HomeMy WebLinkAbout1143 BUCKINGHAM DR - Building Permits' • Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. -
- CITY OF COSTA MESA - -' - - PERMIT NO. TRAC7NA9 LOT NO: - - BLDG. - - -
CONSTROCTIONPERMIT $•r//�9q 11144�J z" j4J,' C
Project Address 4 i _ TYPE OF CONSTRUCTION LXNEw LJ ADD Ll ALTERATION L I J'REPAIR-
ApplicantsMailingAddress�4 rate •Plan Suite 1O ❑ CONVERSION ;❑ DEMOLISH ❑ OTHER- - - q,p #y ' _. 'Y' U Zpne
DESCRIPTION OF WORK
owner's Name McLain Development Co -pnpn¢ 640-0800 S Main Building: ssory Buildm 2
Address Same _ E - 8 N
TYPE'OF PERMIT : GRADING : ❑ FOUNDATION STRUCTURAL T Front 7
Arch/Eng. fnrhin-YdmdfUjl License No. C-6832 ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL , ' BRear ,�.:�� _•N
Aadress'17992.Mitchell 'So: ,�,-� Irvine 92714 .❑ OTtiEa - - - A
Contractor's Nam Mel din Development CO—Phon,640-6800 PROJECT DESCRIPTION* SO. FT. OCCUPANCY C Right n _ -p 'G
.. - K - - ` R
Address (mailing) 4 fnrppratePlaza, Suite 101 + CONSTROCTION TYPE 'VALUATION$ • Oa S v E
ZONE I GRADINGCU.YDS. it!
O
City -License No. IRR73 Ping. Ref. —/ Park. es $'
LICENSED CONTRACTOR DECLARATION -Parking- - - U
Remarks: —g I Req./Provided I _ i
1 hereby affirm 7 that 1 am licensed of the
provisions of Charter 9 (commencing �/ 'J - R
with section 7000) of Division 3 of the Business and Professions Code and P�i7 ' 2S �Z' Use of Building: U �V .. ,E
my license is �4 u force and effect. _ L• M
\ icense Class 6-1 ' L 3 PLUMBING . FEES Planning Notes:
Date 11-21-93 Signature inCCnrtC�t p� E,
\ WORKERS'COMPENSATIOND A 1 Bar Sink Showers fitn FOR CPFft At. F.01IlREMEM N N
I hereby affirm that I have a certificate of consent to self -Insure or a certificate T
\ of Workers' Compensation Insurance, or -a -certified copy thereof (Section Backflow Prevent¢r _ Service Sink:
3800, Lab, G� 83-112689 �dme5 Econn Backflow Irrigation Sewer.Cap I''• ELECTRICAL I FEES
1¢y No. J Company 11
Certified copy is hereby furnished. ! ./% Bathtubs Sewer Connection Z Automatic Washer I 'Transformer ❑ 15-50 KW +_
Cert re p filed with the city �gui}�% �1 .Gblf� - - 1 - ❑ 50+ KW
Date 1�-L1-83 AppncSni X����/l_ >.�.71�' Clarifiers Solar -Collectors '"Li Construction Pole Sub. J�
-EXEMPTION FROM WORKERS'CO N TIO D ARATION - D13hwaaher 1 " $Olef Pi In _I - - -
(This section need not be completed if the permit is for one hundred ($100) or , P 9 _ Cooking Unit Meter ❑up to'100'amps'-
lI ce) tify that in the performance of'the work for which this permit is issued I Drinking Fountains Sola�'Tank I Dishwasher Meter ❑over 100 amps : ^�
shall: not employ any person in any manner so as to become subject to the , -,
Workers' Compensation Laws of California. I Floor Drainsi I Swimming Pool w/Spa ' Dryers ❑Gas ❑Electric 'Sub Panel I ) '
Date Signature
NOTICE: If, after making this declaration, you should become subject to the Floor Sinks Urinal Fan Motors ❑0.1 HP ❑1%- 8
Workers' Compensation provisions of the Labor' Code, you must forthwith - - - - - _ - comply with such -provisions,, or this permit shall be I deemed revoked. Gas Service Outlets Water Closet' I F.A.U. Inc. Solar,❑9-15 HP❑16-15+-
CONSTRUCTION
• LENDING.'AGENCY� ' - '- - -11
I hereby affirm that there is a construction lending agencyfor the performance Interceptors Water Heater - Fixtures
of the work for Y�tft pF81'tet`alf'gStaJ195��'- 3097_ Civ. C:)
P _ e Microwave
`J Kitchen Sink - ,Water. Service Device Boxes Pole Light
Lender's Name' " - ' , +
Lender's Address 13160 Mindanao Warr, Marina De l= Rev - - _
OWNER BUILDER DECLARATION - pp((11gqgq11 Lavatories - Outlets I Range
I hereby affirm that 1 am exempt from the(Cdntractor's:Licensi-9QZ-fdr the + - -
following reason (Section 7031.5 Business and.Professional Code: Any city or P -Trap + ' j L: _ Switches l Sign I
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 Roof Drains - - Garbage Disposal Standing Sections
to file alsigned statement that 'he/she is licensed pursuant to the provisions of
the Contractor's License Law (Chapter 9 (commencing with Section 7000) of s - - - Generator ❑0-5 KW ❑5-15 KW 'Trash Com actor
Divisioni 3 of the Business and Professions Code) or that he/she is exempt - - I _ P
therefrom and the basis for the alleged exemption. Any violation of Section
7031.5 by,�any applicant for a, Perm t su ( acts - the applicant to a civil t
,penalty of not more than five hundred dollars$500). I 'Reinspection Fee $25 issue Fee $,3
LJ I, as, owner of the, property or myemployeeswith wages as their sole MECHANICAL Reinspection Fee $25 Issue Fee' $'3
compensation, will do the work, antl the structure is not intended or offered FEES
for sale (Section 7044, Business and Professional Code: The Contractor's PUBLIC SERVICES REOUIREME TS:
License Law does not apply to an owner of a property who,builds or improves Boiler - Hood or Type I ❑
thereon, and who does such work himself/herself'or through his or her own -' Zoning Approved By Dete
employees, provided that such improvements are not intended or offered for - Canopy Type II ❑ .
