HomeMy WebLinkAbout3333 BEAR ST - Building Permits (113), e ,
� CITY OF COSTA MESA -
� sq B{IILDING DIVISION
F` � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (774) 754-4856 • wv�rw.ci.costa-mesa.ca.us
�•��� FOR INSPECTI S CALL: (714) 754-5626
� PERMIT NUMBER: BC08-00028
�
PERMIT TYPE: B COMBO � A STATUS: ISSUED
— � 1]
i�
Sub Type: COM_ALT ��Q�
'�, ���_1� _, � _
�oa no�rtess: 3333 301 BEAI88T,,C.C�M'� a�� 1
APN: 41249207 OA'y+� Zoning: , ,
Vicinity:
Const Type: I-A
Sd. FT: 0
DATE ISSUED: 02/01/2008
ISSUED BY: CAC
Suite/Unit: 301
Primary Occ: 301
, Valuation: 81,892.00
SCOPE OF WORK: FOR SUITE 301 ONE ILLUMINATEO FRONT STORE SIGN AND A A LOGO SIGN FOR ADRIANO
GLODSCHMIED � �
OWNER: SOUTH COAST PLAZA Address: CIO C J SEGERSTROM AND SONS Unit: COSTA MESA,
CA
Phone: City/State2ip: 3315 FAIRVIEW RD
APPLICANT: BOBBIR DUDDEY
Phone: 818-764-6791
Address: 7422 VARNA ST .
Ciry/Slate/z2ip: NORTH HOLLYWOOD, CA
coNrrtnCTOR: COMM�RCIAL SIGN AND LIGHTING INC License No. 263327
Phone: 818-764-6791 Address: 7422 VARNA STUnit:
Cell: Ciry/State: NORTH HOLLYWOOD, CA
ARCHITECT:
ENGINEER:
COMBINATION PERMIT FEE SUMMARY
Building Plan Check:
Building Fees:
Electrical Fees: '
Mechanical Fees:
Plumbing Fees:
SMIP Residential: '
SMIP Commercial:
Bldg Std Admin Fund
TOTALFEES:
^Reter to tee receipb (or all feps paltl lor projecl
License No.
License No.
$43.03
$6620
$48.10
$0.00
$0.00
$0.00
$0.00
��
$157.33
Unit:
ZipCode 91605
PHONE:
PHONE:
NOTICE: The work auNorized by this permit shall wmply wiU all applicable handicap access requirements under Calitomia statutes and related
regulations. (Ord. No. 92-28, $ 1, 12-21•92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPEC710NS: In order for the work authorized under this permil to be considered legal, such work must comply with all applicable codes, and all
required inspections and final approval must be oblained. Failure lo obtain inspecfions and fnal approval will result in the expiration of Nis permit.
oC DE�. �NsvecnoNme �ng �x�mu tooe� wsaecnoNme QnT� x u
1616 Fixed $ys�em Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final 208 Final Plum�ing
200 Final Re-Roof 210 Final Electrical
201 Final Blotk/ReWining Wall 212 Final Fire Prevention
202 Final Faclory Fire Place 220 Final Planning Appmval
203 Final Sign 222 Final Site
204 Final Demolition 250 Final BuildinglOccupancy
WORKERS' COMPENSATION DECLARATION:
I hereby affirm untler penalry ot perjury one o( the follovring declarations:.
❑ I have antl will maintain a certificate of wnsent to self-�nsure tor workers'
compensation, as provided for by section 3700 of the Labor Cotle, (or the
peAormance of the work for which this permit is issued.
❑ I have and will maintain workers' compen5alion insurante, as required by
section 3700 of the Labor Code, for the peAormance o( the �+ark !w which this
permit is issued. My wnrkers' compensation Insurance carrier and policy
number are:
Carner:
(Tnis secfun neM riol be mmpeteea�ne perm4 u valuetl al me nunared mtlars (4100) a/ess )
Policy Num�er:
❑ I certily that in the peRormance of the work lor which this permit is
issued. I shall nol employ any person in any manner so as to become subject
to the workers' compensation laws of Califomia, and agree that i! I shoul0
bacome subjett to the vrorkers' compensation provisions o( Section 3700 0l
the Labor Cotle, I shall forthwith comply wiN these provisions.
Appli�infs SignaWre Date
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLAF2S
($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVI�ED FOR IN SECTION 3706 OF THE LABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirm thal I am licensed under provisions of Chapter 9(commencing
with Section 7000) of Division 3 of the Business antl Professions Code, and
my license is in full force and eHect.
Lic. # Class #
Gomrazior's SgnaWre Daie
CONSTRUCTION LENDING AGENLY:
0� I hereby aH'um that there is a construction lending agency for the
pertortnance o( the work fa which this pertnit is issuetl. (Sec. 3097, Civil Code).
Lender s Name:
Lender's Atldress:
Date
OWNER-BUILDER DECLARATIONS:
I hereby affirm that untler penalty of perjury that I am EXEMP7 FROM 7HE
CONTRACTORS LICENSE LAW fOr the following rea5on (SeC. 7031.5,
Business and Professions Code: Any city or counry which requires a permit to
constmct, alter, improve, demolish, or repair any swcWre, prior to its
issuanca, also requires �he applicant lor such pertni� �o fle a signed statemenl
thal he Of She i5 licen5ed pursuanl lo lhe pmvision5 0l Ihe CoNraclors
License Law (Chapter 9(commencing with Section 7000) ol Division 3 ot the
Business and Professions Code) or thal he or she is exempt therelrom and
tha ba5i5 for Ihe alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjecls the applicant to a civil penalry of not more than
five huntlreC tlollar5 ($500).):
❑ I, as owner of tha property, or my employees vrith wages as their sole
compensation, WILL DO THE WORK, and the str�cture is not intended or
ofleretl lor 5ale (Sec. 7044, Business and Prolession5 Code: The Contratlor5
License Law does not apply to an ovmei of property who builds or improves
thereon, and who does such work himself or herselt or through his or her ovm
employees, provitletl ihat such improvements are not intended or offered for
sale. If, hovrever, the building or improvement is sold within one year of
completion, Ihe owner-builder will have the burtlen of proving that he or she
did not builtl or improve for purpose ol sale.).
