HomeMy WebLinkAbout2518 BACK BAY LOOP - Building Permits -
•
`p 9 CITY OF COSTA MESA
a
BUILDING DIVISION
> .J ru,r„ .A1 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER
%1 ^ I :
oWm PERMIT
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P05-00132
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626
PLUMBING PERMIT
Job Address: 2518 BACK BAY LOOP Status: ISSUED
Suite No Applied: 02/11/2005
Issued: 02/16/2005
Vicinity:
ISSUED BY: ri
Parcel Nunmber: 93765078 If 1
Applicant: COAST ROOTER PLUMBING HTG &NC
Address: 17390 MT CLIFFWOOD
Phone: (714)241-1414
FOUNTAIN VALLEY Zip: 92708
Owner: RISLEY, SUSAN CAIRNS TR
Address 2518 BACK BAY LOOP
Phone:
COSTA MESA,CA Zip: 92627
Contractor: COAST ROOTER PLUMBING HTG &NC
Address: 17390 MT CLI FFWOOD
Phone: (714)241-1414
FOUNTAIN VALLEY Zip: 92708
License: 529127
SCOPE OF PERMIT
WATER HEATER CHANGE OUT.
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 50.00 0
Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0
Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0
Clarifier System $0.00 0 Process Piping(per 10 ft)" . $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0
Connect(Ice,Soda,etc) $0.00 0 Receptors '$0.00..,_ 0 Vacuum Brkr Bkflow(5+) $0.00 0
Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0
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 $0.00 0 Water Heater/vent $12.30 1
Drinking Fountain $0.00 0 - Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0
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 $0.00 0 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: $35.80
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92.28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5628
2446-46(6-00)
DECLARATIONS il
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.
—Wave 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: I BB 5
,Carri„sr.-5.5TOPE- fU.0 n Policy,Nur1bar` LO- LLD vy
-(Tis 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 C lifomia,an thpt If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall fdrthwlth
comply with these pro ' ions f
Applicant SIre: cete: 21 l L(O JS
WARNING:FAILURE TO SECURE W S•COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,1100),IN ADDITION TO THE COST OF COMPENSAI1ON.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
ionhereby affirm that I am licensed under provisions of Chapter 9 ommencJng with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full
force and effec(,Li ,-a--�'SZ'(I 7i'1 . [ask.. C 3 (o
Contractors Signature: ALL.^._- Date: 2 if es./o S
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lenders Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more then five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). •
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions
Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s)
license pursuant to the Contractors License Laws.).
❑ I am exempt under sec. Business and Professions Code for this reason:
Signature: Date:
Owner ID verified by driver's license. 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:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
' business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas et standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑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 aapermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? j�Yes LJ No
(Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No
(If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the 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 and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
•nature• Legal Owner(s) Date
24 1 (o%OT
i�:�.ultibrized Applicant - L—Date_.._;
CODE I INSPECTION TYPE PATE INTRIALS CODE( INSPECTION TYPE PATE RLEWALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical L1 [� �L�_
1266 Pool Spa Final 208 Final Plumbing 3-1+85 c.d 4. „?"
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retalning 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
'w"•, CITY OF COSTA MESA -
)1,11-''p- �'!, *BUILDING DIVISION /
�r DEVELOPMENT SERVICES DEPARTMENT / P98-00394
PERMIT VVV PERMIT NUMBER
(714)754-5273 • Fax(714)754-4856 PLUMBING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
•
Job Address: 2518 BACK BAY LOOP Status: ISSUED AZ
Suite No Applied: 05/22/1998
Issued: 05/22/1998
Vicinity:
Parcel Nunmber: 93765078
Applicant: ADAMS, LEX
Address:
Phone: -
Zip:
Owner. RISLEY, SUSAN CAIRNS TR , . .
Address 2518 BACK BAY LOOP - _ - .