Duct - Under Ground
sale. If, however, the will
have
ng a improvement Is sold within one year of r im. .. Application Approved By �' Date
pletion, the owner will have the burden of proving he/she tlitl not build or im-
rove'for the purpose of sale). Duct - Structural I Refrigeration System Application Issued By Dat
I, as owner of the propertyam exclusively contracting with licensed con- -
tractors to construct the project (Section 7044, Business and Professions Code: Duct - Ventilating ❑0,100,000 BTU ❑100,
, 000 BTU SUMMARY OF FEES
The Contractor's License Law does not apply to an owner of property who- - - "-BUILDING PERMIT $ SMIP , $ - •SO
builds or improves thereon,and who contracts for such projects with a con- Exhaust System 13 Multiple 11 System Repair/Alteration +
tractor(s) license pursuant to the Contractor's License Law). PLAN CHECK $ PERMIT 1
El .I am exempt under Section B. & P. C. for this reason Firepl/Fact. Bit. ICBG +
PLUMBING ISSUANCE $ 1
$ l
Date11-21 +23 Owner Heating System &Ducting I PLAN CHECK $ ENERGY P.C. $
I hereby certify that I have read this application antl state that the above ❑0-100,000BTU ❑100,00067 ELECTRICAL - GRADING $
Information is correct: I -agree to comply with all ci antl county grtllnances -' - I $
and state laws relat, to builtl' construption, hereby authorize repre- I PLAN CHECK $ MICROFILM $
sentatives of this . t p E e -mentioned pro perry •for I �q ^�
inspection pJtrp '� 11-21-83 , MECHANICAL $ TOTAL FEE $
Signature Jl Date
Drivers' License or SS 9F I Reinspection Fee $25' Issue Fee $ 3 ' PLAN CHECK $
CMF 0865-46 rev. 7/83 White -'Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor
CONSTRUCTION AND PLANNINGrOOL
' APPROVALS., Permit q#
Dater,
Inspector
& SPA
APPROVALS Permit#
Date
Inspector
.1. Temporary Electrical Service or Pole'
52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd. - _`
-
53. Steel Reinforcement _
3.; Electrical Conduit Utility-Undrgrnd.
54. Forms -
4.eElectrical Conduit-Undrgrrid.
55. Electrical Bonding
5. -,Steel Reinforcement"
i
56. Rough Plumbing & Pressure Test
6. Electrical UFER Grrid. ,-
41712
57. APPROVAL TO COVER=GUNITE
7. Footings -
58. Electrical Conduit-Undrgrnd.
8. Foundation -
59. Gas Pipe, O Undrgrnd., Test
9. Water Pipe-Undrgrnd..
60. Backwash Lines, P -Trap, ❑ Undrgrnd.
10. Structural Floor System
61, APPROVAL TO DECK
11. Property Sewer Line & House Connection
62. Backwash & Receptor -Final
12.' Sewer Cap
63. Heater & Vent -Final
13. Roof Drains r
64. Plumbing System - Final
.
14. Rodgh Plumbing
65. Electrical -Final
15. Rough Electrical -Conduit
66. Solar System -Final
16. Rough Electric Wiring
67. Fencing & Access Approval
17. Rough Wiring Sign
-
68. APPROVED FOR PLASTERING
18. Rough Electrical -T Bar Ceiling '
69. POOL/SPA SYSTEMS FINAL
19. Rough Heating &Air Conditioning
FIRE DEPT. REQUIREMENT
APPROVALS Permit #
20. Rough Factory Fireplace
21. Ducts, in Structure ' -
A
70. Underground Hydro
- 22. Ducts, Ventilating-•� . I
71. Product Piping ❑ Gas ❑ Oil
23. Gas Pipe -Rough &.Test
72. Underground Flush
.4. Roof Framing
73. Undergrnd. Storage Tank ❑Gas ❑Oil
25. Roof Sheathing
3f U
.a73
74. Overhead Hydro
26. T -Bar Ceiling (Structural) & Monocoat
75. Dry Chemical
27. Frame,and Flashing
7 i
�3
76. Dry Standpipe
-28. Lathing & Siding
77. FIXED SYSTEM FINAL
29. Insulation
78. FIRE PREV. FINAL
30. Drywall Nailing ?
)
HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat �'�
79. FINAL INSPECTION
�•
" 32. Electrical Power Meter -Final.
