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HomeMy WebLinkAbout2463 ELDEN AVE - Building Permits I' • 4(w9 / CITY OF COSTA MESA ^ �71� BUILDING DIVISION F ' , �i DEVELOPMENT SERVICES DEPARTMENT PER IT NUMBER PERMIT V , F07-00092 "� FIRE SUPRESSION PERMIT (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 2463 ELDEN AV Status: ISSUED Suite: D Applied: 04/04/2007 Vicinity: UNIT D Issued: 05/08/2007 Parcel Nunmber: 43928128 Zoning: / / Applicant: NGUYEN, VINCE ISSUED BY: der'✓//� Address: 12600 WESTMINSTER AV o UNIT D ,Phone: 714- 554-8500 - SANTA ANA,CA. -. - • Zip: 92706 Owner: DECINCES;TIM " . `- Address 711 W,17TH ST _ - . SUITE'B012, ' _ - Phone: 949-574-0222 , COSTA MESA,, Zip: 92627 - - - - • Contractor: J B T'FIRE SPRINKLERS INC Address: 12600 WESTMINSTER AV . UNIT D Phone:.. 714-554-8500 ' SANTA ANA,CA Zip: ,. 92706 ' License: 740280 SCOPE OF PERMIT UNIT D 20 OVERHEAD SPRINKLERS FOR A NEW 2712 S.F.S.F.D.W/473 S.F.ATTACHED GARAGE AND 114 '• S.F.FRONT PORCH. 1ST FLOOR 1,297 S.F.,2ND FLOOR 1,415 S.F.,.3 BEDROOMS AND 3 • BATHROOMS. _- REF:B06-00387 C' .FEE SUMMARY -, — Plan Check: $63.21 ' _ Calc Valuation: $3,550.00 Permit: $97.25 ; Claimed Valuation: $3,550.00 Other: $0.00 _ = Total: $160.46 . FFP - c w - 3Ia\ log . - - - -- 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 • fora 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(6/C0) - 627 IiDECLARATIONS j WORKERS'COMPENSATION DECLARATION: v I hereby affirm under penalty of perjury one of the following declarations: ❑ I e 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. ( d 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 .o •:rs'compensation Insurance carrier and policy number are: ,�/ Carrie 4 -tit V T7.IS IA— IS- l ouN4 •� Pmber: -8r. -col-01-- (Thls'secfion nee•not.: ..mplefed It the permit Is valued at one hundred dollars($100)or less.) ❑ I certify that in t._ - orma ice 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 : a i. :nd a.ree that I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with •• : • wish.. . AppUV'Signa 4 I r !o �� Data: Obi Dig 07-- t.---- FAILURE •• � ERS'COMP ON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE($10,00),IN ADDITION TO THE•. T OF COMPENSATION,DAMAGES AS PROVIDED FOP IN SECTION 37060F THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. UCENSED CONTRACTORS DECLARATION: I hereby affirm that I am liven ed under•rovisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business andel Professions Code,and my license Is in full force and effect.Licjl., �.SL.:.s_ Class a ( Contractor's Signature: Ian: A Date: O�- n • 07-- CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction I:nding 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 afInn 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 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 end Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. 0 Yes 0 No Driver's License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-slx(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: • Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas 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 era 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 a plication apernit for such construction or modification from the South Coast Air Duality Management District or from any other air pollution control district or agency? Yes 0 No (Section 65850.2 of the California Government Code requires that the requested Information be fumished 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(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 01 the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes ❑No 8 (1f 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 corec),.I agree to comply with all slate laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the • abo - described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. , I / jitet r Si,nature Of Legal Owner(s) 06- C� O�Date — • d/Or Authorized Applicant-' (Date) POPE r INSPECTIONTYPE gAIF. ILLS CODE6 INSPECTION TYPE EMI IALS 1616 Fixed System Final -Ire 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 3 "c1' Z A 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 4�0 XftS�➢ CITY OF COSTA MESA a BUILDING DIVISION F 1 4I DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 441I PERMIT P06-01091 4810.0 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa..nW.! T • 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 2463 ELDEN AV Status: ISSUED Suite No D Applied: 12/21/2006 Issued: 12/21/2006 Vicinity: UNITD 49• Parcel Nunmber: 43928128 �•: , I. Applicant SIEMONSMA, DAVE MDAddress: 1048 IRVINE AVE pp1`Q+ ISSUED BY: SUITE 430 - Ph'Q: 949-722-0628 NEWPORT BEACH, - . Zip: 92660 '-f Owner DECINCES,TIM, . • , Address /711.W 17TH ST (" ' ., - �% SUITE 8012\ j,= - Phone: 949-574-022V ' - ' ,. ;-;'COSTA MESA,,;,,: Zip: 92627 " //" 7 Contractor: SIEMONSMA CONSTRUCTION Address;-, 1048 IRVINE AVE SUITE 430 Phone: 949-722-0628 • .,� NEWPORT BEACH Zip: 92660 ' •License: 536498• „ • • ,i. _ •- SCOPE OF PERMIT •, PLUMBING.PERMIT FOR PLAN 2 - NEW 2712 S.F.S.F.D.W/473 S.F.ATTACHED GARAGE AND 114 S.F.FRONT PORCH. 1ST FLOOR 1,297 S.F.,2ND FLOOR 1,415 S.F.,3 BEDROOMS AND 3 BATHROOMS. ' REF#:B06-00387 / - . . - - . . -f' - WORK TO INCLUDE: 1 BACKFLOW IRRIGATION,3 BATHTUBS, 1 DISHWASHER, 1 GAS(1-4 OUTLETS),L 1 GAS SERVICE, 1 LAUNDRY TUB/WASHER, 1 LANDSCAPE IRRIGATION, 1 SEWER CONNECT, 1 SJHOWER,1 KITCHEN SINK,4 WASH BASINS,1 WASTE AND VENT SYST,3 WATER CLOSETS, 1 WATER HEATER AND 1 SERVICE: FEE SUMMARY. ' AMT QTY 'AMT QTY - AMT QTY ISSUE FEE ' $23.50 Laundry Tub/Washer • ,$9.80 1 Sump Pump $0.00 0 Backflow irrigation . $9.80 0 Landscape Irrigation $14.80 1 Swimming Pool $0.00 0 Backflow Preventer $0.00 1 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub .. $29.40 3 Pressure Regulator ,$0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process-Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc)`,, $0:00 > . 0 - Receptors „$0.00' . 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units ; i ' $0.00 ' ; 0 -,-.--- Septic Tank - $0.00 "0.- Wash Basin $39.20 4 Dishwasher , $9.80 ' 1 , ' Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain,Floor - .