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HomeMy WebLinkAbout2541 BACK BAY LOOP - Building Permits b. V r - .. CITY OF COSTA MESA i ► BUILDING DIVISION >:i . ,. rt DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 1. 1 1 r PERMIT J r+��_1ll p 801-01301 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 BUILDING PERMIT Job Address: 2541 BACK BAY LOOP Status: ISSUED Suite: Applied: 08/21/2001 Vicinity: GARAGE Issued: 08/21/2001 Parcel Number: 93765061 Zoning: (//� Applicant: MILLER, PAUL ISSUED BY: 4 Address: 544 SOUTH LOCUST ST " , Phone: (909)623-2053 -POMONA,CA" ,% -; " " Zip: 91766 Owner AUSTIN;-PAULfM �� Phone: Address 2541 BACK BAY LOOP ,, � �� .COSTA MESA,CA' Zip: 92627 6-4 DATE Contractor: MA'(& MIDKIFF CONSTRUCTION CORP Address: 544 SOUTH LOCUST ST . , Phone: (909)623-2053 , • POMO/NA,CA Zip: 91766 ' License: 383829 Arch : - Eng: Address: - Address: Phone: Phone: Zip: - - - License: License: SCOPE OF PERMIT FIRE DAMAGE TO GARAGE;DRYWALL TO BE REPAIRED WITH POSSIBLE REPAIRS TO FRAMING, ETC.ELECTRICAL& PLUMBING PERMIT TO COVER REPAIRS TO PLUGS,WIRING,ETC IN GARAGE. - (FIRE REPORT DATED 7/3/01). FEE SUMMARY : •• ' Plan Check: $0.00 Calc Valuation: $6,359.00 Permit: $139.25 Claim Valuation: $6,359.00 SMIP Res: $0.64 SMIP Corn: $0.00 Other $0.00 Inspection: $0.00 • Total: $139.89 ' '' -' .. 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 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 WOO) 24464618/00) 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 yNrk for which this permit is Issued. E 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 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 Cal . that if I should become su act to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with those pro ,. � Applicant Signature: i p #.0r .,:e Date: ' '7!-O)- WARNING:FAILURE TO 5 /RE WORKERS'COMPENSATION E IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS(5100.033),IN ADDITION TO THE COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3106 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.if Class H Contractors Signature: ��./77 7 Date: it —Z/-0/ V 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 far 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 perrrr subjects the applicant to a civil penally 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 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 safe.). ❑ 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 set. 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(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 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 fore 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 end 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 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? 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 penally 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. al er(s)7 Date And/Or thorized Appli Date FOOL t INSPECTION TYPE PAIL INIMALS ;WEI INSPECTONTYPF PAIL BMW 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 v- CITY OF COSTA MESA o�• � BUILDING DIVISION I'i DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER • F PERMIT v 41%e.mm4. P01-00502 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT Job Address: 2541 BACK BAY LOOP Status: ISSUED Suite No Applied: 08/21/2001 Issued: 08/21/2001 Vicinity: GARAGE ISSUED BY: Parcel Nunmber: 93765061 • Applicant: MILLER, PAUL: - - - .. . / Address: 544 SOUTH LOCUST ST - / N Phone: (909)623-2053 POMONA;CA, % ' • Zip: 91766 , , Owner:. / AUSTIN, PAUL M - Address 2541 BACK BAY LOOP Phone: COSTA MESA,CA Zip: 92627 S\ scie2 ):!-t _ Contractor: MAY & MIDKIFF CONSTRUCTION-CORP yr6'O� Address: 544 SOUTH LOCUST ST - 01' Phone: (909)623-2053 POMONA,CA : Zip: 91766 / ' License: 383829 Arch / Eng: / . Address: Phone: • Zip: " License: - SCOPE OF PERMIT FIRE DAMAGE TO GARAGE;DRYWALL TO BE REPAIRED WITH POSSIBLE REPAIRS TO FRAMING,ETC. ELECTRICAL&PLUMBING PERMIT TO COVER REPAIRS TO PLUGS,WIRING,ETC IN GARAGE. (FIRE REPORT DATED 7/3/01). 