80. FOOD CERTIFICATE ISSUED
33. Final Electric
Notes:
34. Final Heating & Air Conditioning
35. Final Gas Pipe -Test
36. Hood or Canopy
-
37. Final Factory Fireplace
38. Final Plumbing ,
39. Water Service -Final _
40. Gas Service -Final
41. Solar Domestic -Final
42. Backflow Preventer
43. Backflc4- Ir rig t_iom.
44..Lan dscape IrrigationjSystem
45. Sound Attenuation •-
46. Handicap Regulations
-
47. FIN#LSrRUGTURE&BUILDING
1I7�$(
l7S
48. Special fid uirements Completed
(
,
49. is Release to Edison
-
50. Gas lease to Southern California Gas Co
-
`
51. CERTIFICATE OF OCCUPANC
No. �a L Date
/Q
/
f'�c-�/`
d 1
I
City of Costa Mesa
Development Services Department CERTIFICATE O F OCCUPANCY NO. 000892
Building Safety Division
P. O. Box 1200
Costa Mesa, California
The Building located at 1143 BUCKINGHAM DRIVE
has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto
for a Group R—1 Occupancy.
Use of Building IAUDIDRY ROOM
Legal Description 412-084-01
(See reverse side for Mates and Bounds)
Building Permit No B-11099 Electrical Permit No. E-15698 Plumbing Permit No. P-12096
Mechanical Permit No. Number of apartments /and/or guest rooms/
ISSUED TO: Building Official ,7�/,r
IXE LAIN DEVELOPgPf 00.
by� e `�io, FAA,
4 CORPORATE PLAZA, 4101. NE6dPM BEAQC, CA. 1 14,. l ✓ �' 7
Date
This Certificate of Occupancy SHALL BE posted in a conspicuous place on thelpremises and SHALL NOT BE removed except by the
Building Official of the City of Costa Mesa under Sec. 307 le) U.B.C.
CMF 1015-46 rev. 1/83 White -Owner; Canary -Numerical File; Pink -Bldg. Permit File
a Cn�J Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
CITY OF COSTA MESA '•./� i PERMIT NO. TRACT NO. LOT NO. BLD
CONSTI�UCTIONPERM �Oy{o,
Project AddressX IIB
TYPE OF CONSTRUCTION NEW LJ ADD LJ ALTERATION 0 REPAIR -
_
P.O BOX 536 SQi'LtA ANQ,,_Ca
❑ CONVERSION ❑ DEMOLIS OTHER'
A:P..
Applicant's Mailing) Address
ft❑
S
Remspection -Fee $25
Owners Name Me iai ' Q.L rQ Phone6141) 6900
DESCRIPTIONoF WORK
S
Main Buildi
Address_4_CQhnnhide Nam 0101 NPIA4WAt RPWrrlf"
a - �,.
•
•TYPE OF PERMIT GRADING FOUNDATION STRUCTURAL
E
T
Front
Arch/Eng. License No.
L�ss
'❑ TENANT ❑ ELECTRICAL 19 PLUMBING. ❑ MECHANICAL
B'
PUBLIC SERVICES REQUIREMENTS:
Zoning Approved By Date
Application Approved By Date��
Application Issued By r / Date.,t$��Q y
Boiler -
A
Rear
Address
,,,❑OTHER
C
Right
Contractor's NamPIP UIDI7S.tl.CQl1..-_IBC«—Phone S�riO
' PROJECT DESCRIPTION Sq. FT. OCCUPANCY
Duct -Ventilating
Address (mailing) pV BOX 5 6 SaBta Ana, • Ca.
CONSTRUCTION TYPE EVALUATION $
PP>I,EmbEng
S
Left
18996
ZONE GRADING CU.YDS. ACRES
Ping. Ref. #
City License No.
'
,
LICENSED CONTRACTOR DECLARATION
/
Remarks:- �/ D�9 -
Parking Req./Pr(
I hereby affirm that I am licensed untler provisions of Charter 9 (commencing
�_ ._ _
with section 7000) of Division 3 of the Business and Professions Code. and
I
Use of Building:
my license is in full f rc }pd effect. '
' �-�0 ' NJ.247J34
'
Planning Notes:
PLUMBING
FEES
Jcense Clas L1ansa
Date Signature \
,
Bar Sink
Showers
- WORKERS'COMPENSATION DECLARATION
+
I hereby'affirm that I have a certificate of consent to self -insure or a certificate
Backflow, Preventer /
Service Sin
6
'
of -'Workers' Compensation Insurance,'or a certified copy thereof (Section''
_ - _ - _
-'
3800, Lab. C.)"- -' , i r
Backflow Irrigation-
Sewer Ca p
'
Policy No. ��8-0 Company
'
Certified copy is hereby furnishetl. I - '
Bathtubs '
Sewer ConnectionI
ip
Automatic'
Certified copy is filed with the city Building Division.
�Da[el.;__1"8._"8 - Applicant
Clarifiers (
Solar Collectors
C&n5truct_io_
EXEMPTION. FROM WORKERS'COMPENSATIO .DECLARATION -
(This section need not be completed if the permitlis'for one hundred ($100j or•
less
I Dishwasher `, -
Solar Piping
P 9
Cooking Ur
ELI
'ole -Sub.