- $0.00 , '0c. , Sewer Connect $24.65 1 Waste and Vent System $9.80 1 Drain,Rainwater • -$0.00,1. 0 -. Sewer Private Line $0.00 0 . "Water Closet(Toilet) $29.40 3 Drain,Roof -'\ $0.00; _0 - Shower -$9.80 1 Water Heater/vent $12.30 1 Drinking Fountain \„%-:‘:‘N�$0.00 { 0"N-. Sink,bar . � .c$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 $9.80 1 Gas(1-4 outlets) $6.15 - '.1 Sink,kitchen , $9.80 1 Water Softener $0.00 0 Gas(Over 4 outlets) $0.00" 0 t- . Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) - . , $0.00 0 - VIOLATION $0.00 Gas Service $9.80 1 -. ,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: $257.80 • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No,92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 �- % 2446-46(6/00) U • .i 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 workrs'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My works co ensation Ince ca and policy number ere: Cartier: .{t/"V{7PolicyNumber: (This section need be completed it the pe itis 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' ould become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply wit = a •rovisions. Applicant Sig - - .---41"---..-- Date: iiA � -i @ WARNING:FAILU -ems- CURE W K S'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALT S,o/ND CIVIL FINES UP TO ONE HUNDRED THOUSAND r• 'RE($108000),IN ODRION 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.Lia 4 Class if Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: 4 ❑ 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: 1 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 License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve to purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The 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. ❑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,faisework,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 W III 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 II 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 appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 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 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? 0 Yes 0 No 8 (If yes".attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to Comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Jr irJ Sign: Legal Owner5s) Date _ — 1 /, And/Or Authorized Applicant / Sr Date CODE 4 INSPEOTIONILE oA�T. INrmALS GOOF( INSPECTION TYPE PATE INITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing f'/&ettl Ir 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 9—/t J1 IrTPC A% CITY OF COSTA MESA 4 BUILDING DIVISION - .•Y •�. , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER F I warty r 1 PERMIT M06-00881 Irebe.exarxe.4. (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us • 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 2463 ELDEN AV Status: ISSUED Suite No D Applied: 12/21/2006 Issued: 12/21/2006 Vicinity: UNITD F Y Parcel Number: 43928128 Y L `VEL, /Ail) Applicant SIEMONSMA, DAVE DATE 1ISSUED BY: Address: 1048 IRVINE AVE.- " SUITE 430, ' - . Phone: 949-722-0628 NEWPORTBEACH - Zip: 92660 /' - ) - Owner: "DECINCES,TIM " - Address:7,. "7,11'W'17THSTv • ', -' - , _ 7 /SUITE B012 ,- - Phone: 949-574-0222 ''1 COSTA MESA,/",, - Zip: 92627 ' . Contractor: SIEMONSMA CONSTRUCTION Address:- 1048 IRVINE AVE SUITE Phone: 949-722-0628 NEWPORT BEACH Zip: . 92660 : ' License:536498''. ' -- •t, ' ' SCOPE OF PERMIT - - - . it MECHANICAL PERMIT FOR.PLAN 2 - " '- d. NEW 2712 S.F:S,F.D.W/473 S.F.ATTACHED GARAGE AND 114 S.F.FRONT PORCH..ISY. FLOOR 1,297 S.F.,2ND FLOOR 1,415 S.F.,3 BEDROOMS AND 3 BATHROOMS. ' , REF#:B06-00387 - WORK TO INCLUDE:1 INST FAU<100 K BTU, 1 FACTORY FIRE PLACE;-1 HOOD W/MECH EXHAUST,4 VENT FANS/SINGLE-DUCT AND 1 COMPRESSOR UP TO 3 HP. FEE SUMMARY �`- t]uantIty -- ___ __ _ - Quantity' ISSUE FEE $23.50 - Repair%Aft Absorbtion Unit $0.00 0 Inst FAU<100 k BTU,' $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU $18.20 1 Ventillation System $0.00 0 Repair/Alt.Cooling/Heaf., , $0.00 0 Evaporative Cooler $0.00 0 Inst/Rep.Recess Wall lib. $0.00 0 _ Commercial Incinerator $0.00 0 Refrig Sys<100 k BTU $0.00 0 ' Domestic Incinerator $0.00 0 Refrig Sys>100 k BTU �<\ $0.00 0 , ti-,fi-- , Compressors/Absorption Systems Gas Piping`, A 1 ��VA, $0.00 0 • '! /- Up to 3 hp/..100 k BTU $14.70 1 Factory Fireplace - . <,\$10.65_..1 ' 3 To 15 hp/500 k BTU $0.00 0 Hood w/Mech Exhaust . -- $10.65 1 •_ '- 15 To 30 hp/1-,000 k BTU $0.00 0 VAV Box ',7- ' '/,,',/- /;/` N$0.00 . 0 - 30 To 50 hp/1,750 k BTU $0.00 0 Vent Fan/Single Duct .../,, ,,j $29.00- 4 , _ Over 50 hp/Over 1,750 BTU , $0.00 0 Appliance -$0.00';c7.0 ,-,` ' ' Boilers , Fire Dampers �� %i $0 00 0 �'= - �Up to 3 hp - . $0.00 0 Smoke Dampers $0.00' ' 0 • 3 To 15 hp • $0.00 0 Inst or Relocate Appl Vent $0.00 . '0 - ` . 15 to 30 hp $0.00 0 Air Handlers< 10000dm '. $0.00 0 30 to 50 hp $0.00 0 Air Handlers> 10000dm - $0.00 ' "0 ' Over 50 hp. $0.00 0 Floor Furnace $0.00- 0 Other Mechanical Fee Floor or Suspend Heater $0.00--0 ' . Investigation Fee , , $0.00 - _ Plan Check Fee $0.00 Reinspection Fee $0.00 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. 7-7-9 FOR INSPECTIONS CALL: (714)754-5626 / i 244646(6/00) v • 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 works co pensatio su�/ran1 er and policy number are: Cartier: 4 f ' Policy Number: (This section n not comp ted if the omit Is valued et one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which • it Is Issued,I shall not employ any person in any manner so as to become subject to the workers' compensation la. alifomia. :•- •r ee that Ill. •ecome subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply wit. Applicant S•: = u���V � a Date: ./W71-120e.:2 WARNING:F•A• 0 SECtI' WO''COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED TIXIUSAND DOLL ARE Wool a),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST.AND ATTORNEY'S FEES. LICENSED CONTRA TORS 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.Lia# Class# Contractor's Signature: • • I. 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). Lenders 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 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 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.32,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 tem __ _ _._ _ _._ _....._.... 