HomeMy WebLinkAbout2517 BACK BAY LOOP - Building Permits CITY OF COSTA,MESA
a,�..0 ) BUILDING D VISION
1 ` DEVELOPMENT SERVIC i DEPARTMENT PE IT NUMBER
t t PERMIT
06-00204
,kbotPaRarso W' ee
(714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesaEMILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626
Job Address: 2517 BACK BAY LOOP Status: ISSUED
Suite: Applied: 02/07/2006
Vicinity: Issued: 02/07/2006
-
Primary Occ: Type of Construction: V-N
Parcel Number: 93765079 Zoning:
Applicant: JANOSIK, STEVE ` ///��� • ��•
Address: 1621 E ST ANDREW PL i0/(y \ (1 U
Phone: 714-259-5120 ISSUED BY: Vrl Tom)
SANTA ANA,CA - - Zip: 92705 .
Owner: CAMEROS, GERMAINE ,
Address 2517 BACK BAY LOOP _ `
Phone:.
COSTA MESA,CA . Zip: 92627-5416
Contractor.,- -ALUMINUM ROOFING SPECIALISTS-DIAL ONE WINDOW REP -
Address ' 1621 E ST'ANDREW-PL'
'- Phone: 714-259-5120 - '
SANTA ANA;CA . '
. Zip:, 92705;Jj' ,License: 523043 ' ,
•
'Arch': - !/ - Eng: '
Address: ,, Address:
Phone: _ • Phone: •
•
, Zip: . . License: - - License:
•
SCOPE OF PERMIT
CHANGE-OUT OF A PATIO SILDER AND REPLACE DOOR FROM RESIDENCE TO GARAGE(LIKE FOR LIKE).
• FEE SUMMARY ,
Plan Check: ' • $0.00 ' ' ( ',_//, - •• ; C"' Calc Valuation: $4,000`00
Permit: $97.25 Claim Valuation: $4,000.00
SMIP Res: $0.50
SMIP Com: . $0.00
Other: ., $0.00
Inspection:' $0.00
Total: ' $97.75
-PLANNING &ZONING
SETBACKS
MAIN STRUCTURE Front 0-0 Rear-r '0-0 Left 0-0 -. Right 0-0
ACCESSORY Front "0 0- . -Rear 0-0 ' - Left- 0-0 Right '0-0
PARKING' 'Existinq:-, 0 • "Required: 0 Proposed: 0 - .
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related
regulations.(Ord.No.92-28,§ 1, 12-21-92)
EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned
for a period of 180 days.
INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all
required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.
FOR INSPECTIONS CALL: (714)754-5626
244646(600)
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 works 'compensation,as provided for by section 3700 of the Labor Code,for the performance of the
work for which this permit Is issued.
II ha✓`'ve 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.
M'y workers'compensation Insurance carrier and policy number are: ,�p
Carier:-'Sl> $e \613 trollcyNumber�3-\.O� blo
=(i'his section need not be completed if the permit is valued at one hundred dollars($100)or less.) L—-'--'--�--,-r
❑ 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•R." ion es
Applkem-Signature: ,(tQ-+. ' • - ► Data: a j)(p /n Cc
WARNING:.FAILORE TO SECURE WORK.-•MPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDI••• TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37W OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
Ihereby.affiatbaLl am licensed under•rovisions of Chapter 9(commencing with Section 7000)of Division 3 otthe•Business d Professions Code,and my license is in full
force and effect.Lic.ter ' Class Ar'-`l
`C`ntra&LOfs DSS rt.)/ t Cv/ 0 Co
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit
to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than fNe 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. ❑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? ❑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 will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the 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 a ermit for such construction or modification
from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 0 No
(Section 65850.2 of the Califomia 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? ❑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 Duality Management District or other air pollution control district or agency is required for the work which is the subject of this
application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑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 Materiels 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.
i afore• •a Owner(s) Date
1�. oZ/ ig."/o(o
n r A•
Applicanty�.n...A �e
CODE I INSPECt.Q1 PE ZEE RIM/ LODEt INSPECTION MI MBA
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
��` CITY OF COSTA MESA
:y' ", BUILDING DIVISION
i DEVELOPMENT SERVICES DEPARTMENT
PERMIT PERMIT NUMBER
M98-00316
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
MECHANICAL PERMIT '
Job Address: 2517 BACK BAY LOOP Status: ISSUED
Suite No Applied: 07/21/1998
Issued: 07/21/1998
Vicinity:
Parcel Nunmber. 93765079
Applicant DEANGELIS, ANGELA _ --- " - -
Address: %'!_ =-------
�f-----------1 Phone: _..