❑ I, as owner of ihe property, am EXCLUSIVELY CON7RACTING WI7H
LICENSED CONTRACTORS to consiruct the prqect (Sec. 7044, Business antl
Professions Code: T�e cont2ctors License Law does not apply to an avner of
property who builAs or improves thereon, and vrtw contracts for such project with
a contractor(s) ticense pursuant ro the Comractors License Laws.).
❑ 1 am exempl untler sec.
BuSiness and Pro(essions Code for Ihis reason:
�
Owner ID venfed by tlriver s Iicense. ❑ Yes ❑ No ��
Driver's License No. Expires:
Venfication of Ownership by (rype of tlocument, i.e. - property tax Dill or deed):
F INDUSTRIAL SAFE7Y PERMIT CERTIFICATION: �
ify �hat no excavation fve (5) or more (eet in tlepth into wfiich a
p n i end, will be made in connection with vrork authorized
is pe a sirucNre, scaffdding, falsev.ork, or demoli�i0n
or dismantli of, b Ihan thirty-six (36) leet high. (Chap. 3.2, Grp
2. M 2, Se . lif Administrative CoCe).
❑ As ownervbuilder, I ot employ anyone ro tlo work which would
require a permit from Ihe Division of Industrial Sa�ety, as notetl above, unless
such person has a permit to do such work (rom the division.
ApplitlnCs SignaWre Dale
Division of Intlustnal Salely Pertnit Number.
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. will the applicant or present or future building occupant neetl to file and
certify a Business Plan (or emergency response to release or threatenetl
release of a hazardous material? ❑ Yes ❑ No
(Seclion 25505 of the California Health and Safety Code requires, wim some
exceptions, that a Business Plan be filetl vnlh the Costa Mesa Fire
Department by every business which has at any one lime tluring a reportetl
year a quantiry of hazardous materials equal to or greater lhan a weight of
500 pountls, or a volume of 55 gallons, or 200 cubic feet of compressed gas
at standard temperature and p�essure).
2. Does or will the applicant or present or fuNre building occupant neetl to file
a registralion form for acutely hazardous materials? ❑ Yes ❑ No
(Section 25533 of the Cali(omia Health and Sa(ety Code, with some
exceptions, requires registration with the Costa Mesa Fire Department by
each business which at any one lime has on hand a quantity of acutely
hazardous matenals equal to or greater than a weight of 500 pounCs, or a
volume ol 55 gallons, or 200 cubic feel of compressed gas at standartl
temperaWre and pressure).
3. Does or will ihe applicant or present or tuNre building occupant need to
prepare an RMPP (Risk Management and Prevention Program for awtely
hazardous matenals)? ❑ Yes ❑ No
(SectiOn 25534 of ine Califomia Health and Sa(ety Code provides lhat Ihe
Costa Mesa Fire Department may require the preparation, cetlificaUon and
lling wilh the Fire Department ot an RMPP by businesses which are required
m register acutely hazardous ma[erials with the Fire Department.
4. If an RMPP is presently required, has Section 25534 of Ihe Califomia
Health antl Safely Code been fully complied with? ❑ Yes ❑ No
5. Does or will Ihe applican[ or presenl or WWre buildinq occupant require for
the woAc which is the subject ot Ihis application a permil for such construction
or modification from ihe South Coasl Air Qualily Management DisMcl or fmm
any other air polWtion control tlisirict or aqency9 ❑ Ye5 ❑ No
(Seclion 658502 0l Ihe Cali(omia Govemment Code requires ihat the requested
information be (umished on applications !p non-resitlenlial building pertnils).
6. Will any part of Ihe facility to be constructed under this permit be within
1000 (eet Irom the outer bountlaries of a school7 ❑ Yes ❑ No
pf'ye5". lhB faCility mUsl meet the requiremenl of Secti0n5 25534 antl 42303
ol the California Heallh antl Safety CoOe).
7. II a permit from the SoWh Coast Air �uality Mana9ement Districl or other
air polWtion control tlistrict or agency is required for t�e w+ork which is the
subjecl o( this application, have all of the tlisclosures prescrihetl by Calilomia
Health and Safety Code Section 42303 been matle7 ❑ Ves ❑ No
8. pf 'j�es", atWch certi(cate of compliance from Ne appropnate air pollution
control oKcer).
CERTIFICATE OF COMPLIANCE: I certify that untler penalty of perjury the
information given above is correct. I agree to comply with all state laws an0
city ordinances regarding Hazardous Materials and Emissions.
SignaWre �yte
CERTIFICATE OF COMPLIANCE AND AUTHORIZATON OF ENTRY: I
certify under penalty of perjury [hat I have reatl this application and sta[e I�a[
the inlormation given is correcL I agree to comply with all sWte laws and city
orainances relating to building conswction, antl aWhorize represenWtives of
the City of Costa Mesa to enrer upon the aboveCeuribed property tor
inspection purposes. I agree not to occupy or allow occupancy o( any building
aulhorized by this permit until final inspection. �
SgnaWre oi Legal Owner(s�
]OS)i61��7 An0/or Aol�or¢ee AOOliwm Ddle
April S, 2010
/
CITY OF COSTA MESA
P.O. BOX 1200 • 77 FAIR DRIVE • CALIFORNIA 92628-1200 ..
DEVELOPMENTSERVICES DEPARTMENT
BUILDING DIVISION
COURTESY NOTICE OF PERMIT EXPIRATION
South Coast Plaza
c/o CJ Segerstrom & Sons
3315 Fairview Road
Costa Mesa, CA 92626
PERMIT NUMBERS: BC08-00028
3333 301 Bear Street., Costa Mesa, CA
FOR: Store & Logo Sign for Adriano
Our records indicate the above listed permit(s) were obtained for property improvements or
aiterations at the above address. Per the 1997 Uniform Building Code, Section 106.4.4
Expiration, permits are valid for 180 days from the date of such permit, or the. date of the last
inspection for the project. ,
Our records do not show an inspection for these permits within the last 180 days nor have
they had an approved final inspection. If you have a signed inspection card showing that an
inspection was made within 180 days, or that the final inspection was approved, please
contact this office so we may correct our records. If you do not have an approved final
inspection, your permits will expire on April 19, 2010. Additional fees will be required to
finalize expired permits.