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 Califomia 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 Calif omia 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 permit for such construction or modification from the South Coast Air Duality 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 end 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 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 inspec' urposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. �� Sign e Legal Owner Date !/ � And/Or thorikd Appli .op 1„te CODE t INSPECTION TYPE PITS INRI1AL4 LODE. INSPECTION TYPE �2aIE 1616 Fixed System Final Fire Prevention 206 Final Mechanical yi1T O-1 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 — 44 6111Ms `- CITY OF COSTA MESA BUILDING DIVISION F 0 re,,, �1 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER PERMIT E06-01537 SbftoeMspee (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesaELECTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 2463 ELDEN AV Status: ISSUED Suite No D Applied: 12/21/2006 Vicinity: UNITD X Issued: 12/21/2006 Parcel Nunmber: 43928128 EX D Applicant: SIEMONSMA, DAVE DATEi . {{{//�JJ Address: 1048 IRVINE AVE // 8.5) SUITE 430 - Phone: 949-722-0628 ISSUED BY: /�--��/ NEWPORT BEACH, • - :. Zip - 92660 Owner DECINCES,TIM - Address 7.11:W.17TH ST ' - _ -_ . .. \SUITE 8012 \ `. (-i:•-:--,--: =Phone: 949-574-0222 _ - _ - /. '' COSTA MESA,. /" - -. Zip: 92627 -- / \ � � � : - Contractor SIEMONSMA CONSTRUCTION ' Address: 1048 IRVINE AVE SUITE 430 Phone: 949-722-0628 , f NEWPORT BEACH Zip: 92660 - , License:536498 / . //' i/ ' ,''1' ` SCOPE OF PERMIT - '' ' .. -ELECTRICAL PERMIT FOR PLAN 2 - _ _ ' ' '- NEW 2712 S.F.S.F.D.W/473 S.F.ATTACHED GARAGE AND 114 S.F.FRONT PORCH. 1ST FLOOR 1,297 S.F.,2ND FLOOR 1,415 S.F.,3 BEDROOMS AND 3 BATHROOMS. REF#:B06-00387, ' ''WORK TO INCLUDE:2273SF 1 UNIT RES, 1 SERVICE TO 200A,6LIGHT-FIXTS,3 OUTLETS,2 SWITCHES FOR THE GARAGE. -- - cr -FEE SUMMARY Quantity - --- - - - - Quantity • ISSUE FEE $23.50 - Temp Dist System/Lighting $0.00 0 Temp service test ; $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units)• ,`\ $151.87 ' 2712 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 - ''\<'$6.60 6 ,;�.'• _up to 50 kva/kw $0.00 0 Recept Outlets -. $3.30 3 up to-100 kva/kw $0.00 ; 0 s Switche ,c,->v < ', $2.20 2 ;- ` - 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 , % $30.50'- , 1 - Misc.Conduit , - . $0.00 - 0 Service to 1000a " ' < $0.00 �A0.,� , -- - , Misc.Conductor -_ $0.00 ,'- 0 Service over 1000a �\ ;$0.00 0„ - „ Circus(gen or ride) - $0.00 0 - ' Motors to 1 hp $0.00, - 0 ' ' - Circus(mech ride or lights) $0.00 -0 Motors to 10hp . $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0- Fireworks Stand $0.00 0 Motors to 100hp $0.00 0` - Other Electrical Fee . $0.00 Motors over 100hp $0.00 0' - _ Communication drops $0.00'-• - .A-. Investigation Fee . $0.00 Sub panel to 200a $0.00 -0 ,-, _ Plan Check Fee ,-,-.% - " $0.00 Pole Light Pkg $0.00 0 ' - - - "- ReinspectionFee - . $0.00 Sign Circuits $0.00 0 Temo Pwr Pole $0.00 0 TOTAL CALCULATED FEES 5217.97 • 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. i , FOR INSPECTIONS CALL: (714)754-5626 {- 2448-46(6/00) C,' 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 `�'condensation I rance ccnte2nd policy number are: Carrier: JL 1� ( �'Ir` J\ Policy Number: (This section need not be comple it the permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for hic his permit i • ued,I shall not employ any person in any manner so as to become subject to the workers' compensatio California,an agree th 1111-hould be bject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply ,,,oh s. 7 Applicant Signature: J/ Date: 1// / J//yb WARNING:FAILURE • ' URE WORK RS -ENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL ENALTfES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOILARE($100,000),IN ADD ION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE.INTEREST.AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: ' I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect.Lic.M Class a Contractor's Signature: " Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency far the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders 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).): ❑ 1,as owner of the properly,or my employees with wages as their sole compensation.WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If.however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the properly,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 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 preset 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 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 aRPermit for such construction or modification from the South Coast Air Duality Management District or from any other air pollution control district or agency? DI Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No (If"yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes ❑No B (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S ure Of Legal wner(s) / J j Dpt And/Or Authorized Ica 6/ CODE# INSPECTION TMPD GATE INTFTIALS CODE I INSPECRON TYPE DATA INTITIAL6 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing u ,` 200 Final Re-Roof 210 Final Electrical -I O-05 201 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 _ A 4;501 Ms - CITY OF COSTA MESA 4 + BUILDING DIVISION SiMtriA f •,, -a1 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER PERMIT B06-00387 BUILDING PERMIT (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 2463 ELDEN AV Status: ISSUED Suite: D Applied: 03/08/2006 Vicinity: Issued: 12/21/2006 Primary Occ: R3/1.11 Type of Construction: V-N Parcel Number: 43928128 Zoning: si," II? c 1 / Applicant: SIEMONSMA CONSTRUCTION - a Address: 1048 IRVINE AV 1.01‘ DSUITE 430 __Phone: 949-722-0628 NEWPORT BEACH,CA ,r, - -Zip:-,- 92660 . ISSUED BY: ,,_ Owner: DECINCES,TIMc2� ' — ,./.,-":- f -- Address 711 W 17 STri -i. i - \ �� SUITE8012/ c i Phone: .949-574-0222` ` .. ` i M. A,C _ r r ` •' . COSTA MESA,CA\_.,---, \ � Zip: 92827 r , � -->.c.