 8 FEET WIDE AND ENLARGE ATTIC ACCESS.ENCLOSE WATER HTR IN LAUNDRY ROOM.SUBJECT TO FIELD INSPECTION. FEE SUMMARY' ' ' • • Plan Check: $0.00 - Cat Valuation: $3,000.00 Permit: $83.25 Claim Valuation: $3,000.00 SMIP Res: $0.50 _ ._ .. SMIP Corn: $0.00 . . . - ._ Other $0.00 Inspection: $0.00 . Total: $83.75 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0' PARKING Existing: 0 Required: 0 • Proposed: 0 NOTES: 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 notcommenced 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 / 7 DECLARATIONS WORKERS'COMPENSATION DECLARATION: • I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. ❑ I have and wilt 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: . Carrier: Policy Number: (This section need not be completed If the permit Is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE($106,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby 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.Lie.M Class N _ 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). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I lam EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions 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 sub cts the applicant to a civil penalty of not more than five hundred dollars($500).): I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not Intended or offered for sale(Sec. 7044,Business end Professions Code:The Contractors License Law does not appy 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 oft ' • ••arty, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec. 7044, Business and Professions Code:Th' •ntractors •cense Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) linens: •ursuent to the •ntrec ors License Laws.). ❑ I a •exempt u r s:•. 4110 Business and Professions Code for this reason: I , Signature"r/ LIf 4 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,wiil 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 tile end certify a Business Pen 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,ore volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or wit 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 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 0 N (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. 4 If an RMPP is presently required,has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑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 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 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 end Emissions. Signature: Date: CE• I- • -OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application end state that the information given is c• ect. I sore, to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the •.ve-de. r•:•property for inspecti/poses.I gree not to occup ,or allow occupancy of any building authorized by this permit until final inspection. is ,'Z s / C y/sT/a o Signa Of Legal Owner(s) GG Date And/Or Authorized Applicant Date CODE F INSPECTION TYPE WK/E EMU CODE( INSPECTION TYPE MTh _____LS 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 Finaf Factory Fire Place 220 Final Planning Approval ' 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy ?k/00 T 1�T 2446-46 • �,• CITY OF COSTA MESA _ v.� BUILDING DIVISION PERMIT NUMBER t' •^^" ' DEVELOPMENT SERVICES DEPARTMENT. °4Postorto�• . PERMIT E00-00309 (714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 2390 ELDEN AV Status: ISSUED Suite No Applied: 04/04/2000 Vicinity: Issued: 04/04/2000 Parcel Nunmber: 43926213 Applicant: PAT SANDBERG ISSUED BY: Address: 18832 WINNWOOD LN Phone: (714)288-9376 SANTA ANA,CA Zip: 92705-1233 • Owner SANDBERG R.W TRUST PT Address 18832 WINNWOOD LN Phone: (714)288-9376 SANTA ANA,CA Zip: 92705-1233 Contractor: OWNER-BUILDER Address: + - Phone: • Zip: License: 0 ' SCOPE OF PERMIT 8 LIGHTS,4 OUTLETS AND 1 SWITCH TO REPAIR EXISTING ELECTRICAL IN SFD.SUBJECT TO FIELD INSPECTION. REF:B00-00435 FEE SUMMARY Quantity - Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 _ Standing Section- $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $8.80 8 up to 50 kva/kw $0.00 0 Recept Outlets $4.40 4 up to 100 kva/kw $0.00 0 Switches $1.10 1- 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 1 hp $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 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a - $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $37.80 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS 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 notcommenced 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 / DECLARATIONS I 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 carrier and policy number are: . Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) ❑ I certify that In the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVEPAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOIJ.ARE($100.000),IN ADDmON 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.Lic.0 Class a Contractor`Siigncatur: 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.(Soc.3097,CMI Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that l 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 su cts the applicant to a civil penalty of not more than five hundred dollars($500).): I,as owner of the property.or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve to 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 : • 5 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 p uant to th. Contractors License Laws.). ❑ I am ex-mit u •:r'.c. Business and Professions Code for this reason: , •- Signature: / -5V-570a Owner Owner ID verified by driver's license. ❑Yes 0 No Driver's License No. ��/ Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet In depth Into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(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 Safely 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 wit 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 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 0N (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP Is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application 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 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 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:1 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 . '•' CE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct.I agree • comply ith all state laws and city trances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-descdb.• prope • r inspection purposes. not occupy or allow occupancy of any building authorized by this permit unti fine;Inspection. �G�.�u crlr) l/!/ 700 Signature Of Legal Owner(s) D to And/Or Authorized Applicant Date ;ODE I INSPECTION TYPE ME MILS CODE; INSPECTION TYPE DATE ILM,61.s 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical d ;,?-DO /?L c.- 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 24846 I - � � CITY OF COSTA MESA s t y A. BUILDING DIVISION PERMIT NUMBER t' .13,....z...1/44 I DEVELOPMENT SERVICES DEPARTMENT. 00j41 si• . PERMIT ?WOO--CA Kit `4•0080m0 r (714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,CO IML YM 92626 MECHANICAL PERMIT • Job Address: 2390 ELDEN AV Status: ISSUED Suite No Applied: 04/05/2000 Issued: 04/05/2000 Vicinity: KITCHEN 43-7)9 ISSUED BY: // Parcel Number: 43926213 Applicant: PAT SANDBERG Address: 18832 WINNWOOD LN Phone:. (714)92705123376 SANTA ANA,CAS - Zip: 92705-1233 .Owner: SANDBERGR W TRUST PT \s#11>1°........ellit Address: 18832 WINNWOOD LN Phone: SANTA ANA,CA Zip: 92705-1233 Contractor: OWNER-BUILDER Address: Phone: Zip• .. License: 0 " Arch/Eng: ' / , • Address: - - , . ,.Phone: - . Zip: , License: SCOPE OF PERMIT / . INSTALL 1 HOOD W/MECH EXHAUST OVER RANGE. , , REF:B00-00435 • FEE SUMMARY _ ,Quantity Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU ' $0.00 0 - Ventillation System . $0.00 0 • Repair/Alt Cooling/Heat $0.00 0 - Evaporative Cooler $0.00 0 Inst/Rep.Recess Wall Htr "$0.00 0 Commercial Incinerator $0.00 0 Refrig Sys<100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems Gas Piping $0.00 0 Up to 3 hp/100 k BTU $0.00 0 Factory Fireplace $0.00 0 • 3 To 15 hp/500 k BTU $0.00 0 Hood w/Mech Exhaust $10.65 1 15 To 30 hp/1,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp/1,750 k BTU $0.00 0 Vent Fan/Single Duct $0.00 0 Over 50 hp/Over 1,750 BTU $0.00 0 Appliance $0.00 " 0 Boilers Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp - • $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers< 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $34.15 COMMENTS/SPECIAL CONDITIONS ' 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./ r1 FOR INSPECTIONS CALL: (714)754-5626 /} U 1 DECLARATIONS _ r WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: l ❑ I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. 0,', I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. My workers'compensation Insurance carrier and policy number are: . Cartier: Policy Number: (This section need not be completed i1 the permit is valued at one hundred dollars($100)or less.) ❑ I comity that In the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHAH SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDMON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST.AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is In full force and effect.Llc.N Class 4 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,CMI Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: ,� I hereby affirm that undeiriienalty of perja.ry thatI 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 tb construgt7alter,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 Ucense 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.My vitiation of Section 7031.5 by any applicant for a permit subjects� the applicant to a civil penalty of not more than five hundred dollars($500).): ($ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not Intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors Ucense 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 oflhe roperty,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044, Business and Professions Code: econtract Ucense Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) licen purs nt to th Contractors Ucense Laws.). ❑ I a ex cm • Business and Professions Code for this reason: Signatur • _ Expires: Verification of Ownership by(type of document,i.e.