Requestinq an inspection - If you need to request an inspection, please call our Inspection
Request Line at 714-754-5626.
Requestinct an extension -If you wish to request an extension, requests must be made in
writing addressed to Bill Nunes, Chief of Inspection at the above address, detailing
ciroumstances and fisting an estimated date of compietion.
If you have any questions, please contact the Building Division at 714-754-4871, between
8:00 a.m. and 4:30 p.m., and a gtaff inember will assist you. The accuracy of records
affecting your property is our goal and we appreciate your working with us to resolve this
matter.
Sincerel ,
Va1lilUv�
Barbara J. Zw rt
Office Specialist II
cc: Commercial Sign 8 Lighting Inc.
BuUding Division (774) 754-5273 • Co�e EnforcemeN (7t4) 754-5623 • Planniny Division pt4) 754-5245
FAxt7tal]54.4856 • 7DDO74V59-5244 • vMw.ci.Gosla�mesa.Ca.us
� � � � ' CITY OF COSTA MESA �
suno�NG ��v�s�oH F08-00044
i � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(7'14) 754-5273 • Fax (714) 754-0856 • www.ci.wsta-mesa.ca.us
:
� FOR INSPECTIONS CALL: (714) 754-5626 •
•}�m "�'.
FIRE SUPRESSION PERMIT
,lobAddress: 3333 BEARST
Suite: 301
Vicinity: SPACE 301, ADRIANO GOLOSCHMIED
Parcel Nunmber: 4'1250107
npp�icant COFFMAN, JASON .
Address: �. � �
Owner: SOUTH COAST PLAZA
Address %C J SEGERSTROM & SONS
COSTA MESA, CA �
3315 FAIRVIEW RD
Contractor: COFFMAN, JASON
Address: 7707� W SEQUOIA AVENUE
ORANGE;CA
Zoning: PDC� PDC
Phone: 714-870-1010 �
Zip: 92626
Phone:
Zip: 92626
_ . • ^ � •-'
` Plione:� .:714�870-1010:.. .
Zip: 92686 , . .
License: �802591
Slatus: ISSUED
Applied: 02/19/2008
Issued: 02/292008
SCOPE OF PERMIT
REPLACE 29 SPRINKLER HEADS FOR "ADRIANO GOLDSCHMIED" STORE TI, RE:B07-00383
FEESUMMARY ,,, '
Plan Check: $72.31 Calc Vaivation: 3a,000.00
Permit: $11125 Claimed Valuation: 55,000.00
Other: $0.00 �
Total: $183.56 � � .
NOTICE: The work aulhorized by Ihis pertnit shall wmply with all applicable handicap access requirements under California statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
INSPECTIONS: In order for the work authorized under this permit to be consitlered 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 ezpiration of this permit.
LODE/. INSPECTIONTYPE 01T IN1111RL5 OOEN INSPECTION7YiE ORTE INTI111L5
1616 Fixed System Final Fire Prevention 206 Final Mechanical
1266 Pool Spa Final . 208 Final Plumbing
200 Final Re-Roof 270 Final Electriwl
201 Final0lock/Retaining Wall 212 Final Fire Prevention �_�� �� �
202 Final Faclory Fire Place 220 Final Planning Approval
203 Final Sign 222 Final Site
204 Final Demoli�ion . 250 Final Building/Occupancy
WORKERS' COMPENSATION DECLARATION:
I hereby a�rm under penalry ol perjury one of the following Ceclaretions:
❑ I have and vnll maintain a certifiwte of wnsent to self-Insure for workers'
compensalion, as provided for by section 3700 of the Labor Code, for the
performance the work tor which this permit is issued.
ave antl will maintain workers' compensation insu2nce, as requirad hy
section 3700 of the Wbor Cotle, for the peAamance of the work !or which this
permit is issued. My v,nrkers' compensation Insurance cartiar and policy
number are: ��J �
�COrtief: ,�r� _6-� � w q�� iiNBf1JJ!/� L O.
Ivs seqim neeE ndGe mnpereE /tlie pttnN s rdhreC al orm �unbM Eolars f5f001 akss )
Policy Number. /�/G /G /L S 7/
❑ I cerlily that in the perfortnance of the work for which ihis permit is
issued, I shall not employ any person in any manner so as lo become suhject
to the vrorkers' compensation laws ol Califomia, antl agree thal if I should
become subject to the workere' compensation provisions of Section 3700 0(
the Labor Cotle, I shall forthvri nply vrith these provisions.
, -� s>_• �y� e�
M0� �q�aWre �—Da�e '
WARNING: E TO SECURE WORKERS' COMPENSATION CAVER4GE
IS UNLP. L AND SHALL SU&IECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE IABOR CODE, IMEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affrtn that I am licensed under provisions of Chapter 9(commencing
with Seclion 7000) ot Division 3 of the Business and Professions Code, and
my license is in full torce anC effect.
Ovmer ID veri(etl by tlriver's licb.._ .. � Yes ❑ No
Dnver's License No. Expires:
Verifcation ot Ownership by (type of document, i.e. • property tax hill or deed):
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certHy that no excavatbn frve (5) w more (eet m depih into wfiich a
persm is required lo descend, will De maCe in connection with v.ork author¢etl
by this permil, antl that no builtling sWCNre, staFfdding, false»ork, tt demolition
or dismantling Ihereof, will be more than thitly-s& (36) feet high. (Chap. 32, Grp
2, M 2, Sec, 341, Tille 8, Califomia Administrative Cotle).
❑ As ovmer•builtler, I will nol employ anyone lo tlo work which would
require a parmit Irom the Division of Industrial Safery, as noteC aDove. unless
such person has a permil to do such work from lhe tlivision.
Apoliwnfs SignaWre Da1e
Division of IntlusMal Safety Permit Number.