I ,
)
1 certify that the performance any
work fon whto this per u is t to the
Drinking Fdunta ins 1 Solar Tank Dishwasher
shall not employ any person in any manner so as to become subject to'the s, - ,
Workers' Compensation Laws a California. FIOOf Drains. ( Swimming Pool w/Spa • (j ' Dryers ❑Gas IDEA
Date Signature -
NOTICE: after making this declaration, you becom¢ subject to the FIOOf Sinks , Urinal + Fan.
C
Workers' Compensation provisions"of the Laborr Cod Code, you must forthwith . -
comply with- such provisions„ or this' permit shall be ke
deemed revotl. Gas Service S Outletsr - .Water Closet' O F.A.U.
CONSTRUCTION LENDING -AGENCY •�� - _
I hereby affirm that there is a construction lending agency for the performance Interceptors ./ Water Heater a Fixtures
of the ,work for 'which• this permit 1s issued' (Section 3097 Civ. C.)'
Lender's Name _ Kitchen Sink Water Service Device Boxes
Lender's Addres5f_
OWNER BUILDER DECLARATION - Lavatories' _ Outlets
I hereby affirm that I am exempt from the Contractor's License Law for the P -'Trap
following reason (Section 7031.5 Businessand Professional Code: Any city or P Switches '
a sianed statement that
.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
enalty of not more than five hundred dollars ($500).
I, as. owner of the property or my employees with wages as their sale
compensation will do the work, and the structure is not intended or offered
for sale (Seciion 7044, Business and Professional Code: The Contractor's
Law s not t an owner of a property who builds or Improves
License La tloe apply 0 p p Y P
thereon, and provided
es such work himself is are
or through his or her own
employees, ed that such improvements are not intended or offered for
sale- If, thehowever,owthe building a Improvement is g h within one year of r m-
pletipn, the owner, will have the burden Of proving he/she did not build or Im-
rove for the purpose of sale).
I, as owner of the property, am exclusively contracting with licensed Con-
tractorsto construct the project (Section 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who.
builds or improves thereon, and who contracts for such projects with a con-
tractor(s) license pursuant to the Contractor's License Law).
❑ Tam exempt under Section B. & P. C. for this reason
i
Date Owner;
I hereby certify that I have read this application and state that the above
'Information is correct: I agree to comply with all city and county ordinances
and state laws relating ;to building construction; and hereby authorize repre'
sentatives of this!city toenterupon the above-mentioned property ;for
Inspection purposes.
Signature ti\. .y�p� 'w�_t>_4 l'�a- Data"3-13—SIL{
'
Drivers' Li 1
CMF 0865-46 rev. 7/83 1 White -Building; Canary -Applicant; Pink' *Accountir
6783. 3/20/84
Zone
Accessory Building:
Park: Fees $
TICAL
Transformer ❑ 15.50 KW
❑ 50+KIN
Meter ❑up'to 100 amps"-.
Meter ❑over 100 amps I
Sub Panel '
Motors ❑01 HP ❑1'h-8
Inc. Solar ❑9-15 HP 016-15+
Mir-rnwava
Pale Light
Range
i_
FEES
'TL
Z
O
N
I
N
G
R
E
Q
U
I'
R
E'
M
E
N
T
S'
Roof Drains
_ -
_
Garbage Disposal Standing Sections
- --
-
Generator 00-5 KW 05.15 KW Trash Compactor
Remspection -Fee $25
Issue Fee
- $ 3
Fee $25 • Issue Fee $' 3
I -MECHANICALeinspection
FEES
PUBLIC SERVICES REQUIREMENTS:
Zoning Approved By Date
Application Approved By Date��
Application Issued By r / Date.,t$��Q y
Boiler -
Hood or TiY'Pe I' ❑ -
Canopy Type 11 Eli
_
Duct'- Under Ground
Duct - Structural
Refrigeration System I
❑0100,000BTU 0100,00013TU
Duct -Ventilating
SUMMARY OF FEES
BUILDING PERMIT $ SMTP $
PLAN CHECK $ PERMITPLUMBING $ _. ISSUANCE $
PLAN CHECK $ ori OC) ENERGV;P.C. $
' ELECTRICAL $ GRADING i$
PLAN CHECK I $ - MICROFILM $
MECHANICAL $ i TOTAL FEE $L
PLAN CHECK $
Exhaust System ❑ Multiple ❑
System Repair/Alteration
•• Firepl/Fact. Blt. ICBG#
Heating System &Ducting
❑0100,000 BTU❑100,000BT
�_ ._ _
I
Reinspection Fee $25,
oltlenrod-'Assessor'"'
I Issue Fee
$ 3
CONSTRUCTION AND PLANNING -
` APPROVALS Permit #
Date
Inspector
• JOL & SPA
APPROVALS Permit #
Date
Inspector
• 'M' Temporary Electrical Service or Pole
52. Pool & Equipment Location
12. Soil Pipeiyndrgrnd. ry
i�1�/�
4C6
53. Steel Reinforcement
_3. -u ectr;'calFonduif�ti,ly-yndrgrfd.
.
54. Forms
4. tElectri�al onduit UridrGr,nd.
41
55. Electrical Bonding
5.,$t6el ,Re'r�forcem6if, V
56. Rough Plumbing & Pressure Test
-6. , trr`ya fUFER Gird.