1 WATER HEATER ' REF:B01-01301 - - ' FEE SUMMARY AMT QTY AMT QTY AMT On 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,eto) $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 siJ19AVIENf 1ettstr $ e# jifJyyPfaJ Fg 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 2446-46(&00) DECLARATIONS - WORKERS'COMPENSATION DECLARATION: . I hereby affirm under penalty of perjury one of the following declarations: ❑ Ive 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 ork 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 et one hundred dollars($100)or less.) ❑ I certify that in the performan t of the work for which thl permit is iss ed,I shall not employ any person in any manner so as to become subject to the workers' compensation laws of C and agree that If I s becom fact to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these pror� Applicant Signature: � p Date: d b/— 6/ WARNING:FAILURE T•4CURE WORNE COMPENSATION RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE(S103.000),IN ADomON TO THE COST 0 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 pr. of Chaster 9(commencing wi Section 7000)of Division 3 of the Business and Professions Code,and my license is In full force and effect.Lic.4 Class N Contractor's Signature: „Sri-- ' Date: -60/-0/ 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,CM!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 pear+' 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 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 Drivers 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,Op 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 []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 end pressure). 3 Does❑Yes or wilt th❑e applicant Or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? 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 ere required to register acutely hazardous materials with the Fire Department, 4 If an RMPP is presently required,hes 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 appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U 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 n 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 yea',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 prope for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. L wner(s) Date S"--0/—al n 0 utho cant Date ODE I INSPECTION TYPE DAIS INTRIALS CODEC INSPECTION TYPE all EMU 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 BUILDING DIVISION >:� ,-,,, _ ,i DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F r 1 PERMIT �� EO1-00744 • (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 ELECTRICAL PERMIT Job Address: 2541 BACK BAY LOOP Status: ISSUED Suite No Applied: 08/21/2001 Vicinity: GARAGE Issued: 08/21/2001 Parcel Nunmber: 93765061 Applicant: MILLER, PAUL ISSUED BY: 4 da,_____. Address: 544 SOUTH LOCUST ST • - , " .� Phone: (909)623-2053 - POMONA,CA,/,•; - - Zip: 91766 - ; / . - - Owner /AUSTIN, PAUL M Address -2541 BACK BAY LOOP , - Phone: - la COSTA MESA,CA Zip: 92627 ffYY����.• Contractor: MAY-& MIDKIFF CONSTRUCTION CORP vat �� Address: 544 SOUTH LOCUST ST - Phone: (909)623-2053 POMONA,CA Zip: 91766 . License: 383829 SCOPE OF PERMIT FIRE DAMAGE TO GARAGE;DRYWALL TO BE REPAIRED WITH POSSIBLE REPAIRS TO FRAMING,ETC. ELECTRICAL&PLUMBING PERMIT TO-COVER REPAIRS TO PLUGS,WIRING,ETC IN GARAGE. (FIRE REPORT DATED 7/3/01).2 LIGHT FIXTURES,2 OUTLETS,.1 SWITCH. REF:B01-01301 FEE SUMMARY ' Quantity ,i 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 $2.20 2 . up to 50 kva/kw $0.00 0 Recepl Outlets $2.20 . ' - 2 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 lhp , $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 $29.00 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 not commenced within 180 days,or it 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 / 2446e6(WOO) G DECLARATIONS WORKERS'COMPENSATION DECLARATION: • I hereby affirm under penalty of perjury one of the following declarations: ❑ I have end 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 �ork for which this permit is issued. I(d' I have and MS maintain workers compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which thhis 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 pertormanc• • the •rk 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 Calif. a,and:.r.' ',at if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these Pro vi : �j I /Applicant Signature: • i Date: �� 2/-0/ WARNING:FAILURE TO- • RE WORKERS'COMPENSATION r•• RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML RNES UP TO ONE HUNDRED THOUSAND DOLLARE 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 u provisions of Chapter 9(commencing with Section 7000)of DMsion 3 of the Business and Professions Code,and my license is In full force and effect.Uc.