HAZAROOUS MATERIALS AND EMISSIONS CERTFICATION:
1. Will the applicant or present or future building occupant need to file an0
certify a Business Plan for emergency response to release or Ihreatenetl
release of a hazardous material? ❑ Yes ❑ No
(Section 25505 0l I�e California Health and Sa(ety Code requires, with some
ezceptions, thal a Business Plan be filed with lhe Costa Mesa Fire
DepaAment Dy every business which has at any one time during a reportad
year a quantity of hazardous malenals equal to or greater than a weighl of
500 pounds, or a volume ot 55 gallons, or 200 cubic feet of compressed gas
at stanEard lempereture and pressure).
2. Dces or will the applicant or present or future building occupant need to file
a registralion form for acutery hazardous matenals? O Yes ❑ No
'Cic-#�G�02SQ/ �` qass #� L� • (Section 25533 0( the Califomia HeaIN and Sa(ery Code, with some
- .- exceptions, requires registration vrith Ihe Costa Mesa Fire Department by
n2 • JSt yG each business which at any one time has on hantl a quantiry oi acutely
a• ' �gna ure (oaye-- -. hazartlous matedals equal lo or greater than a weight of 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at standard
CON57 LENDING AGENCY: temperature and pressure).
❑ I reby aKrm that there is a construction lending agency for the 3. Does or will Ihe applicant or present or future building occupant neetl to
peAormance o! [he work for which lhis pertnit is issueC. (Sec. 3097, Gvil Code). prepare an RMPP (Risk Management antl Prevention Program for acutely
Lender'S Name: hazardous malenals�? ❑ Yes ❑ No
(Section 25534 of Ihe CaliFomia Health and Safety Cotle provides Ihat the
Lender's Address: Costa Mesa Fire Department may require the preparation, certification and
filing with the Fire Department of an RMPP Dy businesses which are required
to register acutely hazardous malerials vrith the Fire Depanmen�.
SignaWre Date
4. If an RMPP is presently required, has Section 25534 of the Califomia
OWNER-BUILUER DECLARATIONS:
I hereby affirm that under penally ol peryury that I am EXEMPT FROM THE
CONTRACTORS LICENSE LAW (or Ihe follovring reason (Sec. 7031.5.
eusiness antl Professions Cotle: Any city or county Which requires a pefmit 10
ConStruGt. aller, improve, demolish, or repair any strucNre, prior to ils
issuance, also requires the applicant for such permit to file a signaA statemant
ihal he or she is licensed pursuant to the provisions ol Ihe Contractors
License Law (Chapter 9(wmmencing with Section 7000) of Division 3 of ihe
Business and Pro(essions Cotle) or that he or she is ezempt therefrom antl
the basis tor t�e allegetl exemption. My violation ot Section 7031.5 by any
applicant for a pertnit subjects the applicant �o a civil penalty of not more than
fve hundred dollars ($500).):
❑ I, as owner of the property, or my employees with vrages as their sole
compensalion, WILL DO 7HE WORK, and the structure is not intended or
ottered for sale (Sec. 7044. Business and Professions Code: The Contrectors
License Law dces not apply to an owner of property who builds or improves
thereon, and who dces such work himself or hersell or [hrough his or her own
employees, provided that such improvements are not intentled or ofleretl for
sale. II. however, the building or improvement is sold within one year of
compleGon, lhe ovmer-builtler will have lhe burden of pmving that he or she
did nol buila or improve for purpose of sale.).
❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH
UCENSED CONTRACTORS to constnict the project (Sec. 7044, Business and
Protessions Code: Tlie contraclors License Law dces rwt appty to an owner of
propeAy who builds or improves thereon, and who contracts lor such project with
a contracta�s) license pursuant to the Contractars License lavrs.).
� I am exempt under sec.
Business and Professions Code !or Ihis reason:
305�.d613N))
Heallh antl Safety Code been (ully complied vnth7 � Yes ❑ No
5. Dces or will lhe applicant or present or fuWre builtling occupant require (or
�he work which is the Subjec[ of this appliCation a pertnil (or such conslruction
or motlifcation fmm ihe South Coas� Air Qualiry Management DisMcl or from
any other air pollution conirol district or agency? ❑ Yes ❑ No
(Section 65850.2 of Ihe Califomia Govemment Cotle requires that Itre requestetl
information be fumished on applications fa ran-residential bu'Jdirg pertnits).
6. Will any part o( tha laciliy to be conslructed under this permit De vrithin
10001eet !rom Ihe outer boundanes o( a 5chool? ❑ Yes ❑ No
(I( yes", ihe facility must meet I�e requirement of SecGons 25534 and 42303
of I�e Calilomia Heall� antl Safery CoAe).
7. If a pertnil Irom the South Coast Air Qualiry Manaqement District or other
air pollulion tontrol dislrict or agency is required for the work wtiich i5 Ihe
subject ol this application, have all of the disclosures prescribed by California
Health antl Salely Cotle Section 42303 been made? ❑ Yes ❑ No
8. (If'Yes", altach certifcate ol compliance from the appropriate air pollution
control o�cer�.
CERTIFICATE OF COMPLIANCE: I certi(y lhat under penalty o(.perjury the
information given above is cortect. I a9ree to comply with all state laws antl
ciry ordinances regarding Hazardous Materials and Emissions.
CERTIFICATE OF COMPLIANCE AND AU7HORIZATION OF ENTRY: I
certify under penally of perjury that I have read this appliwtion and state thal
the informalion given is correct I agree to comply wilh all sWle laws antl city
ordinances relaling to building construction, and authorize representatives of
the City of Costa Mesa to enter upon the above-described propeey for
inspection purposes. I agree not [o occupy or allow occupancy of any builtling
aulhorized by this pertnit until final inspection.