57. APPROVAL TO COVER-GUNITE
,7. &3iin�s" r i -
58. Electrical Conduit-Undrgrnd.
8.c•F,o undationY� _
IAI
59. -Gas Pipe, 0 Undrgrnd., Test
9. N r Pipe-
��17�atf�
-
60. Backwash Lines, P-Trap, 0 Undrgrnd.
tO.�Stwctura`C•Floor Sysem
o
-61. APPROVAL TO DECK
11. ProOpertWSewer Line &House Co� rection
yfh
p•
62. Backwash &Receptor-Final
12.Sewkcap r✓ .c
63. Heater & Vent-Final
13. Rodf Dra+hs
64. Plumbing System - Final
14. RougFt Plumbing 4
(Q(//��'(
(..�11
65. Electrical-Final
15. Rough Electrical-'Conduit
--
66. Solar System-Final
16. Rough Electric Wiring ,
67. Fencing & Access Approval -
1 7,. Rough Wiring Sign
68. APPROVED FOR PLASTERING
18. Rough Electrical-T Bar Ceiling
69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning
FIRE DEPT. REQUIREMENT
APPROVALS Permit #
20. Rough Factory Fireplace
21. Ducts, in Structure
70. Underground Hydro
22. Ducts, Ventilating ci
71. Product Piping 0Gas 00il
23. Gas ppe-Rough & TIt
72., Underground Flush
24. Roof Framing �%
_
73. Undergrnd. Storage Tank []Gas 0Oil
25. Roof Sheathing
74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat
75. Dry Chemical
27. Frame and Flashing
76. Dry Standpipe
28. Lathing & Siding
-
77. FIXED SYSTEM FINAL
29. Insulation
78. FIRE PREV. FINAL
30. Drywall Nailing
HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat
79. FINAL INSPECTION
32. Electrical Power Meter-Final,
80. FOOD CERTIFICATE ISSUED
33. Final Electric
.Notes:
34. Final Heating & Air Conditioning
35. Final Gas Pipe-Test
j/ t
6'
36. Hood or Canopy
,
37. Final Factory Fireplace
38. Final Plumbing
39. Water Service-Final ,
40. Gas Service-Final
41. Solar Domestic-Final
42. Backflow Preventer ,
I e'�
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE & BUILDING
48. Special Requirements Completed
'
49. Electric Release to Edison
50. Gas Release to Southern California Gas Co
_
51. CERTIFICATE OF OCCUPANCY
No. Date
,a 3--
,
Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
CITY -OP COSTA MESA CONST UCT ON PERMIT tk�
(
Project Address '-C Lt 3
Applicant's Mailing Address 2_eC?21 F f P'1 --
Owner's Name L '�- Phone ter. n _ Q
&A
Address Y �.eumx4 O
r
Arch/Eng. �T-License No.
Address _
Contractor's Name Phone
Address (mailing) ZOq2_1 &.(1•E .
City License_ No. '
y.. LICENSED CONTRACTOR DECLARATION
-/ 1 hereby affirm that I am licensed under provisions of Charter 9 (commencing
[Yl with section 7000) of Division 3, of the Business and Professions Code, and
W my license is in full force and effect. ,'-t -7`4
-(cense Clas l: � 0 License No. �� / l
late O- Signature
WORKERS' COMPENSATION DECLARATION
�. I hereby affirm that I have a certificate of consent to self -insure or a certificate
•'�.:, of Workers' Compensation Insurance, or a certified copy there off (Section
3800,
Policy N0. Lab.LSN' i'� �S� Company �K/l (17/Le-R.ptt-
�'/
Certified copy is hereby furnished.
Certified cop y i 1 d with the city Bw n slop.
Date /Q Applicant -f+^
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(This section need not be completed if the permit is for one hundred ($100) or
less).
certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so a$ to become subject to the
Workers' Compensatlon� La ws of California.
Date Signature -
NOTICE: If, after making this declaration, you should become subject.to the
Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
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. (Section 3097 Civ. C.)
Lender's Name -.
Lender's Address'
OWNER BUILDER DECLARATION -
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Section 7031.5- Business and Professional 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 applicantfor such permit
the Contractor's License Law (cnapier Y (commencing wun p "mn ruuul m -
Division, 3 of the Business and Professions Code) or that he/she is exempt
therefrom and the basis for the alleged exemption. Any violation of Section ,
7031.5 by any applicant for a permit subjects the applicant - to a civil
�enalty of not more than five hundred dollars ($500).
I, as owner of the property or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered
for sale (Section 7044, Business and Professional Code: The Contractor's
License Law does not apply to an'owner of a property who builds or improves
thereon, and who does such work himself/herself or through his or her own
employees, provided that such..improvements are not intended or offered for
sale. 1f, however, the building or improvement is sold within one year of com-
pletion, the owner will have. the burden of proving he/she did not build or im-
rove for the purpose of sale).
I, as owner of the property, am exclusively contracting with licensed con. .
tractors to construct the project (Section 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
builds or improves thereon, and who contracts far such projects with a con-
tractor( license pursuant -to the, Contractor's License Law). I am aware that
proof o their Worker's Compensation insurance should be provided to me.
❑ 1 am exempt under Section B. & P. C. for this reason
Date Owner.
I hereby certify that I have read this application -and state that the atiove
information is correct. I agree to comply with all city and county ordinances
and State laws relating to building construction, and hereby authorize repre-
sentatives of this city to enter upon the above-mentioned .property for
inspection purp sf_ I r Il j--� . I ro
Signature fYK�s W4.IvNf-tir^ Date d
Drivers' License or SS G
9916 tO/II/94 18. SO TL
TYPE OF CONSTRUCTION LJ NEW LJ ADD LJ ALTERATION LJ REPAIR
❑ CONVERSION ❑ DEMOLISH ❑ OTHER
DESCRIPTION OF WORK/USE OF BLDG.