#_ Class# Contractors Signature: Date: Fr- 7/-0/ 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). 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.Any violation of Section 7031.5 by any applicant for a perr+' subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): ❑ 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 drivers license. 0 Yes 0 No Drivers Ucense 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,end 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 B,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 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). _ or edoil..__ �. ___..... .___ _ 2 Does or will the applicant or present future building occupant need to file a registration form for acutely hazardous maledalsl ❑Yes ❑No (Section 25533 of the California Health end 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 then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas al standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (RRiskskManagement 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.--11 an RMPP is presently required,has Section 25534 of the Califomia 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 a plication epermit 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). pa-rt tidily tobe co hn._.00._._._ _ _l._ _._ 6 Will any par of the facility be constructed under this permit be within 1000 feet from the outer Dounderles of a school? ❑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-Orother 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 COMPUANCE 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. '/0} Le ner(s Date S'- 2/ -SIS ANSI thorizetl IIca7 ate CODE 1 INSPECTION TYPE PATE pfTlTUIS CODE( INSPECTION TYPE PAIL ISLE 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/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 Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. _ ' CITY OF COSTA MESA. C ST UnCITION PERMIT PERMIT NO. TRACT NO. LOT NO. UNIJ�NO /, 0878 4/09/95 I ' - -� '0.0� TL' Project Address -�7Ia2-�j_ 7s0- ipy/�P �} ni )�409 ' rte— _ � 7LY . .- Applicant's Mailing Address //30 �+'' �/ �-!' -�C- ti[A 3-p TYPE•OF CONSTRUCTION EW U ADD LJ ALTERATION H REPAIR / • +r �� w• ' // (qs Z�`/` El CONVERSION ❑ DEMOL SH ID OTHER • AP.# - Zone Owner's Name 27 0'-a. PPPhone Q - DESCRIPTION OF WORK/USE OF BLDG. - - - Address 10-7 2- S e 8uo "�L,. ` .-4tZ..n. . _5'-g- _ S Main Building:. Accessory Building: ' Arch/Eng. - License No. TYPE OF PERMIT ❑ GRADING L I FOUNDATION El STRUCTURAL ' E Front . - - O Address /J ❑ TENANT ❑ ELECTRICAL ❑ PL_UMBING MECHANICAL B Rear N .r-L.11t••(i.�C ('l j -_2, u 171 -OTHER ht �7\IS C Right - - N Contractor's Name -Phone `J - PROJECT DESCRIPTION SQ. FT. OCCUPANCY Address(mailing) t �3 G a-r tr �,L-1 K _ G ; O ��/ q C ON STRUCTI ON TYPE VALUATION s Left l R City License No. • ( ZONE • GRADING CU.YDS. ACRES LICENSED CONTRACTOR DECLARATION Ping. Ref.# Parking Req./Provided E I hereby 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 my license is in (yll -t-a and effect. �tfCl �- • // ,Q/ • • TS License ass --t- `I LIC �L• - Date •3' CSlgnature f.'/_. PLUMBING FEES WORKERS'COMPENSATION DECLARATION Bar Sink Showers ELECTRICAL + - FEES ., lereby affirm that I have a certificate of consent to self-insure or a certificate Workers' Compen tion Insurance, or a certified copy„/hereof (Section_ ssssaaaa Backflow Preventer Service Sink -- ,00, Lab. C.Ra 9/ / / e . .. -. Automatic Washer Transformer 0 15-50 KW- Policy No. ((��( V Company ' Backflow Irrigation Sewer Ca ❑ 50+KW ' ' Certified copy is hereby furnished. _ _ p Construction Pole Sub. Ce rtiLffietl gqctyye�s filed with the city Runoff,. Di'wclo n/////���(/�] Bathtubs • Sewer Connection ' Cooking Unit Meter ❑up to 100 amps + Date 'f-`2b--F7 Applicants 1 0. -4'-- - - • EXEMPTION FROM WORKERS'COMPENSATION DECLARATION Clarifiers Solar Collectors . Dishwasher _ - _Meter ❑over 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 - rinking Fountains • Solar Tank - Fan Motors 00-1 HP ❑1'/z-8 Workers'.Compensation Laws of California. _ . Date Signature ._ - Floor Drains • Swimming Pool w/Spa F.A.U. . 