��
Date
• OB
� - CITY OF COSTA MESA ��
� BI/ILD/NG DIYISION
i` � 77 FAIR DRIVE, COSTA MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • �wwi.ci. sta-mesa.ca.us
:
�.�� fi. FOR INSPECTIONS CALL: (714) 754-5626
PERMIT NUMBER: BX07-00218
PERMIT TYPE B MISC STATUS: ISSUED
APN: 41249207 DATE ISSUED: 1 111 3/2 0 0 7
Zoning: , ISSUED BY:
' ��r
JOB ADDRESS: 3333 307 BEAR ST CM ..' Suite/Unit: 301
Viciniry: SPACE 301 -.'�-�Primary Occ' Const Type :??
S�. FT: 0 - ' Valuation: �. E8,000.00 _ �
SCOPE OF WORK: NON-STRUCTURAL DEMO AND GAP EL IN PREP FOR FUTURE T.I. AT SPACE 301.
i'
OWNER: SOUTH COAST PLAZA� - " Address: %C J SEGERSTROM B�SONS..�. Unit COSTA
MESA, CA ' ' " " � � �
City/State: 3315 FAIRVIEW RD ': '�• Zip Code: 92626 .�
Phone: � � ' �-�-� ' �
APPIICANT:
City/State:
Phone:
HAGLUND; STEVE ; ��� ,• � Address: 502 S SANTA FE �, -�. Unit
SANTA ANA, CA � , . .. " � Zip Code: 92705 . � " - -
714-550-9997 ' - - "
� ,I
CONTRACTOR: RS HAGLUND CONSTRUCTION -
Address: 502 S�.SANTA FE�;� , , , � Unit�.,,,.; ; "' � '�
Ciry/State: SANTA ANA, CA� � ��" � . - .. -'
Zip Code: 92705 -� � � � _
5....
ARCHITECT: CORTLAND MORGAN = -�� - _ _
Phone 2143683687 �� - �
ENGINEER: � � � .
Phone � . � � � -
' .
License No.
Phone � 714�-550-9997
� � License No. C25519
` FEE SUMMARY
Building Plan Check \ , $99.61
Building PermiC . , , � � ..$15325
Electrical Permit: � � . $4170
SMIP Residential � _ - _ $0.00 .
SMIP Commercial �--'- � � --'�' $1:68 �
$1.68TOTAL FEES "-- � � - ' ., _ ` $296.24
License No.
�
• �F �
412567 ,
Cell:
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related
regulations. (Ord. No. 92-28, § 1, 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION.
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 expiratlon of this permit.
CODE t, INSPEClIONTYPE
1616 Fixed System Final Fire Prevention
1288
200
201
202
203
204
Pool Spa Final
Final Re-Roof
Final Block/Retaining Wall
Final Factory Fire Place
Final Sign
Final Demolition
pR�F IN1111AL5 COOE/ INSPECTIONTYPE
206 Final Mechanical
208 Final Plumbing
210 Final Electrical
212 Final Fire Prevention
220 Final Planning Approval
F 222 Final Si�e
il FPp 250 Final Builtling/OccuDancy
1�
DRTE INTRIRLS
WORKERS' COMPENSATION DECLARA710N:
I hereby aKrtn under penally of perjury one of Ne following tleclarations:
❑ I have and will mainlain a certifcate of consent to self-Insure for wvrkers'
wmpensation, as provided for by section 3700 of the Labor Code, for the
peAormance of ihe vrork for which Ihis permit is issued.
❑ I have antl will maintain workers' compensalion insuranca, as required by
seclion 3700 of ihe Labor Cotle, fa the peAortnance o( lhe v.ork tor which this
permit is issued. My workers' compensation Insurance carrier antl policy
number are: �+ '
�Camer.� �l�e +un�
—"(TliissecYionneetlnolbecampleteORthe imlisvaluedafrnehunOreGtlollars(5100)alessJ
fPUicY.Nu� ber: f)(j_J 2-! }h L
❑ I cerlily thal in the peRortnance of the work for which this permit is
issuetl, I shall not employ any person in any manner so as to become subject
to Ihe workers' wmpensation laws of Calitomia, an0 agree that if I should
become subjec� to the workers' compensation provisions of Section 3700 of
the Labor Code, I shall forthvn[h com ly with Nese provisions.
�Q _=1� llr-�I3� 0"1
/p�1lonCsbl Wre� Dete-��
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby affirtn Ihat I am licensetl 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 eftact.
�;c,n. 4125Co`l c�ia 5a L3-�
.,c?�j ll_�3-0�7
ContactwhsigASwre �.Da�e �
CONSTRUCTION LENDING AGENCY:
❑ I hereby aHirtn that there is a construction lentlin9 a9ency for the
pedormance of the �nork ta wfiich this pertnit is issued. (Sec. 3097, Civil Code).
Lender's Name:
Lentler's Address:
SignaWre �ate
OWNER-BUILDER DECLARATIONS:
I hereby affi�m ihal under penal[y of perjury that I am E%EMPT FROM THE
CONTRAC70RS LICENSE LAW for the following reason (Sec. 7031.5,
Business and Professions Code: Any city or wunty which requires a permit to
conswct, alter, improve, demolish, or repair any struclure, prior lo ils
issuance, also requires the applicant (or such permit to file a signetl statement
[hat he or she is licensed pursuant to ihe provisions of the Contractors
License Law (Chap[er 9(commencing with Section 7000) of Division 3 of t�e
Business antl Prolessions Code) or Nat he or she is exempt therefrom antl
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalry of not more Ihan
five hundred tlollars ($500).):
❑ I, as owner of the property, or my employees with wages as iheir sole
compensation, WILL DO THE WORK, and lhe structure is nol intentletl or
oKered for sale (Sec. 7044, Business and Professions Code: The Contractors
License Law Coas not apply to an ovmer of property who builds or improves
thereon, and who does such work himself or herself or through his or her own
employees, provided thal such improvements are not intended or ottered for
sale. If, however, the building or improvement is sold within one year of
completion, Ihe owner-builder will have ihe burden of proving Ihat he or she
did not build or improve for purpose of sale.).
❑ I, as ovmer of the property, am EXCLUSIVELY CONTRACTING WITH
LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and
Pro(essions Code: The contrac[as License Law tices not apply to an owner of
property who builds or improves thereon, and who contracls fa such project with
a contractor(s) license pureuant to the Contractors License Lav.s.).