A.P. # Zone
S
Main Building: Accessory Building:
TYPE OF PERMIT GRADING
❑ TENANT ElELECTRICAL
1-1 OTHER
LJ FOUNDATION STRUCTURAL
1-1PLUMBINGM`ECHANICAL
E
T
Front
-
Z
O
B
A
Rear
N
I
C
Right
N
PROJECT DESCRIPTION SO. FT.OCCUPANCY
CONSTRUCTION TYPE VALUATION$
ZONE GRADING CU.YDS. ACRES
K
S
Left
G
R
Ping. Ref. # Parking Req./Provided
E
Q
Remarks: �
-
Planning Notes:
-
M
T
S.
PLUMBING
FEES
Bar Sink
Showers
ELECTRICAL
FEES
• Backflow Preventer -
Service Sink -
3- Automatic Washer ;-
Construction Pole Sub.
- Transformer ❑ 15-50 KW
❑ 50+ KW
- Backflow Irrigation Sewer Cap
Bathtubs
Sewer Connection
Cooking Unit
Meter ❑up to 100 amps
Clarifiers
Solar Collectors
Dishwasher
Meter ❑over 100 amps
Dishwasher -
Solar Piping
{
Dryers Gas ❑Electric
L Sub Panel
nc
Drinking Fountains
Solar Tank !
/
Fan
Motors ❑0-1HP❑1 Y.-8
Floor Drains
Swimming Pool w/Spa
F.A.U. '
Inc. Solar' 09-15 HP 016-15+
_ Floor Sinks I
Urinal
Fixtures -
Microwave
Gas Service -Outlets
Water Closet
Device Boxes
Pole Light
2,C
Interceptors
Water Heater
-
Outlets
Range
Kitchen Sink
Water Service
2 Switches
Sign
Lavatories
-
Garbage Disposal
Standing Sections
P -Trap -
Generator ❑65 KW ❑5-15
KW Trash Compactor ,
Roof Drains -
Reinspection.Fee
$15
Issue Fee
-
$ 3
Reinspection Fee -
$15 Issue Fee
$ 3
MECHANICAL
�
FEES
DEVELOPMENT SERVICES REQUIREMENTS:
Zoning Approved By Date
Building Approved By Date
Application Issued By Dat
Boiler Hood or T
Type ❑
Duct - Under Ground Canopy Type I I ❑
Duct - Structural
Duct - Ventilating
Refrigeration System
❑0-100,000 BTU 0100,000BTU
BUILDING PERMIT
PLAN CHECK
PLUMBING
PLAN CHECK 25%
ELECTRICAL
PLAN CHECK 50%
MECHANICAL
PLAN CHECK 25%
SUMMARY OF FEES
$ SMIP $
$ PERMIT
$ ISSUANCE $
$ ENERGY P.C. $
$ GRADING $
$ 5 Z� MICROFILM $
$ TOTAL FEE $ '
$
Exhaust System ED multiple ElSystem Repair/Alteration
Firepl/Fact. Bit. ICBG#
Heating System & Ducting
❑0-100,000 BTU ❑100,0006T
'
Reinspection Fee
$15 Issue Fee
$ 3
CMF 0865-46, rev. 4/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor
-, CONSTRUCTION AND PLANNINu
APPROVALS Permit
Date
Inspector
TOOL & SPA
APPROVALS Permit#
Date
Inspector
1. Temporary Electrical Service or Pole
52. Pool & Eq'uipment Location
i
2. Soil Pipe-Undrgrnd.
-
53. Steel Reinforcement
3. Electrical Conduit Utility-Undrgrnd.
-
.54. Forms
4. Electrical Conduit-Undrgrnd.
55. Electrical Bonding
5. Steel Reinforcement
'56. Rough Plumbing & Pressure Test
.'6• Electrical LIFER Grind.
57. APPROVAL TO COVER=GUNITE
'
7: Footings
58. Electrical Conduit-Undrgrnd:
8.•Foundation
59. Gas Pipe, D Undrgrnd., Test
'
:9.' Water Pipe-Undrgrnd.
60-. Backwash ELines, P -Trap, D Undrgrnd.
10. Structural Floor System
61. APPROVAL TO DECK
11. Property Sewer Line & House Connection
62. Backwashi& Receptor -Final
12. Sewer Cap -
63. Heater & Vent -Final
13. Roof Drains _
-
64. Plumbing iSystem - Final
14. Rough Plumbing
65. Electrical Final
15. Rough Electrical -Conduit
66. Solar System -Final
16., Rough Electric Wiring �
�/
67. Fencing & Access Approval
'