48 Phone: ,
COSTA MESA,CA Zip: 92627
/
Contractor., QUALITY SERVICE
Address: 12821 WEDTERN AVE "
D - Phone:. 897-2223- , ,
GARDEN GROVE,CA ' .Zip: .- 92841 - -'
License:535434 •
Archl Eng: - . _ •
•
Address:
Phone:
Zip:
License:
. SCOPE OF PERMIT
CHANGE OUT A SINK AND SHOWER IN AN EXISTING BATHROOM.
FEE SUMMARY.' /
AMT QTY • AMT i QTY AMT QTY
ISSUE FEE $22.00 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 $8.75 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 . ' • $8.75 1 Water Heater/vent $0.00 0
Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0
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 $0.00 0 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: $39.50
COMMENTS/SPECIAL CONDITIONS
EXPIRATION: This permit shall automatically expire and become void it 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 content 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:
Cartier: Policy Number
(This section need not be completed it the permit is valued et 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, agree that if I should become subject to the workers'compensation provisions of Section 3 • of •- Later Code,I shall forthwith
comply with these prowls /-��'Q h
Applicant Signature: Date:/•r8 S 7 5
WARNING:FAILURE T SECURE RS'COMPENSATION COVERAGE IS UNLAWFUL AND SMALL SUBJECT AN EMPLOYERA CRIMI •TI AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARE(s100,000).IN OPTION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE -• •• .INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provision of Chapter 9(commencing with Section 7000)of Division 3 of the Business end Professions Code,and my license is in full
force and effect.tic.p Class s
Contractor's Signature1 Date 154-VI,•75
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).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that 1 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.My violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not Intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors Ucense Law does not apply to an owner of property who builds or improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I, as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec. 7044, Business and Professions
Code:The contractors License Law does not apply to en owner of properly 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:
1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Pian be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application eereit 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 Cale requires that the requested information be furnished on applications for non-residential building permits).
6 Will any part of the facility to be ccnsbucted 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 Safely 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 end city ordinances
regarding Hazardous Materials and Emissions.
Signature: Date:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct.I agree to comply with all state laws end city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final
Inspection.
Sig
Of
And/Or
Legal Applicant Owner(s)t •
V
And/Or Authorized Applicant ••
ORES IBSPFCTION TYPE DATE IRSPFCTIN TYPE CA7E IfllM
1616 Axed System Final Fire Prevention 206 Final Mechanical -yam
1266 Pool Spa Final 208 Final Plumbing 112-' -C 1
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 Anal Sign 222 Final Site
204 Final Demolition 250 Anal Building/Occupancy
2446-46
4 CITY OF COSTA MESA
? "x4. 4,'J BUILDING DIVISION
b., ��98-00893
' �•"�'� ' DEVELOPMENT SERVICES DEPARTMENT
�• PERMIT PERMIT NUMBER
%3/40.:4•4°.
(714)754-5273 • Fax(714)754-4856 BUILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 2518 BACK BAY LOOP Status: ISSUED (7J4
Suite: Applied: 05/22/1998
Vicinity: Issued: 05/22/1998
Parcel Nunmber: 93765078 Zoning:
Applicant: ADAMS, LEX
Address:
Phone:
Zip:
Owner: RISLEY, SUSAN CAIRNS TR
Address 2518 BACK BAY LOOP -
48 - Phone:
COSTA MESA,CA - Zip: 92627 —• _ . . ,
Contractor: QUALITY SERVICE �.
Address: ` 12821 WEDTERN AVE
D Phone: 897-2223 _
GARDEN GROVE,CA Zip: 92841 .
Licenser 535434
Arch/Eng: •
Address:
Phone:
Zip:
License:
SCOPE OF PERMIT
REPLACE EXISTING SHOWER AND SHOWER PAN.
FEE SUMMARY
Plan Check: $0.00 ..- - •Calc Valuation: $1,400.00
Permit: $45.75 Claimed Valuation: $1,400.00 •
•
Other $0.00
Inspection: $0.00
Total: $46.25
PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear . 0-0 Left 0-0 e Right 0-0
ACCESSORY Front 0-0 Rear 0-0' Left 0-0 Right 0-0 •
PARKING Existing: 0 Required: 0 Proposed: 0
NOTES:
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:
Carder: _ Policy Number.