Zip. j { A� A
-� �� •- - -_t L �/ C"
Owner: SOT0,ESTHER.r�
2517B7 n/7ACKBAY,LOOP�j��,- `' � �'^` �"^ \� N �\•'`
Address:/ 49 \ ../��/- Phone: \�/..
> .
�F) COSTA MESA'CA V� Zip: 92627 A„. // /7) ��
Contractor. _./ �� \N.IA�A/ , ..
Address:,/) /7‘,/ * , 77 ‘\ \>'.
c5 Phone I ��r•��\ ��.
U _ P
�.
/,5�! Address Of i l ii j .��z; _,7 _ i="1 �
r \1 i A
�' ' J, r lj-.'�-� Phone: !
Ii <\ 'ilTV/ Zip:
\�
,t i r,f//? License. \ \
=1 .;' S (P)1/-1 SCOPE OFP.ERMIT C : ' �i `
; tkt\\I 1 ;1i, I INST 1 30000BTU A/C-AND 1 50000 BTU FURNACE - -._y / .
X1 \ \ ` ;A;;\
VV (
'1re".,i-'4:f1.1 ,F.EE'SUMMARY ' �ats, -ter
\ ‘A L' l��i1�;
- .)Quantity
ISSUE FEE;'�\ '\ \h $22.00 Repair/Alt Absorbtion Unit 7 .:$0.00, 0 1
Inst FAU<100 le-ITU '\ $1325 Repair/AIt Refrigeration Unit / x.$0.00 O` 7
Inst FAU>100 k BTU, \N\\ $0.00 \ Ventillatioh.System 7' --$0.00 /6'�
Repair/AIt\CoolingMHeat �, $0.00 0 Evaporative Cooler ,-$0.00 d0/
Inst/RepARecess Wall''Htr �"\ $0.00 0 ..� Commercial Incinerator y --.,..„_$0:02,,i,'0
Refrig Sys,<100 k.BTU $13.25 1 1�"'1wy'>Domestic Incinerator i /7�%� $0.00/ /0
Refng Sys>100 k BTU \, v $0.00 0 , �Et o Coniiessors/Absorption Syste'ms�
Gas Piping\'�\ -tc..<, \N$0.00 0 i Ao /4;1'4 Ur,�?o,Up to 3.hp/100 k BTU , - $0.00' 0
Factory Fireplace $0.00. 0 ' "� j3:-TO)5 hp 7500 k BTU ./:.,4,/./2// -$0.00 0
Hood w/Mech Exhaust �ji-. 8000�0 cy� li _< e �, %C,_15 To 30 hp/1,000 k BTU ' ;/' , $0.00 0
VAV Box \<7.-.:\ G $0.60:>-0:\z.,,,,---it.: ro`-1 0 ,;,-630 To 5011P/1,750 k BTU .2 C/i/ /i,,40.00 0
Vent Fan/Single Duct. �/$0.00 C0 � �� .-.)-A.":" (6.'6 'Oyer 50 hp/.Over 1,750 BTU -.�"<' $0.00 0
Appliance \\ v//$0.00-0 (-1/41-5"-s..71..:.,- Boilers- y '` - K., // .
\
Fire Dampers N \ \ 50.00 0'--� -.- ,,--- _- -=_Up to 3 hp `V' . / $0.00 0
Smoke Dampers V-.N $0.00y0,- i, - -- _ 3To 15hpc- \y ` �/ $0.00 0
Inst or Relocate Appl Vent \.$0.00 /0A ,/1r v �_t-,,Cr-,15 to 30 hp:' , 772'>' $0.00 0
Air Handlers< 10000cfm -$000- 0 `1 I[ , ' .30 to 50 hp; <7-14 $0.00 0
Air Handlers> 10000cfm $0.00 �0-__ N-2 . .�\.- . -Over 50 hp ' '
$0.00 0
Floor Furnace $0.000 -' _ „,,.OtherMechanicalFee-
Floor or Suspend Heater $0.00 0 -- , ,-,7T-v--+-Investigation Fee $0.00
__Plan Check Fee $0.00
Reinspection Fee $0.00
TOTAL CALCULATED FEES $48.50
COMMENTS/SPECIAL CONDITIONS
•
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.