„:' , / / / / Contractor 7'SIEMONSMA=CONSTRUCTION" - Address:// - Address/1048 IRVINE AVE -�'' ,i '\ SUITE 43 0>/�j , Phone: 949-722-0628 - , v/(/ , , , NEWPORT-BEACH ` / )i,�/Zip• 926604{,y,,„/- License:License: 536498 ��� ; ,Aron : ' / 'i/ Eng: MANSHADI, FARHAD ,j Address: - i/:1/ Address: 1800 E 16TH ST- . . - /'!y - • - - Phone: 714.835.2800 ' --- - ,, Phone: ; , 1v - - - , ••ii. • �'� SANTA ANA,CA ,Zip:- , /,,�/7 1! License:"- - I. 92701 - License: •36840 ` - ' `PLAN 2 SCOPE OF PERMIT '_ • - ';".' -� , , NEW 2712 S.F.S.F,D.: /473 S.F.ATTACHED GARAGE AND 114 S.F.FRONT PORCH.1ST FLOOR-1,297 S.F.,2ND FLOOR 1,415 S.F.,3 BEDROOM BATHROOMS. > "' _ REF:G06-00010 , l 1-'1 I) : �( ci: V` + ,, %K \\ \ N FEE SUMMARY ,r- -Plan Check l ', $1,242.90 1 rr'-‘ r z , Calc Valuation: $263,920.38 / ` Permit $1,912.15 r, -�--Lc3 - '%_,v ` 1 -;2/4 • Claim Valuation: . Woo,,SMIPRes)`, '„ $26.39 SMTP Com $0.00 - Other �A ' • $0.00 .Inspection: AAy $0.00 �- - ._ y:Total. $3,181.44 : �1 ,. AU - A‘ A : ...o .. �c, .,- `` ./ � � •I fir . ' „PLANNING &ZONING` c max,, - SETBACKS // .1C\,\ c MAIN STRUCTURE Front�'0-_0 N---..',"\-.:::‘;".:-.. Rear,- 0:6 � ` - Left-' 0-0 Right 0-0. ''�/ AC N, ACCESSORY ', Front ,00--� --Heals, 0 ,0Left -0-0 Right - 0-0- „��, PARKING 'Exislinq:- "o i ///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. ,i FOR INSPECTIONS CALL: (714)754-5626 - 7{,./7/ ' 2446-46(6/00) k.'7 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. Yi 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. F My w rk rs'c pensation s rance rrier and policy number are: Carrier: / / i / t Policy Number: (This sec ion need no be completed permit is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for w.' • this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws• alifornla,and agree hould become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with t s. Applicant Signature: Date: �,G�'�i7 �� WARNING:FAILU' 0 SECUR- ORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES ND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE I$100,14 t,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: " ✓ t 1 hereby affirm that I am licensed der provis ons of• apter 9(commencing with Section 7000)of Division 3 of the Business a•• •rofessions Code,and my license is in full force end effect.Lie.a _... j �r IP 'S Class x Contractor's Sign- • _allikr"C _ Date: CONSTRUCTION LENDING A.ENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business end 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 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,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? Q 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? ❑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 0N (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑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 appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any 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? ❑Yes 0 No 8 (If'ryes",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 Or 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 pur :poses.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Oral Owner(s) Date // / 4 And/Or Authorized Applicant . Da CODE I INSPECTION TYPE DATE INTI CODE INSPECTION TYPE DATE INTIALS • 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 ,L 250 Final Building/Occupancy 1 bip l • 204 Final Demolition _ 51111 CITY OF COSTA MESA 4/ BUILDING DIVISION j gal . DEVELOPMENT SERVICES DEPARTMENT PER T NUMBER 1. 1 �.� . . 1 PERMIT 4. rill 9 B06-01193 1 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.cILDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 2463 ELDEN AV Status: ISSUED • Suite: Applied: 07/19/2006 Vicinity: Issued: 07/19/2006 Primary Occ: R3 Type of Construction: V-N Parcel Number 43928129 Zoning: Applicant:dd048IR NEAVESIEMONSM,DAVID Address: 1048 IRVINE AVE SUITE 430 Phone: 949-722-0628 ISSUED BY: NEWPORT BEACH - Zip: 92660 Owner: DEUCES, TIM - ,r , Address 711 W 177H ST. - , SUITE B012 Phone: 949-574-0222 COSTA MESA,CA Zip: 92627 Contractor SIEMONSMA CONSTRUCTION Address: 1048 IRVINE AVE - SUITE 430 Phone: 949-722-0628 NEWPORT;BEACH Zip: 92660 License: 536498 Arch : Eng: . Address: Address: • Phone: Phone: i Zip: License: . . License: SCOPE OF PERMIT DEMOILSH EXISTING STRUCTURES ISI 1-UNIT A ND B 1750 SF WITH 480 SF GARAGE , 2-UNITS C AND D 1333 SF -400 DETACHE GARAGE FEE SUMMARY Plan Check: $0.00 Calc Valuation: $9,906.00 ' Permit: $181.25Claim Valuation: • $9,900.00 SMIP Res: $0.99 SMIP Com: $0.00 - Other: $0.00 Inspection: $0.00 Total: $182.24 , PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0Right - >0-0 , ACCESSORY Front 0-0 ` Rear 0-0 Left 0-0 Right 0.0 . PARKING Existing: 0 Required: 0 ' Proposed: 0 f / i E. 1 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 2448-46 WOO 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 for which this permit is issued. .` nil will maintain workers'compensation Insurance,as required by section 3700 0 •: .•" ."_ • the performance of the work for which this permit Is Issued. rke•.' 'moonset •n Insure :carrier and policy number are: � %/e a! A 4, o Icalumber:c•„ iJ_ a wI•• •: •t be•• •leve•N permit ,the permit is valued et one h ••dollars($100)or less.) dba�� dit �••.• . ify •Vii• -.Ian.: . he • for w. •: m .issued shall not employ any person in any manner so as to become subject to the workers' f••-•nsa ion laws of Cat oml: . •ag :: U : .7•n • +4• -- . : . ._ .•• , .