'NOTICE: If,after making this declaration, you should,become subject to the . Inc.Solar 0915 HP 01615+ • Workers' Compensation provisions of the Labor Code,.you must forthwith - _ Floor Sinks - - - Urinal - t ' . - 'Fixtures Microwave comply with such provisions or this permit 'shall' be deemed revoked. _ • _ CONSTRUCTION LENDING AGENCY Gas Service 'Outlets • Water•�Cioset c I hereby affirm that there Is a construction lending agency for the•perforrharice • Device Boxes Pole Light of the work for which this permit is issued (Section 3097, Civ. C.) Interceptors t Water Heater Lender's Name' h- - - - p Outlets Range • Lender's Address ' • Kitchen:Sink Water Service •' . ' - Switches Sign OWNER BUILDER DECLARATION - _ . . I hereby affirm that I am exempt from the.Contractor's-License Law for the ' Lavatories .V Auto-Wash - Garbage Disposal 'Standing Sections r • 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 Generator ❑0.5 KW❑5-15 KW any structure, prior to Its issuance, also requires the applicant for such permit Trash Compactor to file a signed statement that he/she is licensed pursuant to the provisions of Roof Drains • -e • 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 _ - - - ierefrom and the basis for the alleged exemption. Any violation of Section •- - . - - 031.5 by any' applicant for a permit subjects the applicant -to a civil - - - . penalty of not more than five hundred dollars ($500). ' ❑ 1, as owner of the property or'my'employees with wages as their sole - Reinspection Fee I $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 (Section 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 I 0 sale. It, however, the building or improvement is sold within one year of com- Canopy Type II ❑ Zoning Approved By Date • pietion, the owner will have the burden of proving he/she did not build or im- Duct-Under Ground. , I prove for the purpose of,sale). + - . Building Approved ByDate Iq ❑ I, as owner of the property, am exclusively contracting with licensed con- ' Duct-Structural Refrigeration System Application Issued By Data U l ' 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 - ❑00100,000 BTU ❑100,000 BTU SUMMARY OF FEES builds-or improves thereon,and who contracts'for such-projects with a-con- , $ tractor(s) license pursuant to the Contractor's License Law). I am aware that ' - I BUILDING PERMIT $ SMIP ' of Exhaust System ❑ Multiple ❑ System Repair/Alteration I proof their under Compensation insurance should P.C.for dedthis to me. PLAN CHECK $ PERMIT 0 1 am exempt under Section B.& P. .for this reason Firepl/Fact.Bit. ICBO# Fire Dampers PLUMBING $ ISSUANCE $ Date - owner f Heating/� System&Ducting Registers • PLAN CHECK 25% '$ ' _ ENERGY P.C. '$ ' 'I hereby certify that-Ithave;read this application and state that the above ['s ISO-100,000 BTU 0100,000 BTL'- --- - - � 00 ELECTRICAL $ GRADING .$ - information is correct. I'agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize repre- MICROFILM ,$ sentatives of this city Ito enc pon the above-mentioned property for PLAN CHECK 50% $ a .rim inspection purses' /J Jo/�/p �/ ^ I - `_ MECHANICAL $ •t�0 C-1 �/, +Signature f 1 o.,0 a-v- , Date v1-L-b-js $ Q� TOTAL FEE I$ CMF 0865-46,rev. 10/84 White - Building; Canary - Applicant; Pink -Accounting; Goldenrod - Assessor • CONSTRUCTION AND PLANNING • POO. ,. SPA Date -Inspector' Date Inspector ; APPROVALS Permit# APPROVALS Permit# es I 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Piiie-Undrgrnd. , , i .7- -o • 53. Steel Reinforcement • -s3:•'Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding '"4 ro 5. Steel Reinforcement' i .156. Rough Plumbing& Pressure Test '` 6: Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE m 7. F.00ting�- 58. Electrical Conduit-Undrgrnd. -8.•I°oundation ' " - 59. Gas Pipe; 0 Undrgrnd.,Test 9. -Nater Pipe-Undrgrnd_ -",� 60. Backwash Lines, P-Trap, 0 Undrgrnd. 1.0. Structural •Floor System ._� 61. APPROVAL TO DECK 11. Property Sewer Line`& House Connection. . •, . 62. Backwash & Receptor-Final 12. Sewer'Cap ' . . .� v., 63. Heater & Vent.Final 13. Rdof Drains .;''i" 64. Plumbing System - Final ,_0 14. Rough Plumbing 65. Electrical-Final 15. Rough Electrical-Conduit 66. Solar System-Final 16. Rough Electric Wiring 67. Fencing & Access Approval t 17. Rough Wiring Sign 68.