Mils 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 it I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith
comply with erwislpgL ) Q
WF
Applicant Signature:: #r/j` Date: 3-G Z� 6
WARNING:FAILURE TO SEOPo(ERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER NAL PENALTIES AND CML FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($104000),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 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.eClass x
Contractors Signature:
Datep f Z • 78
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).
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 Cade)or that he or she Is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not Intended or offered for sale(Sec.
7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or Improves thereon,and who does such work
himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or Improvement is
sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.).
❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec. 7044, Business and Professions
Code:The contractors License 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,Tide 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 the and certify a Business Plan for emergency response to release or threatened release of a hazardous
material? 0 Yes 0 No
(Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every
business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, '
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No -
(Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire
Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department.
4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No
5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit 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).
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:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is
correct.I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.
nature Of Legal Owner(s) P .
i2 a di
And/Or Authorized Applicant Date
CODE F INSPECTION TYPF DATE UEMALS CODE I INSPECTION TYPF OATS ICALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plumbing
200 Final Re-Roof 210 Final Electrical
201 Final Block/Retaining Wall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final Building/Occupancy P/
2446-46
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. 0899 4/09/85 6.Ge1
- •
1
CITY OF COSTA M.•IESA p CO/�N�ST/�/j UCTIONPERMIT PERMIT NO. R TRACT NO. LOT NO. . UNITO. �:,,t. _
Project Address • ✓_ t! _unC6 � 1 1'' U "' tel/( {{��-- - -`-t-.
V� '7 'Z,�y
Applicant's Mailing Address I�*30 E- al.�' � TYPE OF CONSTRUCTION r/nl NEW U ADD, LJ ALTERATION H REPAIR /. —
g // /7 ❑ CONVERSION ❑ DEMOLISH ❑ OTHER_ A p # - Zone
Owner's Name nYYtOoe` W 6-e Phone •S Z--/Nl Y DESCRIPTION OF WORK/USE OF BLDG. - - •
Address l 0'7 1-S -� �'y�'r-'41�C "ZOZ - � - ' S Main Building: Accessory Building:
E - Z
Arch/Eng. License No. TYPE OF PERMIT , •U GRADING ❑ FOUNDATION. ❑.STRUCTURAL T Front • - - - • 0
Address - /n��� /I� / - ❑ TENANT ❑ ELECTRICAL'❑ PLUMBINC7XJ MECHANICAL B Rear , . _ N
Contractor's Name �-V . '• •`'tilt Phone 4 3`l Z/�G _❑ 'OTHER y'•�-� SVS A - I
/ PROJECT DESCRIPTION SQ. FT. - J ( OCCUPANCY• C Righi - , N
CityAddLicens(mailing) t/•3 n S e_._/t-cp-(242-at; K - G
y P CONSTRUCTION TYPE VALUATION$ s Left •
City License No. 0�4I'3� ZONE GRADING CU.YDS. ACRES Ping. Ref.# Parking Req,/Provided • E
LICENSED CONTRACTOR DECLARATION - - 0
I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: , Planning Notes: - ryl
with section 7000) of Division 3 of the Business and Professions Code, and T
my license is in ful to cs antl effect. 3- 5 Lg , - - - S
Licenso
e Class _ G.-o N .
•
Date • -• Lta Signature - - PLUMBING• FEES -
WORKERS' COMPENSATION DECLARATION Bar Sink - Showers - ELECTRICAL .FEE$ '
I hereby affirm that I have a certificate of consent to self-insure or a certificate
' f Workers' Compensation Insurance,,or a certified copy thereof (Section Backflow Preventer - --Service Sink -• - - -' - - - ' -- -
,8o0,'L-ab. C.) `r - Automatic Washer �Transform¢r 0 15.50 KW
Policy No. p'3 7 �` t Company )CSF•- Backflow Irrigation • Sewer Ca • I - ❑ 50+KW
O P Construction Pole Sub.
certified copy is hereby furnished.