(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 CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE.INTEREST,AND ATTORNEYS FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full
force and effect.Lie.# 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,CMI Code).
Lenders 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.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 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 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.).— /
,,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 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. Buslne Professions Code for this reason:
nam. "/h9�te if lair
Owner ID v tied by d ers license. 0 Yes 0 No Drivers License No. Expires: -1L1
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,faisework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Gm 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? ❑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 lime during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons,
or 200 cubic feet of compressed gas at standard temperature and pressure).
2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑No
(Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any
one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of
compressed gas at standard temperature and pressure).
3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)?
❑Yes ❑No
(Section 25534 of the 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 ❑No
5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a permit 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 0 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: 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 end city ordinanc s relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
e-descd pro a action rposes.I agree o 0 occupy or allow occupancy of any building authorized by this permit until fi I inspection.
Signature Of Legal ner(s) Date
And/Or Authorized Applicant Date
CINES INSPECTION TYPE gait 10IDaia caaE1 INSPECTION CPE DA7F 1=15
1616 Fixed System Final Fire Prevention 206 Final Mechanical $I LO/1(4"- t
1266 Pool Spa Final 208 Final Plumbing I
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
__„zolif..!4.4.
CITY OF COSTA MESA
'r, ,o BUILDING DIVISION
4 DEVELOPMENT SERVICES DEPARTMENT
• in
PERMIT PERMIT NUMBER
�,;
E98-00773
(714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626
ELECTRICAL PERMIT
Job Address: 2517 BACK BAY LOOP Status: ISSUED
Suite No Applied: 07/21/1998
Vicinity: Issued: 07/21/1998
Parcel Nunmber: 93765079
Applicant: DEANGELIS, ANGELA
Address: _ -- - ---- _
��� //-C Phdne 714=858=8136.
Zip:
Owner: 5010,,dJ/ S ' v = / �� / \
BA
Address 2517%BACKB\AYVOOP�j'-� -cw--- �-- � : ������ \��) �v
/49�\ vi Phone � N mac\✓ ' /• \�,
',/COS��SA,CA-- Zip: 92627 \V��VA// /�\-,\
Contractor./ 4,2/ /, � •\��� \\,\ •
Address: 1�N,
��/ �� Phone),, I ---::-
_. \'.1';','‘‘ ,, \ \`
/ / n"1 __ „ Zip Z •
� `,\\
1
I W r,N /" 1 (' )6,2--, � r . � ,
1 FI( ' /;1 f ��i �j� SCOPE OF PERMIT - ��
BVI v
/inet new circuit and disconnect for new a/c.
i ,1 /- I!-_1 fr,7-r,) _ .-, 'lir-�',p0 C-1,':'',f.>' v
1, r- FEESUMMARY rti = '
�� _ ,
( l.�i "I ii \Quantity /n.. -- ,- Quandty'
ISSUE FEE-' c i-, $22.00 �i-'i�'- _Temp,Dist System)Lighting, $0.00 0 / ' i d,
- .