17. Rough -Wiring Sign
-
68. APPROVED FOR PLASTERING
18. Rough Electrical -T Bar Ceiling
69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning
FIRE DEPT. REQUIREMENT
APPROVALS Permit 4k
20. Rough Factory Fireplace
21. Ducts, in Structure
70. Underground Hydro
i
22. Ducts, Ventilating -
71. Product Piping O Gas D Oil
23. Gas Pipe -Rough &Test
72. Underground Flush
24. Roof Framing
73. Undergrnd. Storage Tank D Gas []Oil
25. Roof Sheathing
74. Overhead iHydro
26. T -Bar Ceiling (Structural) & Monocoat75.
Dry Chemical
27. Frame and Flashing
76. Dry Standpipe
28. Lathing & Siding
77. FIXED SYSTEM FINAL
29. Insulation
78. FIRE PR EV. FINAL
30. Drywall Nailing,
HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat
79. FINAL INSPECTION
32. Electrical Power Meter -Final
80. FOOD CERTIFICATE ISSUED
33. Final Electric -
/y
v
Notes: toa25 �� ��_17 G IU044
34. Final Heating & Air-Conaitioning
35. Final Gas Pipe -Test'
-
36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing
39. Water Service -Final
40. Gas Service -Final
41. Solar Domestic -Final
42.'Backf low Preventer
_
43. Backflow Irrigation
44. Landscape Irrigation System
45. Sound Attenuation
46. Handicap Regulations
47. FINAL STRUCTURE &BUILDING
'
48. Special Requirements Completed
49. Electric Release to Edison -
-
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF OCCUPANCY
No. Date
r
/L.GVl/✓� Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations.
CITY of coSTACO ST UCT ON PERMI
r f p
Proj@ct Address
Applicant's Mailing Addrtess 2.09z_1
Owner's Name ��✓� Phone
Address
Arch/Eng. License No.
Address pe --Xb7.`0! p
ContractoNam �—7
Address (mailing) 26 C/'2.1 61AI"r— [�
City License No. t3a71-1
LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Charter 9 (commencing
with section 7000) of Division 3 of the Business and Professions Code, and
my license is in full fprce antl effect. 7
Date400 s C�� I ll Lit�egsg N_
Date 4(L '� c'o�af WLi.!/YY1C
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure or a certificate
of Workers' Compensation Insurance, or a certified copy thereof Setflon
3800, Lab. C.)
Policy No. 7 9,5 IJ h IV I Company r
B
Certified copy is hereby with
the city
o
Date ertifie py }ciNetl '^' Applicant y Builtl, p r
EXEMPTION FROM WORKERS' COMPENSATION DECLARATION
(This Section need not be Completed if the permit Is for one hundred ($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.
Date Signature
'NOTICE: If, after making this declaration, you should become subject to the
Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is issued (Section 3097 Civ. C.)
Lender's Name
Lender's Address
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Section 7031.5 Business and Professional 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/she is licensed pursuant to the provisions of
the Contractor's License Law (Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code) or that he/she is exempt
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
Enalty of not more than five hundred dollars ($500).
I, as owner of the property or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered
for sale (Section 7044, Business and Professional Code: The Contractor's
License Law does not apply to.an owner of a property who builds or improves
thereon, and who does such work himself/herself or through his or her own
employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of com-
pletion, the owner will have the burden of proving he/she did not build or im.
shrove r the purpose of sale).
LI I, afos owner of the property, am exclusively contracting with licensed con-
tractors to construct the project (Section 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
builds or improves thereon_ , and who contracts for Such projects with a con.
tractor(s) license pursuant to the-Contracto,'S License Law). I am aware that
proof of their Worker's Compensation insurance should be provided to me.
❑ 1 am exempt under Section B. & P. C. for this reason
Date Owner
I hereby certify that I have real
information is correct. I agree to
and state laws relating to buildir
sentatives of this city to enter
inspection purpoN$R,1 `
Signature
Drivers' License or SS
5299 1/09/85
Ihe25 111
TYPE OF CONSTRUCTION LJ NEW LJ ADD
LJ ALTERATION LJ REPAIR
❑ ❑ ❑
CONVERSION DEMOLISH OTHER
$15 Issue Fee
A.P. Zone
DESCRIPTION OF WORK/USE OF BLDG.
FEES
DEVELOPMENT SERVICES REQUIREMENTS:
Zoning Approved By
Building Approved By
Application Issued By
Date
Date
Data
S
Main Building: Accessory Building:
BUILDING PERMIT
PLAN CHECK
PLUMBING
PLAN CHECK 25%
ELECTRICAL
PLAN CHECK 50%
MECHANICAL
PLAN CHECK 25%
TYPE OF PERMIT GRADING FOUNDATION
STRUCTURAL
T
Front
❑ TENANT ❑ ELECTRICAL ❑ PLUMBING
❑ MECHANICAL
B
❑ OTHER
A
Rear
PROJECT DESCRIPTION SO. FT.C
OCCUPANCY
KLeft
Right
CONSTRUCTION TYPE VALUATION $
$
ZONE GRADING CU.YDS.
ACRES-1Ping.
Ref.* Parking Req./Provided
Remarks: F I /J 6� l i3
1Planning Notes: ,
3ackflow Preventer
3ackflow Irrigation
3athtubs
Clarifiers
Dishwasher
Drinking Fountains
Floor Drains
Floor Sinks
Gas Service Outlets
Interceptors
Kitchen Sink .