Certified porgyL5 filed with the city Bunch:e Q.1. slon. (]�y/� Bathtubs Sewer Connection! Cooking Unit .Meter ❑up to 100 amps '
Date ?'-14 -d5' Applicant �S' �J +/-"'��" .
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION' Clarifiers . I Solar Collectors I - Dishwasher _ Meter Dover 100 amps - __,_ '
(This section need not be completed if the permit is forone hundred ($100)or - _ `
less). - - Dishwasher - Solar Piping Dryers ❑Gas ❑Electric Sub Panel, '
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 Drinking Fountains Solar Tank Fan
• - Motors❑0-1 HP ❑.1%-8
Workers.'Compensation Laws of California.. _
. Date. - Signature Floor Drains • Swimming Pool vv/Spa . • F.A.U. Inc.Solar D9-15 HP D16-15+
'NOTICE: If,after making this declaration,you should become subject to the - - '
Workers',Compensation provisions of the Labor Code, you.must forthwith Eldor Sinks .- i - _ - ,Urinal -, - - - • - -• . - • • Fixtures r - •Microwave
comply with such provisions or this permit shall be deemed revoked. - _
CONSTRUCTION 'LENDING AGENCY: Gas Service' Outlets Water Closet _ Boxes
Device ,
I hereby affirm that there is a construction lending agency for the performance - Pole Light
of the work for which this permit is issued (Section 3097 Civ. C-) . _ ' 1
Lender's Name - - r Interceptors Water Heater' - Outlets Range
' Lender's Address - • Kitchen Sink• ' I Water Service -
OWNER BUILDER DECLARATION • - - - Switches Sign
, I hereby affirm that I am exempt from the Contractor's License Law for the ' Lavatories .. • - Auto-Wash '- ' - '
following reason (Section 7031.5 Business and-Professional Code: Any city or Garbage Disposal • ;'Standing Sections •
county which requires a permit to construct,alter,improve;demolish or repair ' P-Trap' I,, - Laundry Trays Generator ❑0.5 KW❑5-15 KW Trash Compactor
any structure; prior to its-issuance, also requires the applicant:f or such permit i , - P
to file a signed statement that he/she is licensed pursuant to the provisions of. - Roof Drains • -'
the Contractor's License Law(Chapter 9(commencing with Section 7000)of . __ - _ _ ,
Division-3 of the Business and Professions Code) or that he/she is'exempt - . - - , , _ - I
herefrom and the.basis for the alleged exemption.-Any violation of Section _ - t:
'031.5 by any,applicant for a permit. subjects the.applicant .to a civil '' - - -
LIenalty of not more than five hundred dollars($500). - . - i - 1,
I, as'owner of the property or my employees with wages as their soI le , Reinspection Fee - $15 Issue Fee $ 3
compensation, will do the work,and the structure is not intended or offered - Reinspection Fee I $15 Issue Fee $ 3 '
for sale (Secion 7044, Business and Professional Code: The Contractor's - MECHANICAL - FEES -
License Law does not apply to an owner of a property who builds or improves ,
thereon, and who does such work himself/herself or through his or her own - - - DEVELOPMENT SERVICES,REQUIREMENTS:
employees, provided that such improvements are not intended or offered for Boiler Hood or Type ❑
sale. If, however, the building or improvement is sold within one year of corn- ,Canopy Type II ❑ - Zoning Approved By ' Date
pletion, the owner will have the burden of proving he/she did not build or im- Duct- Under Ground •
prove for the purpose of sale). r _ Building Approved By Date
El I,as owner of the property, am exclusively contracting with:licensed con- - Duct-Structural Refrigeration System Application Issued By _ Date 1 1
tractors to construct the project (Section 7044,Business and Professions Code: ,
The Contractor's License Law does not apply to an owner of property who • Duct-Ventilating 00400 000 BTU_0100,000 BTU 1 SUMMARY OF FEES '
builds or improves thereon,and who contracts for-such projects-with a con- - - -- 1
tractor(s) license pursuant'to the`Contractor's License Law). I am aware that i Exhaust System ❑ Multiple D 'System Repair/Alteration i BUILDING PERMIT •$ SMIP $ •
proof of their Worker's Compensation insurance should be provided to me. • PLAN CHECK $ ERMIT •
D I am exempt under Section • B. B, P.C.for this reason Firepl/Fact.BIt. ICBG# Fire Dampers PLUMBING $ . • . ISSUANCE $
Date owner • I ,H/,eating System& Ducting Registers PLAN CHECK 25% $ ENERGY P.C. ,$ -
I hereby certify that.1 have-read this application and state that the above - ---I ,0.100;000 BTU 0100,000 BTLS ' -- - •' - •• , .