• .:•''tion provisions of Section 3700 of the Labor Code,I shall forthwith C. rte �� ••plicNG:Signa rre./ / Date: - INO:FAILUR- ($ EGURE WO• . RS'COMPENSATION PERS TIUN,DAND SPRVDEDSUBJECT IAN N ' ' rYER TO 'IMINAL NODI L RDFSUPTO NEYSHUNDRED . • ail,• •�'e -E(SloO,000l,h ••dT10N TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECn• ••f' THE COD INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby aff e. -• -• liven-:•under provisio - of Chapter 9(commencing with Section 7000)of Division of the Business an. • : :sslons Code,and my license Is In full for.: :a per' i / c . Con : lVMS sl�J D. • �IZli ;Ali CONSTRUCTION LENDINr •GENCY: ❑ I hereby affirm that the re 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 em 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 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,em 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,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,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? ❑Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes ❑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? LI Yes d No (If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health end 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 end city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws 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 a• •e not to occupy or allow occupancy of any building authorized by this permit until final inspection. // �Ot Le:_r•.--_) -- ,//ff/� -______Date f j ..�Or •uthorized Ap Cant !�/r to OBE L . ' •Ir:., Ei' INITIALS f.09E4 INSPECTION TYPE PALE MOTU& 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 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 ,,C�q��A 222 Final Site 204 Final Demolition 3 Na (,'52 b' 1_ 250 Final Building/Occupancy l �on MF �-- CITY OF COSTA MESA •i ►9 BUILDING DIVISION , ,„ .,�r DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER f t r..r^.r... � %ry PERMIT E06-01462 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesaELECTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 2463 ELDEN AV Status: ISSUED Suite No - Applied: 12/14/2006 Vicinity: Issued: 12/14/2006 Parcel Nunmber: 43928129 Applicant: JOSE DELSANTILLAN Address: 14551 ANDEL DR Phone: 909-574-1400 ISSUED BY: FONTANA,CA , -, - " Zip 92335 - j-, , Owner: DECINCES, TIM Address 711 W 17THST '\ - - -/SUITE 6012 ` - _ - - Phone: 949-574-0222 _ • - COSTA MESA,CA - Zip: 92627 • ' - . Contractor: NATIONAL'CONSTRUCTION RENTALS Address: 14551 ANDEL-OR • . Phone: 909-574-1400 • FONTANA,CA Zip: 92335 License:687160 ., SCOPE OF PERMIT , -1 TEMP.POWER POLE. ' (_,/ FEE SUMMARY v \., - . Quantity Quantity ' ISSUE FEE $23.50 r•• ,. , 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 - 50.00 0 New Res(1-2 units) $0.00 '\ 0 Misc Electrical Equipment 50.00 0 New Res(34-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 $0.00 . _ 0- -. -- -- - up to 50 kva/kw $0.00 0 Recept Outlets - $0.00 0' - up to 100 kva/kw $0.00 0 Switches ' $0.00 0 over 100 kva/kw $0.00 0 Non Res Appt'- $0.00 ' 0 Low Voltage Equipment . $0.00 0 Res App! $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 1hp \\\$0.00 0 - Circus(mech ride or lights) $0.00 0 Motors to 10hp, , \\\$0.00 0 - ` : Christmas Tree Stand $0.00 7,- 0 Motors to 50hp\ ,-` '$0.00 N ,:-C-.,0.. ' .Fireworks Stand t,. s -- $0.00 0 Motors to 100hp 00.00" 0- " - ' Other Electrical Fee $0.00 Motors over 100,hpA /�/$0 00•I';‘' --- ,,,,,,,, ,,,..0 Communication drops- v 2/ $0.00 0_ _ ' Investigation Fee - $0.00 j� Sub panel to 200a' `-'A $0,00 0> = > Plan Check Fee, $0.00 Pole Light Pk ' g g A��`� "--"$0.00 . , 0���'���_� Reinspection Fee= ; $0.00 -' , Sign Circuits v' ' -. $0.00 . 0� _ Temp Pwr Pole $23.50' ' 1 TOTAL CALCULATED FEES $47.00 Intermed Pole '.,C 50:00, - 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 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 2448-48(8/00) cadlimi WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ ve and will maintain a certificate of consent to sell-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. /// -71-ha 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 arker rgmpen at o I surance carrier and patty number are: ���u r c �� I�O� ( ( J t' / q Poi Num 1 (This section need not be completed it the permit is valued at one hued pliers($100)or less.) ❑ I certify that In the performan work for is this permi s Issued,I shall not employ any person in any manner so as t become bject to the workers' • tion laws of Calif a,and agree if sh subject to the workers'compensation provisions of Sectio 3700 of a Labor Code,I shall forthwith empty wit these pr ' ns. 'Lw /„ j ppl{car -'.nature: � UUaaJJ((e: Lw(/L , cc WARNING:FAILURE TO SE RE WORKERS'COMPS TION RAGE IS UNLAWFUL AND SHALL SUBJECT ANtMPtOYER TO CRIMI PEN ES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARE($100, ),IN AOOfTION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECnON 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CO b••• •CTORS DECLARATION: I hereb ,"u .m licensed under nevi ons of Chapter 9 �mencing with Section 7000)of Division 3 of the 4 siness and Professions Cod.,and my license is In full fo•...:rTr:,::. trn A 7�.r/. - % Class - "I'D • - ... re: Amara /V .. : L�rw _ �r RUCTION 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 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 TIE 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 properly,em 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 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,lalsework,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 AdministratNe 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 Iron 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 end 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 et any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds.or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will 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 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 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 U No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If"yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia 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 ail of the disclosures prescribed by Califomia Health and Safely Code Section 42303 been made? ❑Yes 0 No B (If yes".attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct.I agree to comply with all state laws and dty ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 3 ignatum egal Owner(s) Pate And/ orz n D ODE I INSPECTION TYPE INImALS CODE I INSPECTION TYPE PATE IIfTIIAI& 1816 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing Q y 200 Final Re-Roof 210 Final Electrical d 201 Final Block/Retaining Wall ,. 