Lavatories
P—Trap
Roof Drains
Reinspection Fee $15
Boiler
Duct - Under Ground
Duct - Structural
Duct -Ventilating 1
Exhaust System ❑ Multiple
Firepl/Fact. Bit. ICBO *
Heating System & Ducting
❑0.100,000 BTU ❑100,000
Reinspection Fee 1 $15
CMF 0865-46, rev. 10/84 White - Building: Canary - Applicant; Pink - Accounting; Goldenrod - Assessor
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
Solar Piping
Solar Tank
Swimming Pool w/Spa
Urinal -
Water Closet
Water Heater
Water Service
Auto -Wash
Laundry Treys
Issue Fee
Hood or Type I ❑
Canopy Type I I ❑
Refrigeration System
1-10-100,000BTu ❑100,000
System Repair/Alteration
Fire Dampers
Registers
Issue Fee
ELECTRICAL
Automatic Washer Transformer ❑ 15-50 KW
Construction Pole Sub. El 50+ KW
Cooking Unit
Dishwasher
Dryers ❑Gas ❑Electric
Fan
F.A.U.
Fixtures
Device Boxes
Outlets
Switches
Garbage Disposal
Generator ❑O5 KW 135 15 KW
Meter LJup to 100amps
Mete ver 100 amps
Sub Panel
Motors ❑0-1 HP 01x-'8
Inc. Solar 09.15 HP 016.15+
Microwave
Pole Light
Range
Sign
Standing Sections
Trash Compactor
FEES
Z
O
N
1
N
G
R
E
O
M
T
S
Reinspection Fee
$15 Issue Fee
$ 3
FEES
DEVELOPMENT SERVICES REQUIREMENTS:
Zoning Approved By
Building Approved By
Application Issued By
Date
Date
Data
BUILDING PERMIT
PLAN CHECK
PLUMBING
PLAN CHECK 25%
ELECTRICAL
PLAN CHECK 50%
MECHANICAL
PLAN CHECK 25%
SUMMARY OF FEES
$
$
$
$
$ _1f7• SO
$ 3 7 5
$
$
SMIP
PERMIT
ISSUANCE
ENERGY P.C.
GRADING
MICROFILM
TOTALFEE
$
$
$
$
$
$
$ 3
- CONSTRUCTION AND PLANNING
.APPROVALS Permit #
i
Date
Inspector
POOL & SPA
APPROVALS Permit #
Date
-
Inspector
1+ Temporary Electrical Service or Pole
-
52. Pool & Equipment Location
,
. ..Soil Pipe-Undrgrnd.
-
- 53. Steel. Reinforcement
" 3. Electrical Conduit Utility-Undrgrnd.
54. Forms
-4. Electrical Conduit-Undrgrnd. - -
55. Electrical Bonding
5. Steel Reinforcement
56. Rough Plumbing & Pressure Test
.-
_6. Electrical LIFER Grnd.
-
57. APPROVAL TO COVER-GUNITE
7: Footings
58..Electrical Conduit-Undrgrnd.-
. 8: -Foundation - -
59. Gas Pipe, ❑ Undrgrnd., Test
.
9. Water Pipe-Undrgrnd.
60. Backwash Lines, P -Trap, ❑ Undrgrnd.
10.'StructuralFloor Sysiem
61. APPROVAL TO DECK
'
11. -Property Sewer Line & House Connection
62. Backwash & Receptor -Final
12: Sewer Cap63.
Heater & Vent -Final
i.
1 13. Roof Drains
64. Plumbing System; Final
•"
14. Rough Plumbing :
65. Electrical -Final
15. Rough Electrical -Conduit
66. Solar System -Final
-
16. Rough Electric Wiring
67. Fencing & Access Approval
17. Rough Wiring Sign
68. APPROVED FOR PLASTERING
18. Rough Electrical -T Bar Ceiling
69. POOL/SPA SYSTEMS FINAL
19. Rough Heating & Air Conditioning
FIRE DEPT. REQUIREMENT
APPROVALS Permit #
20. Rough Factory Fireplace
21. Ducts, in Structure
70. Underground Hydro
22. Ducts, Ventilating
71. Product Piping ❑ Gas ❑ Oil
23. Gas Pipe -Rough & Test -
72. Underground Flush
24. Roof Framing
73. Undergrnd. Storage Tank 0Gas ❑Oil
25. -Roof Sheathing -
74. Overhead Hydro -
-.
26. T -Bar Ceiling (Structural) & Monocoat
75. bry Chemical
-
27. Frame and Flashing
76. Dry Standpipe
28. Lathing & Siding
-
-
77. - FIXED SYSTEM FINAL
" 29. -Insulation
-'
78. FIRE'PREV. FINAL
. 30. Drywall Nailing
HEALTH DEPT. REQUIREMENT
31. -Plaster Brown Coat
79. FINAL INSPECTION
32. Electrical Power Meter -Final
�-
I v _
811. FOOD CERTIFICATEiSSUED
33. Final Electric
f! r
n /
Notes: - -
34. Final Heating & Air Conditioning
- -
35. Final Gas Pipe -Test
-
- -
.36. Hood or Canopy
37. Final Factory Fireplace
38. Final Plumbing
.
39. Water Service -Final
40. Gas Service -Final
-
41. Solar Domestic -Final
-
42. Backflow Preventer
43. Backflow Irrigation
44. Landscape Irrigation System
-
45. Sound Attenuation
'
46. Handicap Regulations
-
47. FINAL STRUCTURE & BUILDING
48. Special Requirements Completed
,r
-
49. Electric Release to Edison
-
-
50. Gas Release to Southern California Gas Co
51. CERTIFICATE OF -OCCUPANCY
No. - Date