❑ I am exempt under sec.
Business and Protessions Code for lhis reason:
SiB�aWre
0059-06 �]IO))
Owner ID verified by driver's li�_ .e. ❑ Yes ❑ No
Dnver s License No. E<pires:
Verification of Ownership by (type of tlocument, i.e. - properly tax bill or deetl�:
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation frve (5) or more feet in depth into wTiich a
person is required to descend, vnll be made in connec[ion vdth work authonzed
by this permit, and that no building strucNre, scaf(dding, falsev.ork, v demolition
or tlismantling lhereof, will be more than thirty-six (36) feet hiqh. (Chap. 32, Grp
2, Art 2, Sec. 341, Ttle 8, Cali(omia Admini5t2tive Code).
❑ As owner-builder, I will not employ anyone to do work which would
require a permi[ from lhe Division o( Industrial Safely. as noted above, unless
such person has a permit to do such work (rom the tlivision.
AppliUnl'S $ignature Dale
Division of InduS[rial Safery Pertnit Number:
HAZARDOUS MATERIALS AND EMISSION$ CERTIFICATION:
1. will the applicant or present or fulure Duilding occupam need 10 file antl
certify a Business Plan (or emerqency response to release or threatenetl
release of a �azardous matenal't ❑ Yes ❑ No
(Section 25505 of ihe California Health and Safety Code requires, wilh some
exceplions, that a Business Plan be filed with the Costa Mesa Fire
Department by every business which has at any one time during a reporte0
year a quantiry of hazardous materials equal to or greater Ihan a weight of
500 pounds, or a volume of 55 9allons, or 200 cubic feet of compressetl gas
al slandard temperature and pressure).
2. Does or vrill the applicant or presant orluWre building occupant need to file
a registration fortn for acutely hazardous matenals? ❑ Yes ❑ No
(Section 25533 ot lhe Califomia Health and Safery Code, with some
exceptions, requires registration wilh lhe Cosla Mesa Fire Depanmenl by
each business which at any one time has on hand a quantity of acutely
hazardous materials equal to or greater lhan a vreigM ot 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressetl gas at stanCard
temperature and pressure).
3. Does or win the applicant or present or Wture builtling occupant need to
prepare an RMPP (Risk Management antl Prevention Program for acutely
hazartlous materials�7 ❑ Yes ❑ No
(Section 25534 of lhe Cali(omia Health antl Safety Code provitles ihat the
Costa Mesa Fire Department may require the preparation, certification and
filing with Ihe Fire Departmenl of an RMPP by busines5es which are required
lo register acutely hazardous materials with lhe Fire Department.
4. If an RMPP is presenlly requirad, has Section 25534 of the California
Health antl Safery Cotle been lully complied wi[h? � Yes ❑ No
5. Does or will the applicant or present or fuW re building occupant require for
the work which is the subject of this applicalion a pertni[ for such conSVuctiOn
or modification from the South Coasl Air Quality Management District or from
any other air pollution control district or agency? ❑ Yes ❑ No
(Section 65850.2 of the Califomia Govemment Code requires lha[ the requestetl
fnformatbn be fumishetl on applications fa noo-residential building pertnits).
6. Will any pan of t�e facility to De wnsWcled under this permit be within
1000 feet from the outer boundanes of a school? ❑ Yes ❑ No
pf 'j�es". the facility must meel the requirement of Sections 25534 antl 42303
of the Califomia Health and Safety Code).
7. If a permit from the South Coasl Air Quality Management DisMct or other
air pollution control dislrict or agency is require0 for the work which is the
subject of this application, have all ot the disclosures prescnbed by Calitornia
Health and Safery Code Seclion 42303 been matle? ❑ Yes ❑ No
8. Qf'yes", attach certificate of compliance from the appmpnate air polWtion
control oKcer).
CERTIFICATE OF COMPIIANCE: I certify Ihat under penalry of peryury the
information given above is correct I agree to comply with all state laws antl
city ordinances regarding Hazardous Materials and Emissions.
SignaNre Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certi/y under penalty of perjury that I have read this application antl state that
the infortnation given is wrrecl. I agree to comply wit� all state laws and ciry
ordinances relating to building construction, and authorize representatives o(
the Cily of Costa Mesa ro enter upon the above-described property lor
inspection purposes. I agree not to occupy or allow occupancy of any building
authorized by this permit until fnal inspection.
Sipgr�aWreofLegalOwner�s) Date
�0. ,�Qv�g/l 1��13-0%
A�W/aAutlwr�xe09 p�iran� Oate--�
�_— _— ___�' ___ -Y�
. �, _ .q . �;1 . .: fc . .. y �. . / ..,.. .. . .'�i .. 41�: -., �...p. . ., . . . �... .
� Cl Y� OF COSTA MI �A �
Development Services, Division of Building and Safety
CERTIFICATE OF O�CCUPANCY
„ � . .;.#
<<: ,� � „ �
; ��.
This certificate is issued pursuant to the iequuements of the Unifoim Building Code,SecHon 308 adopted by the City
��.
of Costa Mesa cerHfies that at the time of its issuarice the buIlding strucEure herein below described was inspected and
approved for occupancy as follows �r � ��
3333�' 8ear'`^9t ' Ste 3n't`-.. �. :P,, °>' . _. .
Building Address H C 0 7- 0 0 3 8
Use Retail
Group M
OwnerofBuilding South
c o CJ
Address 3315 Fairview
i2r653 s.f.
>�r
...5 : .. �9.:�.
.. ,<..,.£_ .
instrucHon� �Z FR �� '"'�F
as't,�Plaza "
e"9erstrom and Son:
d.`;�GOsta Mosa.<C1
��
�e XXXRYRBX
° y..
nt�� - �DRI.
:n
Number 3
,
Use Zone P DC �
IO GOLDSN!dIED
,a ��. ..
.���,'By>� "" � ,�. ,�
BUILDING OFFICIAL-K11dTlil Q. NgUyBri� .0 B O '` y /
��'Date OS/0 /0
_ _a,�<.'
� REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE
�
�
CITY OF COSTA MESA
BU/LD/NG D/V/S/ON
i
��
77 FAIFt DRIVE, COS7A MESA, CA 92626 •(714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us
FOR INSPECTIONS CALL: (714) 754-5626
PERMIT NUMBER: BC07-00383
PERMIT TYPE: B COMBO
Sub Type: COM_ALT
STATUS: ISSUED
DATE ISSUED: 01/23/2008
ISSUED BY: BJK
JOB ADDRESS: 3333 301 BEAR ST CM " Suite/Unit: 301
APN: a12a9207 � � Zoning: pD (�/. . .
Vicinity: SPACE 301 ADRIANO GOLDSCHMIED Primary Occ:
Const Type: I-FR -' SQ: FT. �' 2653 �, � Valuation: 5165,000.00
SCOPE OF WORK: 2,653 SF INTERIOR T.I. FOR "ADRIANO GOLDSHMIED" SPACE 301 TO ALSO INCLUDE 2 VENT FANS, 18
OUTLETS AND 1 SWI7CH.
OWNER: SOUTH COAST PLAZA
CA ,
Phone:
APPLICANT: BERNHARP MUELLER
Phone: 323-580-7200 ,
CON7RAC70R: A A CONCEPTS INC
Phone: 323-850-1686
Cell:
ARCHITECT: CORTLAND MORGAN �
ENGINEER: � -.
.� � Address: C J SEGERSTROM AND SONS
�
- "City/State/Zip: 3315 FAIRVIEW RD �
Address:
City/StatelzZip:
License No. 892966
Address: 7215 HILLSIDE AVENUEUnit:
City/State:� �LOS ANGELES, CA
License No.C25519
License No. -
COMBINTATION PERMIT FEE SUMMARY '
Building Plan Check: " , ' , .$220.64 - ,
Building Fees: _ . . .$1,357.75 ' _. .
Electrical Fees: . . - $44.40 .
Mechanical Fees: $38.00
Plumbing Fees: - - �$0.00
SMIP Residential: ' $0.00 -
SMIP Commercial: $34.65
TOTAL FEES: $1,695.44
^Re/or to (ee receipU for all feea paltl for proJect
Unit: COSTA MESA,
Unit: � � -��.�iu°i
UNIT 1
ZipCode 90046
PHONE:214-3683687
PHONE: '
. -:;aNS, �6
. i ��. rnE ^c
• ' . �i.,F.}'.t.7
� n��n[r;
NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia''slatutes and related
regulations. (Ord. No. 92-28, § 1. 12-21-92)
EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. �
INSPECTIONS: In order for the work authorized under ihis permil to be consitleretl legal, sach vrork must comply with all applicable codes, and at{
required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration o( this permit.
cyo�� iNsvernoNrrre np�r iNnn�3 C�OF,� INSYECTIONME � iN i �
1818 Puetl System Final Fi/e Prevention 206 Final Mechanipl �//Q- J �"��
72fi6 Pool Spa Final 208 Final Plumbing fl/ A.
200 Final Re�Roof 210 Final Electri�al
201 Final BIocWRetaining `Nall 212 Final Fire Prevention
202 Final Factory Fire Place 220 Final Planning Approval
:zn-.
203 Final Sign y 222 Final Site '1 � ' �� �
2fM FinalDemolition � �L.QO_ G� 250 FinalBuildin9/Occupancy �i/^ y�, _l���ZIJ��
'� rT T�j�� I i%
WORKER� ENSATION� RATION: �
I hereby aKrtn under penalty of perjury one o( the follovnng declarations:
❑ I have antl will maintain a certificate of wnsent to selFlnsure for workers'
compensation, as provided for by seCtion 3700 ot the Labor Code, tor the
pedormance of the work (or which lhis permit is issued.
❑ I have and will maintain workers Compensation insurance, as required by
section 3700 af lhe Labor Code, fw Ihe peRormance o( Itre wvrk for whicn this
pertnit is issued. My vrorkers' compensation Insurance carrier and policy
number are:
Cartier.
(il�¢ sectqn nee� nof De [omda� Itlrc pennrt d rdh�etl ar wro nuM�eOCWars (51 Wl a less )
Policy Number:
7 certify that in the peAortnance o! Ihe work for which Nis pertn"rt is
' sued, I shall not employ any person in any manner so as to become su6jecl
to Ne v+orkers' compensalion laws of California, and agree thal if I should
bewme subject to Ihe workers' comp@nsation provisions of Section 3700 of
the LaDor Cade, I shall �Rfi �th co ly with these provisions.
�� / 23 O�
Appiwnfs SiBwiure Da�e
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION CAVERAGE
IS UNIAWFUL AND SHALL SU&I�CT AN EMPLOYER TO CRIMINAL
PENALTIES AND CNIL FINES UP TO 4NE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE CAST OF CAMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE U180R CODE, INTEREST, AND
ATTORNEV'S FEES.
LICENSED CONTRACTORS DECLARATION:
I hereby aKrm Nat I am licensed unCer provisions of Chapter 9(commencing
with Section 7000) of Division 3 of lhQ Business antl Pmfessions Cotle. and
my license is in tul orce anE effect. �
Lia # Class #
�°c�G�r,� i 23 ��
Gonvador's &9��ure Dale
CONSTRUCTION LENDING AGENCV;
❑ 1 hereby affum that there is a consWction lending agency for the
peAortnance of the v.ork fa wfiich tttis pertnit is issued. (Sec. 3097. Civil Code).
Lentler's Name:
Lender's Atldress:
SiBnaWre Date
OWNER•BUILDER DECLARATIONS:
I hereby aKrm that under penalty of perjury Ihat I am EXEMP7 FROM THE
CONTRACTORS LICENSE UlW for Ne following reason (Sec. 7031.5.