212 Final Fire Prevention PP 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy _ 1 - CITY OF COSTA MESA 4 i , BUILDING DIVISION >:� DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 4. ji PERMIT ' 41/4%4PoRmiD s*. '/E06-00788 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.rBLS.CTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 2463 ELDEN AV t t Status: ISSUED Suite No Applied: 07/19/2006 Vicinity: Issued: 07/19/2006 Parcel Nunmber: 43928129 Applicant SIEMONSM,DAVID Address: 1048 IRVINE AVE ISSUED BY: SUITE 430 Phone: 949-722-0628 NEWPORT BEACH Zip " -92660 Owner: DECINCES, TIM Address 711 W 17TH ST SUITE B012 Phone: 949-574-0222 COSTA MESA,CA - Zip: 92627 - ' Contractor: ' SIEMONSMA-CONSTRUCTION 1 Address: 1048 IRVINE AVE SUITE 430 Phone: 949-722-0628 NEWPORT BEACH Zip: 92660 License:536498 SCOPE OF PERMIT , DEMOILSH EXISTING STRUCTURES 1-UNIT AND B 1750 SF WITH 480 SF GARAGE 2-UNITS C AND D 1333 SF , -400 DETACHE GARAGE REF B06-01193 _ ELEC.CAP ' . FEE SUMMARY QuantityQuantity 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 $0.00 0 up to 50 kva/kw $0.00 .10, Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0 Switches $0.00 0 over 100 kva/kw $0.00 0 , Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appi $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 - Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 - - Other Electrical Fee $18.20 �' Motors over 100hp $0.00 0 „/". Motors 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 $41,70 Intermed Pole $0.00 0 , ' I 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. 1 FOR INSPECTIONS CALL: (714)754-5628 2446-46(6'00) 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 ork for which this permit Ls issued. ■ :ye an•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. yw•• : :':mpensa • Insurance carrier and policy number are:, artier. ! � /yy7 . p _ licq-Nve�q -- :. I• need •t be completed If the permit Is valued et one hundred dollars(5100)or less.) ❑ I cent that in the performance of the work f this permit Is issued,I - no em•o• : • in any manner so as to become subject to the workers' corn. •• .ws of California,and agree the should become subject to the workers' revisions of Section 3700 of the Labor Code,I shall forthwith •y wit wl•rovisions. •unt Signe /� / `\ dater RE •SECURE Ws,- RS'COMPENSATION COVERAGE IS UNLAWFUL AND SWILL SUDIECT AN EMPLOYER TO GRIM' ES AND CML TINES UP TO ONE HUNDRED THOUSAND DOLLARE(WOOL0), •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 her:• : rm that am licensed under provisl• •of Chapter 9(commencing with Section 7000)of D •• of the Business:-•Professions Code,and my license Is in full fo •: e n. .# I . - 'a or i g111011. 471 CONSTRUCTION LENDING ENCY: ❑ 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 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 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 properly,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 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)feel 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 DMsion 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 ❑No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Flre 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 volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .__ ..._.. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention .Program for acutely hazardous materials)? ❑Yes 0N (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP Is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑No .....ppli._.nt_._r.....r._........t...._...._.__......_.. ._.__ _ _.._ _._ -..._ ._....lon or. codon 5 Does or willo the applicant or QualityiManagement n building occupant at requirer for the work ontch the subject this a plication eppermlt for such construction or modification from the South Coes)Air District or from any other air pollution control district or agency? �Yes u No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 W III any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries 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). .._..._ __._ _._.___.alit_.___ ..i._. _.._.i.._._ _ _ .i..._... a .___ 7 application,a patrofrom the South iscast res Quality edManagement Healtheal or ether epodeion c4l district3been or agency is required for the work which H the subject of this have all of the disclosures prescribed by Californiaia and Safety Code Section 42303 been made? 0 Yes ❑No B (If'yes",attach certificate of compliance from the appropriate air pollution control officer). CER11FICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. • of Owner(s) D to ;ODE L INSPECTION TYPE 981E BMW 800E I INSPECTION TYPE `J MTh 91IML$ 1616 Fixed System Final Fire Prevention 208 Final Mechanical _ 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Flre Prevention 202 Final Factory Fire Place 220 Final Planning Approval _ 203 Final Sign (�L 1(L 222 Final Site 204 Final Demolition ��� l "V 5"�` 250 Final Building/Occupancy • CITY OF COSTA MESA BUILDING DIVISION •/ es DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER j PERMIT G06-00010 (714)754-5273 • Fax(714)754-4856 • www.cl.costa-mesa.c§„){s--DING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 2463 ELDEN AV I�KH Status: ISSUED Suite: Applied: 03/14/2006 Vicinity: Issued: 11/08/2006 • Parcel Nunmber: Zoning: Applicant: SIEMONSMA, DAVID • Address: 1048 IRVINE AV ISSUED BY: 15.T IC-- SUITE 430 Phone: 949-722-0628 NEWPORT BEACH,CA- Zip: 92660 - 1 Owner: DECINCES,TIM,- • Address 711 W 17TH ST SUITE 18012- C', - Phone: 949-574-0222, • COSTA"MESA,CA Zip: 92627 Contractor:/'•SIEMONSMA CONSTRUCTION • Address: 1048 IRVINE AVE " SUITE 430�; i� Phone: 949-722-0628 • / / NEWPORT BEACH Zip:. 