Temp service test�tii: 11 $0.00 -`" Busway/100.R�"--' $0.00 0 ' - , !1;�`
Res.a/c package\\1(,,` $0.00 "--' -' y- Standing Section - $0.00 0,7 ' i i i
New Res(1-2 units) \`\t) $0.00 0 Misc Electncaltquipment 1 $0.00 0 , --
New Res(3+un"its) V I $0.00 ,, 0 Transfdhners up to 1 kva/kw $0.00 /0 ) /-^ /
Pool/Spa ' `� $0.00 0 `` -up to:10 kva/kw $0.00 /0 �'/
LightingFitts \ �,� $0.00 0 up to 50 kva/kw $0 00 ' 0 - i /k 1 1
Receptt Outlets \/ $0.00 0 T - up to 100 kvalkw $0.00//2.0 '/ / /�/
Switches�V" $3.00 3 1 - over 100 kva/kw $0 00,.> 0 �/ /,, � /
Non Res Apply $0,.00 I 0 r-4,�(1,� '- Low Vettage Equipment $0 00 0
Res Appl \,7 Z $0;00 0 �����k° Low�Volt Wiring System/Ckt /._$0.00 0
Service to 200a', - /�$0.00 0 T ti Misc.Conduit ."' s 17;1$0.60 .\ 0 • i'''',"
Service to 1000a VA ///$0.00 'k - o ' 2 , % Mlact Conauctor� {,-...;-*2$0.00/.> 0 /
Service over 1000a -\ K.2 $0.00 0 -,<: - .Circus ' /
< h (gen or.ride) � , _ . ,$0.00)///' 0 ,
,
Motors to l hp �_ $0.607,>, "-----=:0':),-1-"-, " "/ ' Circus'(mech ride or lights) $0.00' ' 0/ " /
Motors to 10hp v NVQ `$0:00 7-----,,, 0�; ,--c,� , Christmas Tree Stand ;
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:
Carder: Policy Number:
(This section need not be completed/1 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 CIVIL FINES UP TO ONE HUNDRED
THOUSAND OOLLARE($100,000),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.Lk.# Class#
Contractor's Signature: Date:
CONSTRUCTION LENDING AGENCY:
❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code).
Lender's Name: Lender's Address:
Signature: • Date:
OWNER-BUILDER DECLARATIONS:
I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the applicant for such permit
to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business end Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars($500).):
❑ 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 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
s hin 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 ' -•-- :ws.).
m exe'•• under sec. i Busire a:nd- Qlessions Code for this reason:
igna . S a1./.'...mffiraS M isf.�•C
�� 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 6,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 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 ❑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 O 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 ❑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. Ia to comply with all state I:. :nd city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the
/v��above-de ri d property f insp ion urpo //gree to occupy or pancy of any building authorized by this��al inspection.
( ISignature Of L-.- •-mar(s) e Date CC�CC�i
And/Or Authorized Applicant • Date
GOOF I. I6SPFCTInN TYPP gATE EMU CQQE/ I66PECTION TYPF DATE =ALS
1616 Fixed System Final Fire Prevention 206 Final Mechanical #441C
�///� (/�1266 Pool Spa Final 206 Final Plumbing r—`• e200 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
'/ Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. - _ -
" PERMIT NO. TRACT NO. . LOT NO• . UNIT O. - 0898 4/09/85 8.00 IL'
ciTY OF COSTA M1ESAONS/TRUCTION PERMIT # j
Project Address ` 5-17. Q PC - ,/��J^,'j LLKJ�O- • ill I " `� r }.fir •' 7C_,y - .. _ ,.
J/,�Q �+ VP ar K ; TYPE OF CONSTRUCTION X4 NEW U ADD U ALTERATION U REPAIR ' " y.
Applicant's Mailing Address `� l /�`-Ct1. c/ El
Owner's Name - '�'-`"��A ��u�•"Ae_ ryllpfle X.S 2.:4,1-
et,
�h,1 CONVERSION CI DEMOLISH III OTHER, - A.P.# _ Zone - r
DESCRIPTION OF WORK/USE OF BLDG. - _
Address IO��--S , Fe �5'L<� Z-0Z •
......31--1'7- • S Main Building: - Accessory Building: •
• Z
Arch/Eng. License No. TYPE OF PERMIT El GRADING ❑ FOUNDATION ❑'STRUCTURAL E Front - Q
Address - ❑ TENANT ❑ ELECTRICAL' ❑ PLUMBING IVECHANICAL A Rear N
Contractor's Name !y�/•w'>�s✓Y 'Phoria 63q-2-7a • -❑ 'OTHER - 1 f'1� �1/4.f�. - T N
• - J I C Right G
PROJECT DESCRIPTION SQ. FT. OCCUPANCY - - '
Address(mailing) /�� �- �t .O- � �-[-. • I K Left - - •
R
/�/ 39 CONSTRUCTION TYPE 'VALUATION $ S � --
City License-No. ZONE GRADING CU.YDS. ACRES • Ping. Ref.# Parking Req./Provided - E
LICENSED CONTRACTOR DECLARATION - - - Q
Thereby,affirm that-I am.licensed under provisions of Charter 9 (commencing Remarks: , Planning Notes: - . M
with section 7000) of Division 3 of the Business and •rofessions Code,and , - : • T
my license is in full force and effect. 3Y572-53,,
tel 5j �y[,�(
Ucense CId55 Z_ U U'1 1 ¢ p. / ✓V _- I •
' 1 'S i
Date 3'-Z Signature • •`M! i_ /r. - ' PLUMBING • FEES -
WORKERS' COMPENSATION DECLARATION Bar Sink Showers ELECTRICAL I FEES
•
I hereby affirm that I have a certificate of consent to self-insure or a certificate • - '
' f Workers' Compensation Insurance,•or a certified copy there0 (Section Backflow Preventer Service Sink - - - -• - - - - - - •
' •
•
800, Lab. C.) q / / - _ _ _ A"utomatic Washer ,Transformer ❑: 15-50 KW
Policy No. �J�G` to• Company ren Backflow Irrigation, • Sewer Cap : 0 50+KW
Construction Pole Sub.