Business and Professions Code: My Ciry or county which requires a permit to
consWct, altar, improve, Cemolish, or repair any siructure, prior to its
issuance, also requires the applicanl fqr such permil to fle a signed statement
that he or she is licensed pursuant to the provisions of lhe Contractors
License Law (Chapter 9(wmmencing vrith Seclion 7000) of Division 3 0l the
Business antl Prolessions Code) or that he or she is exempt iherefrom and
ihe basis lor Ihe alleged exemption. qny violation o( Section 7031.5 by any
applicant for a pertnit subjecis the applicaN to a civil penalty of not more Ihan
five hunGred Collars (5500).):
❑ I, as owner ol the property, or my employees wilh wages as iheir sole
compensation, WILL DO THE WORK, and the slructura is not intendetl or
oHered for sale (Sec. 7044, Business and Professions Cotle: T�e Contraclors
License Law does not aDPly to an owner ol property who builtls or improves
thereon, and who Coes such work himgelf or herself or through his or her own
employees. provided that such improvemenis are not Intended or oflered for
saie. If, however, the Duilding or improvement is sold within one year of
completion, the ovmer-builCer will have the burden of proving Ihat he or she
did noi Duild or improve !or purpose of Syle.j.
❑ I, as owner of the property, am EXCLUSIVELV CONTRAC7ING WITH
LICENSED CONTRAC70RS to construct the projecl (Sec. 7044. Business and
Protessions Code: The conUactors License law dces not apply to an owner of
property who builds a improves thereon, and who contracts for such project with
a contracta(s) ticense pursuant to the Cqnt2ctors License Wws.).
❑ I am exempt untler sec.
Business an0 Protessions CoCe (or Ni5 reason:
9qrelure � Date
J05]J16 (1W )
Ovmer 10 veri(ed by driver'� ❑ Yes ❑ No �
Driver'S License No. Expires:
VerifiW[ion of Ovmership by (type of dxument, i.e. - property lax bill ar deed): �
�IVISION OF INDUSTRIAL SAFETV PERMIT CERTIFICA710N:
❑ I hereby certify that rw excavatbn (rve (5) or more (eet in depth inlo wfiich a
person is required [o descentl, will be matle in conneclion with work autlrorized
by tNs pertnit, and that no builtling sUucture, scaFldtlinq, (alsework, a tlemolition
or dismantting thereo(, vrill be more ihan thi0y-siu (36) feet high. (Chap. 3.2. Gry
2, Art 2, Set. 341, Title 8, Califomia Adminisiralive Cotle).
❑ As ovmer-builCer, I will not emp�oy anyone to do work which would
require a pertnil lrom Ihe Division o( Intlustrial Safety, as notad above, unless
such person has a pertnit to tlo such work from the division.
Applicanl's Signalure Odle
Division of Industrial Safety Permit Number:
HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION:
1. Will the appliwnt or present or (uture building occupant need lo fle antl
certiry a Business Plan for emergency responsa lo release or threatened
release of a hazardous malerial? ❑ Yes ❑ No
(Section 25505 0l Ihe Califomia Health antl Safety Code requires, with some
exceptions, Nat a Business Plan be filetl with the Cosla Mesa Fire
Department by every business which has at any one time Ouring a reporteA
year a quantiry of hazartlous materials equal to or greatar than a weight of
500 pounds, or a volume of 55 gallons, or 200 cubic feet of wmpressetl gas
at stantlard temperature and pressure).
2. Ooes or will the applicant or preseN or fuWre Duilding occupaN need to file
a registretion fortn tor acutely hazardous materials7 � Yes ❑ No
(Section 25533 of the Calilomia Heallh and Salety Code, with some
exceptions, requires registration wim the Costa Mesa Fira Departmenl by
each business x?iich a� any one time has on hanC a quantiry of acutely
hazardous matenals equal to or 9reater than a weight o( 500 pounds, or a
volume of 55 gallons, or 200 cubic feet of compressed gas at stantlartl
temperature and pressure).
3. Does or vnll the appliwnt or present or future building occupanl need lo
prepare an RMPP (Risk Management antl Prevention Program lor aculely
hazardous materials�? ❑ Yes ❑ No
(Section 25534 of Ihe Califomia Health and Safely Code provides that Ihe
Costa Mesa Fire Departmant may require the preparation, cenificalion and
filing with the Fire Department of an RMPP by businesses which are requirea
[o register acutely hazardous materials wilh the Fire Department.
4. It an RMPP is presently required, has Seclion 25534 0! the Calilornia
Health and Safery CoCe Deen fully wmplieC wilh7 ❑ Yes ❑ No
5. Dces or will the applicant or present or luture building occupanl require for
lhe work which is Ne subject of this appliwtion a permit (or such wnsWction
or modification from the South Coast Air Qualiry Management District or Irom
any other air polluGon wntrol disMct or agencyl ❑ Yes ❑ No
(Section 65850.2 of the Calitomia Govemment Cotle requires thallhe requested
inlortnation be fumisheC on appliwtions fa noo-resqential buiWing pertnils).
6. Will any part of Ihe faciliry to be consWcted under this permil be wilhin
1000 (eet from the outer boundanes ol a school? ❑ Yes ❑ No
(If'yes'. the faciliry must meel lhe requirement of Sections 25534 and 42303
of lhe Califomia Health and Safery CoOe).
7. If a permit from the South Coasl Air Quality Managament District or other
air pollution control district or agency is requiretl lor tha work which is the
subject of this application, have all of the disclosures prescribetl by Califomia
Health and Safery Cotle Seclion 42303 been matle? ❑ Yes ❑ No
8. (If'j�es". atlach certi(cate of compliance from the appropriate air pollulion
control oKcer).
CERTIFICATE OF COMPLIANCE: I certify lhat under penalty of perjury the
infortnation given above is wrtect. I agree to comply with all slate laws and
city ordinances regarding Hazartlous Materials antl Emissions.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I
certify under penalty of perjury that I have read this appliwtion and slate Ihat
the information given is wrtect I agree to wmply with all stale Iaws and city
ordinances relating to building wnsWction, and authorize representatives of
me City of CosW Mesa to enter upon the above-described property for
inspection purposes. I agree not lo occupy or allow occupancy of any builtling
authorized by this pertnit until final inspection.
Sig . of leg (s) e
i z3 D�'
MCIorANhonzlEAppliCdnl Ddl¢