-property tax bit or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health end Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has et 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 tho 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 greeter than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? r ❑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? ❑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? 0 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), 8 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes',the facility must meet the requirement of Sections 25534 and 42303•of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and dty ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICA F PUANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I ree to co ly with all state laws and c' rdinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above- scribed pr p for In9pection pu oses. edea not to upy or occupancy of any building authorized by this permit until final inspection. G� 4 C/ /S�a C� Signature Of Legal Owner(s) Date And/Or Authorized Applicant Date CODE! I{SPECTIONTYPF RAM IMI6L5 GOOF( INSPECTION TYPE A ppv�� 1816 Fixed System Final Fire Prevention 208 Final Mechanical tN T 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall • 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy , 2446-46 CITY ( ,OSTA MESA, BUILDING SAFETY f 'SION ,� POST IN CONSPICUOUS PLACE ON THE JOB . NOTICE Schedule inspection one workday in advance. To schedule inspections, call (714) 754-5626. Provide the following information: 1) Permit number, 2) Job address, 3) Inspection item number, 4) Day and date you need the inspection. Building Address: V i C\ E.WE ) AV . Ormer. S ITN,^p fit c-. Building Permit s: Z(y)n—' 9)H Electrical Permits:Crim•c-r) )ci Contractor. r"")..rg tic!`ti Mechanical Permit UM(r,4)g4 Plumbing Permits:ft:4--rr-,!cus- Job Description Type: Y Group: PR,— •.a—,1:J Cr i c REI' CI)L i c) .t37-1 tffC-) aC •� LA OA:4)A)( R.COrS\ tIJ/b\x,- kCCCr^ . Plan Check No. Issue Date: ...-L, •I', (", NEW ' ADD ALTER g REPAIR MOVING DEMOLISH PERMITS EXPIRE 180 DAYS (6 MONTHS) FROM ISSUE OR LAST INSPECTION CONSTRUCTION APPROVALS. . - nems STRUCTURAL Date Inspector hems POOL&SPA Date . Inspector 4 Footings 94 Pool&Equipment Location _ 6 Slab 96 Steel Reinforcement 12 Roof Sheathing 100 Electrical Bonding 14 T-Bar Ceiling-Structural 102 Rough Plumb&Pressure Test 16 Exterior Shear Panel • 104 Approval to Cover-Gunite . 18 Frame& Flashing 106 Elec Conduit-Underground 20 Lathing&Siding 108 Gas Pike/Underground Test 22 Insulation 110 Backwash Lines,P-Trap, 24 Drywall Nailing Underground 26 Plaster Brown Coat 112 Approval to Deck 30 Pre-Grout 116 Pool Plumbing System-Final 33 Disabled Access 118 Pool Electrical-Final _ 122_Fencing&Access Approval ELECTRICAL 124 Approval for Plastering • 38 Elec Conduit-Underground 126 Pool/Spa Systems-Final 44 Rough Elec-Wiring . 48 Elec T-Bar Ceiling . 50 Elec Power Final ,• ',FIRE DEPARTMENT APPROVAL ' • 1610 Overhd Hydro/Overhd Rough PLUMBING &MECHANICAL 1612 Dry Chemical 52 Soil Pipe-Underground 1614 Dry Standpipe 54 Water Pipe-Underground 1616 Final-Fixed System 62 Rough Plumbing • 64 Rough Mechanical ' , FINAL INSPECTIONS • 66 Rough-Factory Fireplace ' Call(714)754-5626 for the following: Date Inspector 72 Gas Pipe-Rough Test 200 Final Re-Roof 90 Gas Pipe Test-Final 201 Final Block/Retaining Wall 92 Water Service-Final 203 Final Sign 204 Final Demolition • -- • - -• 206 Final Mechanical - OO 1 NOTES • 208 Final Plumbing e_ f . r — 210 Final Electrical 4/II 7 - • — Call(714)754-5128 for the following: Date r nspector _ - 212 Final Fire Prevention _ Call(714)754-5335 for the following: Date Inspector 214 Final Transportation Svs. ---- ---- ---t- E------------- - - --- • ---- Call(719754-5671 for the following: .Date inspector _- 216 j Final Engineering Approval _ Call(714 754-5307 for the following: Date Inspector . 218[Final CMSD Approval Call(714)754-5245 for the following: Date Inspector . 220 Final Planning Approval - Call(7144754-5626 for the following: Date I for _ ' , - - '•- ' '• -222 Final Site I 250 Final Building/Occupancy G/Z/OD I�u� • J 0550-46 0m.9,99)