❑
_edified ietl copy is hereby furnished. • '
rtif ietl cop i II tl with the city Buildin �P Do� • Bathtubs Sewer Connection- Cooking Unit .Meter ❑up to 100 amps
Date 374- 3 Applicant (-^'-�✓�(��� - '
EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Clarifiers ' Solar Collectors • Dishwasher Meter Dover 100 amps - '
(This section need•not be completed if the permit is for one 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 ❑114-8
Workers' Compensation Laws of California. - ,
Date - - Signature I Floor Drains: Swimming Pool w/Spa F.A:U. ' Inc Solar 09-15 HP ❑16-15+
NOTICE:If,after making this declaration,you should become subject to the •
Workers' Compensation provisions of the Labor Code, you must forthwith _ Floor Sinks- - . - Urinal 4- - - - - . - - - Fixtures "' --' -- - "I
comply with such provisions or this permit 'shall be deemed revoked. - .Microwaved
CONSTRUCTION LENDING AGENCY -' •
Gas Service ' Outlets - r Water Closet - DeviceBoxes '
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 3091 Civ. C.)- • Interceptors "' • Water'Heat¢f '
Lender's Name • _ P - Outlets Range ,
Lender's Address - , - - Kitchen Sink ' - - Water Service _ - Switches Sign '
OWNER BUILDER DECLARATION -, _
I hereby affirm that amexempt froth the Contractor's.License Law for"the , • Lavatories - Auto-Wash ' - I _ Garbage Disposal Standing Sections
following reason (Section 7031.5 Business and Professional Code: Any city or
county which requires a permit to construct,alter,Improve,demolish or repair P-Trap. Laundry Trays. f Generator CI 0-5 KW❑5-15 KW Trash Compactor any structure, prior to its Issuance, also requires the'applicant for such permit - - - - P
:to file a'signed statement that he/she Is licensed pursuant to the provisions of : - ROOF-Drains •- I - '"
the Contractor's License Law(Chapter 9 (commencing with Section 7000) of • , r I
-Division 3 of the'Business and Professions Code) or that he/she is exempt - - --- - •
Therefrom and the basis for the alleged exemption. Any violation.of Section - • ,
031.5 by any applicant for permit subjects the applicant to a civil I -- - _ ., . - - • '
jenalty of not more than five hundred dollars($500). - ' _ , - - I - : ., .3
O I, as owner of the-property Or..my employees with wages as their sole -ReinSpeCtieh Fee i` $15 Issue Fee, $
' compensation, will,do the work,and the structure is not intended or offered - 1 - t Reinspection Fee f $15 ,Issue Fee ! I $ 3
for sale (Section -7044, Business and, Professional Code: The Contractor's MECHANICAL' FEES \t1 - r --�'
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 tor Boiler Hood or Type I 0 ,
•
sale. If, however, the building or improvement is sold within-one year of com- .- Canopy Type II 0 Zoning Approved By Date _
proven,r h owner will f have the burden of proving he/she did not builtl or im- Duct-Under Ground 1 • Building Approved By •• Date
shrove for the purpose of sale).t I - I e �'�
O 1,as owner of the property, am exclusively contracting with licensed con- Duct-Structural ' Refrigeration System Application Issued By Oat
• 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 00-100,000 BTU 0100,000 BTU SUMMARY OF FEES i • i