92660 :j1 License: 536498 . ' 17 /Eng: D,ZN;ENGINEERING ' Aadress: ' 166 MATISSE CIRCLE Phone: -949-305-8920 _ - ' ALISO VIEJO,CA - Zip: -92656 , - License: C54067 SCOPE OF PERMIT CUBIC YARDS PRECISE GRADING IN CONJUNCTION WITH 4 NEW SFD, PLAN 1A, 1A REVERSE, 1B AND PLAN WORK TO INCLUDE`. GRADING AND SITE IMPROVEMENTS. REF#: 606-00384, 85,86 AND 87 CUT: 325 CY FILL: 275 CY • 600 Plan Check: $33.00 - - Calc Valuation: $20,000.00 $0.00 Permit: $124.50 ' Other $0.00 $0.00 'Inspection: . $0.00 $0.00 • Total: $157:50. i ;- \ v-v A;��� PLANNING &ZONING NOTES: ACHAM _CN 05/16/2006-1 SOILS REPORT GIVEN TO SHA DIAZ_R 10/11/2006 TIMEEXTENSION FOR PLAN REVIEW GRANTED THROUGH 03/09/07. BOW,' ,, - • • • • 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 2446-46(8'00) 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 carder and policy number are: Cartier: Policy Number: (Th/s sect/on 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 alifomla,and roe that uld become subject to the workers'compensation provisions of Section 3700 of the Labor Cale,I shall forthwith comply with th si Applicant Signalur r — Date: /04.Vr- THOUSAD:FAILURE E( SECU0),INADDMO COTE COST OC OVERAGE TI UNLAWFUL AND SHALL IDEDSUBJECT IN EMPLECTIOY37TOFTHE AL PE ODE.INTEREST, FIDESTO ATTORNEY'S HUNDRED THOUSAND DOLLARS(SI 00,000), ADDRION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 370e OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions o hapter 9(commencing with Section 7000)of Division 3 of the Business and PWtgaslons Code,and my license is In full force and effect.Lie,N '¶3G 4 Class N �✓ �^ Contractors Slgnatur. , s — Date:,____14 �2 CONSTRUCTION LEN• NO 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 permit subjects the applicant toe civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or Improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. 0 Yes 0 No Drivers License No. l 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,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 tho 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 materiel? 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? ❑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). _....._t...__..___ an RM _...._.... 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? (J Yes LI 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 pert 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 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. Signature Of L al er(s) / r�yjDale And/Or Authorized Applicantfr Date IOD S. INSPECTION Mg PAIS IBIDSLs CODES INSPECTION TYPE 261E ILLS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1268 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 r?-14-07 204 Final Demolition 250 Final Building/Occupancy • l-fi 1S4r CITY OF COSTA MESA • 4 ,. BUILDING DIVISION j:�it;..4 DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER J: OE I PERMIT .11411 P06-00565 Sbietwoote (714)754-5273 • Fax(714)754-4856 • www.ci.eosta•mesa.caFySL UMBING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 2463 ELDEN AV Status: ISSUED Suite No Applied: 07/19/2006 Issued: 07/19/2006 Vicinity: Parcel Nunmber: 43928129 .Applicant: SIEMONSM,DAVID ISSUED BY: Address: 1048 IRVINE AVE _ - . . SUITE 430 ', '_Phone:""949-722-0628_ , - NEWPORT BEACH' .";- ' : - - c Zip: 92660 Owner: DECINCES,vTIM ' - `, \ Address 711 W-17TH ST � - _ - - - 'SUITE 6012 \ \,- - - Phone: 1949-574-0222- �;'��� Ni \\. / COSTA MESA;CA- _ Zip: 92627 Contractor: �SIEMONSMA CONSTRUCTION Address: 1048 IRVINE AVE i N �.`^ \, ' SUITE'430 Phone:_ 949-722-0628 �. •���V � �� \�_�,' NEWPORT BEACH Zip: 92660 _ /, �. t^License:, 536498 • - , i ._ , . . . _ , , - . - - ." . SCOPE OF PERMIT - y, /, , DEMOILSH EXISTING STRUCTURES �� ' ' ;1-UNIT A ND B 1750 SF WITH 480 SF GARAGE 7 - • ' ' '2-UNITS C AND,D1333 SF �\\ ' '7,' -400 DETACHE GARAGE REF BO6-01193 - -" --"- " ' -- - ! i 1 SEWER CAP.; ; ,--'7"/' /r -v ')1' -r;.' .\' ;/n „AL , . , /;�. �\ �7 . \ J ,� FEE SUMMARY ,-s AMT (-14Y _ ,"` ' AMT /QTY I ' AMT „Oa ISSUE FEE , $23.50 Washer Laundry Tub'/ , ;$0.00 ",/02,,, ' Sump Pump ' '$0.00: •,' 0 Backflow irrigatio $0.00 0 '- -Landscape'Irrigation " $0.00 '0 ' Swimming Pool 7, , $0:00 , b Backflow Preventer,' $0.00 0 ' P-Trap -- N - --"$0.00 ' 0 _ - , Trap Primer l / � $0.00 '0 Bathtub $0.00 0 i Pressure Regulator $0.00:" 0 Urinal j// -„$0.00, 0 Clarifier System , \'_, . $0.00 0, Process Piping(per 10 ft) l$0.00' 0 Vacuum Brkr Bkflow(1=4) - $0.00 ; 0 Connect(Ice,Soda,etc),,,, $0.00 0 Receptors -,$0:00 c .0 Vacuum Brkr.BkOow(5.) x.'$0.00 / 0 Dental Units , ' $0.00 0 Septic Tank $0.00 0 Wash Basin '7 $0.00' 0 Dishwasher $0.00 0 Sewer Cap for Demo- $9.80 1 Wash Basin Set 4. _j $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 ' 1'0 . . Water.Heater event, x, ''$0.00 0 Drinking Fountain $0.00, .0. Sink,bar $0.00 ' 0' . Water Piping(last or Rep.)," $0.00 0 Expansion Tank,' . $0.00 0- , - Sink,commercial $0.00 0 ,r"Water Re=pipe /� % DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ have and w81'malntain 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. ve and will maintain workers'compensation insurance,as required by section 3700 of the Labor Cade,for the performance of the work for which this permit is issued. M works nation range er and policy number are: �'7, sa �i 1�{ miser. �1 . ✓� / Y7 (This need not completed if , permit Is valued at one hundred dollars(5100)or less.) `.._,.J ❑ 1 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.f California,a • -: :: that hould become subject to the workers'compensation provisions of Section 700 of the Labor Code,I shall forthwith , = OR W �� WARM . AJLURE (SEW- ' ADDERS'COMPENSATION ENCOST O COMPENSATION, IS U SFOR IN ESTI O O MI RJCOOE, AND CML FINES UP TO ONE HUNDRED. THOUSAND DOLLARE($100.... IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3708 THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I here) . Irm :t I am lice :•under provisions of Ch:• :r 9(commencing with Section 7000)of Division 3 011 Business Professions Code,and my license is in full for.: :;chin t.Lic.s - O . r a .•• = 'ors Sig . . � � i- _rr CONSTRUCTION LENDIN• AGENCY: ❑ I hereby affirm that them 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:My 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 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 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(e) 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 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 Ls 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 DMslon 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,ora volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). __...._........_._r__... .... —_.._ 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)? (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 apereit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). B 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 U 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: CERTIF1CATE 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 pu ••-es.