information is correct. I agree to comply with all city•and county ordinances {{{ I I` 00 ELECTRICAL $ GRADING, I$
and state laws relating to building construction, and hereby authorize repre- • I - MICROFILM $
sentatives of this city ,tenter upon the above-mentioned property for I PLAN CHECK 50% ,$ _
inspection purposes, it
y^- � property),
Ohl MECHANICAL •
$ 1-00 cS 0
Signature g•T Q�CV/tsa"` Date .3 Z TOTAL FEE $ _
Drivers' License or SS# Reinspection Fee I $15 Issue Fee $ 3 PLAN CHECK 25% $ I -00
'CMF 0865-46,rev.10/84 White - Building: Canary -Applicant; Pink -Accounting; Goldenrod - Assessor
C- CONSTRUCTION AND PLANNING •� POO. -.SPA +
APPROVALS Permit Date Inspector APPROVALS Permit# Date Inspector I
1. Temporary Electrical Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement
3.'Electrical Conduit Utility-Undrgrnd. 54. Forms
4. Electrical Conduit-Undrgrnd. `± - 55. Electrical Bonding
5. SteeReinforcementl ,r,
l' 56. Rough Plumbing & Pressure Test r
6" Electrical UFER.Grrid. �57. APPROVAL TO COVER-GUNITE
7 7Footi'ngs 58. Electrical Conduit-Undrgrnd.
81 'Foundation •'' ' 59. Gas Pipe, O Undrgrnd.,Test
9. Water Pipe-Undrgrnd. 60. Backwash Lines,P-Trap, 0 Undrgrnd.
10. Structural Floor System 61. APPROVAL TO DECK
11.'Property Sewer Line & House Connection - - - 62. Backwash & Receptor-Final
12. Sewer Cap „r 63. Heater & Vent-Final
13. Roof Drains - " 64. Plumbing System - Final
14. Rough Plumbing - 65. Electrical-Final
15. Rough Electrical-Conduit - 66. Solar System-Final
16. Rough Electric Wiring 67. Fencing &Access Approval
17. Rough Wiring Sign 68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT
20. Rough Factory Fireplace APPROVALS Permit#
21. Ducts, in Structure 70. Underground Hydro
22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil
23. Gas Pipe-Rough& Test 72. Underground Flush
24. Roof Framing 73. Undergrnd.Storage Tank 0 Gas 0 Oil
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical
27. Frame and Flashing . 76. Dry Standpipe
28. Lathing & Siding 77. FIXED SYSTEM FINAL
29. Insulation 78. FIRE PREV. FINAL
30. Drywall Nailing HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED • t- '
33. Final Electric / Notes:
34. Final Heating & Air Conditioning /4/j/jS- (SCP
7 I
35, Final Gas Pipe-Test '
36: Hood or Canopy
37.- Final Factory Fireplace
38.-.Final Plumbing
39. Water Service-Final
40. Gas Service-Final
41. Solar Domestic-Final .
42. Backflow'Preventer
43. Backflow Irrigation -
44. .Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations -
47. FINAL STRUCTURE & BUILDING -
48. Special Requirements Completed •
49. Electric Release to Edison • - -' -"
50. Gas Release to Southern California Gas Co i .
51. CERTIFICATE OF OCCUPANCY
:No. Date -_ -
F