builds or improves thereon, and who contracts for such projects with a con- - - - I
tractor(s) license pursuant to the Contractor's License Law). I am aware that Exhaust System 0 Multiple 0 System Repair/Alteration BUILDING PERMIT $ SMIP $
proof of their Worker's Compensation insurance should be provided to me. PLAN CHECK $ PERMIT
O Tam exempt under Section - B.& P.C.for this reason Firepl/Fact.Blt. ICBO# Fire Dampers PLUMBING $ ISSUANCE $
Date Owner - HeatingSystem& Ducting Registers PLAN CHECK 25% $ I ENERGY P.C. $
I hereby: certify.that .I-have read this application and.state that-the above g,I0-10Q000.BTU ❑100,000BT - — -- ---- -- ' ' GRADING $
information is correct. I agree to comply with all city and county ordinances , ( +' OD ELECTRICAL $ ,
and'-state laws relating to building construction,and hereby authorize repre- I • 1 MICROFILM $
sentatives of this city.to e t •upon the above-mentioned property for PLAN CHECK 50% $
inspection purppse I —]
Signature l5 / ' � �` `� Date 3`Z•�r-eS I MECHANICAL •
$ 1-�� • TOTAL FEE $ CS.OC)
Drivers' License or•SS# ; 'I
• Reinspection Fee $15 . Issue Fee r $ 3 , PLAN CHECK 25% • $ l r OCA
� -
CMF 0865-46,rev.10/84 White - Building; Canary -Applicant; Pink -Accounting; Goidenrod -Assessor
47,2441
.
CONSTRUCTION AND PLANNING _ POOL -SPA
r Da
ii
te eInspector Date Inspector,APPROVALS Permit# - APPROVALS Permit #
,1. Temporary Electrical Service or Pole 'I 52.-Pool & Equipment Location -
i
t .2. Soil Pipe-Undrgrnd. ', - 53. Steep Reinforcement
, 3.(Electrical Conduit.Utility-Undrgrnd. • - .54. Forms .:
4. Electrical Conduit-Undrgrnd. • 55. Electrical Bonding • - , -
• 5:'Steel,Reinforcement • , 56. Rough Plumbing & Pressure Test i
• _ 6. Electrical UF ER Grnd. 57. APPROVAL TO COVER-GUNITE
.
7. Footings • - 58. Electrical Conduit-Undrgrnd.
.
•
8..'8.-'Foundation .*..•
•_ - ° 59. Gas Pipe, 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 - '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.tas•Pipe-Rough &Test 72. Underground Flush '
• 24. Roof Framing • 73. Undergrnd.Storage Tank 0 Gas_ 0 Oil
25. Roof Sheathing74. Overhead Hydro _
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical - ,
- . ,27. 'Frame and Flashing76. Dry Standpipe
28. Lathing& Siding , 77. FIXED SYSTEM FINAL
29. Insulation •78. FIRE PREY. FINAL
.30. Drywall Nailing .HEALTH DEPT. REQUIREMENT .
' 31. Plaster Brown Coat 79. FINAL INSPECTION
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED I
33. Final Electric Notes: '
_ 34.. Final Heating'&Air Conditioning 10,11(7s-
35. Final Gas Pipe-Test
36.'Hood or Canopy - C
37."-Final Factory Fireplace - • • -
38. Final Plumbing
39. Water Service-Final
40. Gas Service-Final - '
41. Solar Domestic-Final
42. Backflow'Preventer r
43. Backflow;Irrigation ,
44. Landscape Irrigation System - - ,
45. Sound Attenuation
46. Handicap Regulations ,. i
47. FINAL STRUCTURE & BUILDING • •
48. Special Requirements Completed ,
49. Electric Release to Edison - --• - - . . . - - - ' '
•50. Gas Release to Southern California Gas Co t i ' •
51. CERTIFICATE OF OCCUPANCY _ _
No. ' - bate _ . . _ - -