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Ile -ig 'O Or Legal Owner(s)A '. / /. T- •40. zed APPIICa tit •:to =LS BTS' CTION TYPF laTI BMA ;GDF t g4SPECTION TYPE MTh PIIMAL9 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1268 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall. , 212 Final Flre Prevention _ 202 Final Factory Fire Place _ 220 Final Planning Approval _ 203 Final Sign 222 Final Site _ 204 Final Demolition • - rg-PI-D8 Z1 250 Final Building/Occupancy 11111 . - 14814 CbSTA Lv1E3A UILDING-SAFETY FEE RECEIVED P. O. BOX 317 COSTA MESA. CALIFORNIA . ft 6 4 {l1` 6 -/i I r �� Wv For Applicant to Fill In Completely APDL Q ^^OMAR' 0 urTYPE nOR PRINT CITY ithEBBUILDING ,/ /_ . //q(-pr.' A- war �- If{7 LY , ADDRE59 COSTA MESA. CALIFORNIANI/ /' For Office Use Only OWNER "o1(O/4 `. ntt�Cpor/� � �/y�/� �/RECEIPi N/oq.D I qi vPERMIT/ I ADDRESS �j� 22 ! o�fMcie �/.t'/'�/ n�'/ I /DATEH Cel�/✓///JAI ljDAA/O ISSU f/I TEL. CITY Le f - /%CSjO NO. ADDRESS�J\ Y'� e GG/'✓ `� ARCHITECT TEL. COSTA MESA. CALIFORNIA OR ENGINEER NO. ' FIRE ADDRESS ZONE TYPE ROUP ) da CONTRACTOR R,,4',y.0 4lzD .es /WBY APPROVED � DATE 7-/ JJ (l ADDRESS 2'1.92 �"LI',4,44-T/ O c2 ZONING 63-771r ,{� /' ZON NO.oP USE OP NEV� ]f CITY /fLPJ LC- �i p' 7 y I PLANS Z I BUILDING [�y E/�A/(M LIC.TNO./60 C/'¢ NO. /[ ./f ��..5 U .. riTh OBBBCXIPTION' 'r' 4 .1 Or � /`C L SIZE 7.2-'s NO. °,11.°1-DOT"./^� / OP LOT Z75 NDW ' A.P.NO. 19 _ o Z Z — 3 O USE OF YARDS EVES EXISTING BCDk- APPROVED ALLOWED SETBACK LINE FROM (CENTER LINE 7/1 CENTER OF STREET REAR YARD FRONT / l �' FT. IN. • SIDE YARD I LEFT . I RIGHT R.SIDE 2-5FT. If W7 IN. DESCRIPTION OF WORK 9 8 NEW I / L.SIDE �FFT.. � IN. Y ALTERATION I II ADDITION I REAR /0 FT. 1l IN. REPAIR I II MOVING I II DEMOLISH I + • /// `� C BY;IROV VV I DATE • //�4 / 1{0I3, BUILDING/D/2 1T/ RNO. OF OOMS C STORIES / : D� ��� SIZE (/ EXTERIOR WALIe ROOF /� COVERING ,J/(ICCO COVERING /� USE OF BUILDING AND WORK TO BE PERFORMED • . QeAztx-- tiim s.y Al6ZCIev 0 ,9fic7cHCD 2 at' 6s�.�wr� /.c_e0 -_ /�.v d I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION / THE AMOUNT SHOWN UNDER VALUATION IS FOR THE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- ( PURPOSE OP ESTABLISXINO A PERMIT FEE ONLY. PLY WITH ALL CITY NANCES AND STATE LAWS REGULATINO BUILDING CONSTR Ai;OF ` VALUATION �- SIGNATURE .I1T PERMIT FEE'. s PERMIITTEF 4 7 $ // PLAN CHECK $/ ' AUTHORIZED AGENT /,// a 1' ¢ TOTAL FEE - S n -- +.. 14815 CCSTA mES7+ UILDING-SAFETY DEPARTMENT FEE RECEIVED �,EA CEIV ED,I�- P. O. BOX 917 COSTA MESA. CALIFORNIA WL 6 1961 6 IAV For Applicant to Fill In Completely APpj• .�. .a+IwIT ///_ TYPE /fO^R' PRINTSI �I GG BUILDING ADDRESS L103'(�`'L4 4-aov /L t-, �'COSTA MESA. CALIFORNIANIFor(Office Use Only fysifC� C- 4tGcoc 1 RECEIPT NO. I / VPERMI/S OWNER n I OL MAIL RECEIVED BY DATE RECEIVED DATE ISSUED ADDRESS • •227rClegn4 `'- l-/o� '- 7-cOTEL. / CITY 67s'TA .11t7:47 NO. DRESSS ./ b e -/ ,n - BUBUILDING -- l(' ✓7 4 ARCHITECT - TEL. COSTA MESA. CALIFORNIA OR ENGINEER NO. ,� (n/ - FIRE ADDRESS . ZONE TYPE tS ROUP ,t2 CONTRACTOR //M/fj'/Q //(/1JEj'' /NC APPROVED /'*l_ DATE/11-/7"✓ 1 ADDRESS £122 ,ark/J4e7 BLVD, \` ZONING �}q /�� 2ONr/ J NO.OF .7 USE OP NEW CITY �(/rte ///(�a f o�j �7 /I -(1 I PLANS C- I BUILDING Q 11/V�� f STATE �O OO / TEL. Ate/ 7J.J,0 LEGAL r - jlOrO Ci 1YC `N LIC.NO. NO. // E DESCRIPTION ,` J �j' a OP LOT ,Z7‹ p ,�NO. OF BLDGS.,O // 9 O L Z. -T 0 r NOW ON LOT A.P.NO. USE OF YARDS ((EVES EXISTING BLDG. _ APPROVED 17 ALLOWED . SETBACK UNE FROM (CENTER LINE ST) CENTER OF STREET REAR YARD FRONT -SW ! G(/ IN. SIDE YARD I LEFT I RIGHT R.SIDE ✓9� 'FT. 2 CO IN. DESCRIPTION OF WORK C FT. ` N. J/ L.SIDE NEW II ALTERATION I II ADDITION I REAR 5 ' FT. IN.N REPAIR II MOVING I I DEMOLISH I BPPROVEp�DATE 7-/7 4 / BSIZE DING /3? 9( ROOMS a STORIES / EXTERIOR WA.LLni. I Q ROOF COVERING (/Crq COVERING r. . ATU OF BUILDING ND WORK TO BE PERFORMED IO/Sx -- �.�/giar 84.1/22 vG t. /13-3 r ,. I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. PLY WITH AU. CITY O-• CHB ETA LAWS REGULATING ' 'l BUILDING CONSTRU VALUATION '• 41-0 SIGNATURE OF PERMIT FEE $ (J N PERMITTER (((/�J//� , n 0 $ l4 7(�J� /PLAN CHECK $/��A�. AUTHORIZED AGENT / / S•p/� E E TOTAL FEE $ 0 14816 FEE RECEIVED COSTA.IVIES• BUILDING-SAFETY DEPARTMENT JUL 6 1961 P. O. BOX 317 COSTA MESA. CALIFORNIA FINANCE DEPT. `` �'"� For Applicant to Fill In Completely APPLI&W(p d Th ...1,4/b TYPE OR PRINT BUILDING . /b3 FbOGVt2ADDESS, A,�'C//OSTA MESA. CALIFORNIA�/ y/' For Office Use Only OWNER A44,L,T0 + .. , {/LLCOVI I RECEIPT NO. . I )veRMICT NO.S ADDRESS �'--.�� �"�. .' - �/.�D BY DATE R -44 1 l/ /7DATE ISC �k/D BUILDING CITY ADDRESS ARCHITECT TEL. COSTA MESA. CALIFORNIA OR ENGINEER NO. FIRE ADDRESS Q ZONE TYPE :-GROUP CONTRACTOR X/tf/I//` �(//L iO�.�/,O� APPROVED r4 ly/ 7.-.) J' G /� (IJ'�DATE / ADDRESS/� (�2*?i-.. fika Ve Aro. ZONING CITY(�y//rn //rp O• N�-'r I PLAN' L� I BUILDING c ei� , STATE /V O 6.11g 1.1.70-..._111 93330 LEG• AL TION �� .3�a '�• c {{"�- LIC.NO. SIZE OF LOT 7L qqNO. W SLDOS. X Z7 INOW ON LOT • O /1 F - [7 Z L - 30 `. A.P.NO. USE OF YARDS EVES EXISTING BLDG. _ APPROVED ALLOWED OUTBACK LINE FROM (CENTER LINE BTJ •/y,..�� CENTER OF STREET REAR YARD . FRONT IO ,z;: FF. IN. -/ SIDE YARD I LEFT I RIGHT R.SIDE a FT. if IN. DESCRIPTION OF WORK • L.SIDE `T FT. 8 i N. NEW I ALTERATION I II ADDITION I REAR 7 1 IN. REPAIR I I MOVING I II DEMOLISH I '+' BY��O�D�CAL49 DATE 'T/7(C \SID BUILDING j( NO. OF ra/¢J SIZE ��� I ROOMS / STORIES •ib � J,4 / • EXTERIOR WAL{.. ROOF / 0, COVERING .J 4 I COVERING gee,•• USE OF BUILDING AND WORK TO BE PERFORMED ArlI nJ'n 2- a2 G tfAlCir 4/9-d �7,y I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION THE AMOUNT SHOWN UNDER VALUATION IS FOR THE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM- PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. PLY WITH ALL CITY O CES AND ATE LAWS REGULATING BUILDING CONSTRUCT N. VALUATION - si-el / SIGNATURE OF / PERMIT FEE $ �� N PERMITTEE A P s/R0(/.Io — PLAN CHECK $ `11' AUTHORIZED AGENT � ft TOTAL FEE $ G> ad y