• APPROVED FOR PLASTERING • 18. Rough Electrical-T Bar Ceiling i 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 O Gas ❑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 & AirConditioning /0/f45- L.gO 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 51. CERTIFICATE OF OCCUPANCY . . , No. Date _ _ - _ . . . , . :J 4 itarIII CITY OF COSTA MESA y, : BUILDING DIVISION (...,„� 1.' . DEVELOPMENT SERVICES DEPARTMENT �• PERMIT PERMIT NUMBER moAO P98-00607 (714)754-5273 • Fax(714)754-4856 77 FAIR DRIVE,COSTA MESA,CA 92626 PLUMBING PERMIT • Job Address: 2541 BACK BAY LOOP Status: ISSUED Suite No Applied: 08/03/1998 Issued: 08/04/1998 Vicinity: Parcel Nunmber: 93765061 Applicant: NOCK, RON Address: /={-ci--.__, _ _,\ r� - % '' (Phone: / =�, p ; - i 1 Zi /f��` \‘_.,.-_)- ,,,,,,,) i 1 1 ��`� Owner. /AUSTIN, PAUL My .._---7-....-.:.r. �-� 4 - -��© i , /� V� Address //AUSTIN,NANCY M / �� C , � \,\\_ �/' ,COSTA MESA;CA� Phone: ��A\�� // /�7�\ G�, i iii :. �'.v ! -a A / 2541 BACK BAY.LOOP Zip: 92627 'N 'N'`4`- / ir/2 Contractor: C NOCK'PLUMBING N, , A /I Address 116121KNOTT ST _ l• I • \ , \ \•,'\ 4/ /icy/ - '� I / \ v�� /� ` Phone. 714-895-1246 1 / { /i`') ( 1 GARDEN'GROVE CA M1) :y-<Zip: 92841 �'- ,\ - 1 /A s;, .l�.; L '!l/l �{ i .: .- ___License:- 707775 _ _ ;li.�Arch I Eng Y `' �' \y"--> v . • Address �`�� - r r• i (7/ i r� Phone „ -ate it i \,..,\,.., 1 , ... '') ,7- - ZiP'., _:�\-.,\i..( .. -,>.. .. ` / I , n • i,,/'l t • = _ =License: - - -,-c. - I, ' `SCOPE'OFPERMIT ' -- \��� \. �< INST DISHWASHER. - �_.. _ _ - / . • <', / - . \�� L' \ ? i FEE SUMMARY-L- �, \\�\ \ '� \\`AMT QTY AMT --QTY 7/' /',,. .AMT QTY ISSUE FEE,t _- ` $22.00 Laundry Tub/Washer ,. $0.00 0 Sump Pump- / ./$0.00 0 Backflow irrigation $0.00 0 1 Landscape Irrigation'-,;. $0.00 0 Swimming.Pool -:-,/' '�$0.00 0 Backflow Preventer , $13.00•\_\ 0 P-Trap ' S , $0.00 0 Trap Primer - ' ' $0.00 0 Bathtub \\� - mod �0 Pressure Regulator 4 , • $0.00' 0 Urinal./ - • ,- ;17$0.00 0 Clarifier System\ - . $0.,00 -\\ , - . Process Piping(per 10 ft)' $0.00-,-c0 •--Vacuum Brkr Bkflow(14), $0.00 0 Connect(Ice,Soda;etc) $0.00, N07 - --''Receptors" lr •,-, ; $0 00, 0 ;;Vacuum Brkr Bkflow(5+)' $0.00 0 Dental Units \ <$0.00./> 0 'A,Septic'Tankp° , $0.00 ' ,0 :%-Wash Basin '�" "' $0.00 0 Dishwasher X77. $8.75/7 1. .Sewer-Cap for Demo, 'p,x$0.00 .0 Wash Basin Set ',\ $0.00 0 Drain,Floor J$0.00'/�0- - Sewer Connect , ' _ $0.00- -0- / Waste-and Vent System $0.00 0 Drain,Rainwater �v,`$0.00 v'x.01/ /,� Sevier Private Line $0.00- 0 Water Closet(Toilet) $0.00 0 Drain,Roof ‘$0.00:.,.. �0 i, i /, ''-Shower - $0.00 - - 0 ' ' Water Heater/vent $0.00 0 Drinking Fountain $0.00 t..1...0 'r \ Sink,bar', -N . $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: $30.75 COMMENTS/SPECIAL CONDITIONS • €1\f..1, Ig----••/ . 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 ' i �. WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: O 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. 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. y workers''comp ,trlof Insurance carver and policy number are: L/74 3Z LQ Cartier: C/yt be .L�,/ Policy Number. (This section n not be completed 11 the pe if is valued afore 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,end agree that If I s d become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these pro Ions. _ �'J Applicant Signature: Date: r Y-9 !/ WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL MD SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES MD CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE(5100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,MD ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under pro ions of Cha ter (commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect.Uc.tt Class It Contractors Signature: Date: C) ! b 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 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 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,wit 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 Celifomia 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 en 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 apernit for such construction or modification from the South Coast Alr 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? 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 Alr 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 COMPUANCE 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.e • ign ,.Of :.:I Ow : Air ' 'nr cif( on • And/Or Authorized Applicant • Date GOOF I IMSPECTAN TYPF DATE MISS CODE I INSPFCTION TYPE GATE ISMIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing CJaI-O74, 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